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For those who follow history, the glass of health reform is at least half-full

Introduction by Croakey: If you haven’t already, it’s worth making time to read Health and Aged Care Minister Mark Butler’s recent speech to a Whitlam Institute event celebrating the history of the Community Health Program.

The program, launched in 1973, supported locally-driven, community-controlled, multidisciplinary community health services that addressed the social determinants of health and provided treatment programs and health promotion in areas like drug and alcohol, mental health and reproductive health.

As Butler said, it was a very different beast to the universal health insurance scheme of Medicare and its precursor Medibank, which sought to provide low or no-cost access to a private industry of medical doctors providing mostly episodic treatment on a fee-for-service basis.

While the CHP did not survive the Fraser Government’s election, Butler’s speech suggests that he is committed to integrating principles and elements of the CHP into Medicare reforms, including a focus on equity and “care that looks beyond the medical to the social determinants of health”.

“Instead of a uniform model of care imposed from above, the CHP funded states, local councils and community groups for a wide variety of projects in a truly bottom-up and iterative approach to policy formation,” said Butler.

“As we look to the role that Primary Health Networks might play in a more community-oriented primary care, we need to ask ourselves: How can [we] weave the principles of Whitlam’s CHP into the PHN network and ethos?”

Butler told the gathering that embedding the principles of the CHP into Medicare reforms will strengthen Medicare beyond its health insurance roots – “from universal health insurance…to universal healthcare”, he said.

As Butler and colleagues roll out a series of Medicare reforms – including the voluntary patient registration model of MyMedicare – health policy expert Professor Stephen Duckett is hopeful about the immediate future for health reform, while acknowledging the “wrecking ball” lessons from history.

His article below was first published by Pearls & Irritations.


Stephen Duckett writes:

Another important suite of changes to Medicare recently came into effect. Since the election of the Albanese Government, we have seen a willingness by government to introduce a range of policies designed to update and strengthen Medicare to position it better for the future.

The wrecking-ball days of nine years of conservative governments bent on undermining and weakening Medicare have come to an end, but their legacy will remain for a while.

The Liberal-National government era started with an attempt to introduce a compulsory copayment, and when that was stymied, an attempt at slow strangulation, by freezing Medicare rebates, started.

The intended result was achieved: a decline in bulk billing. The collateral damage of worse access was ignored.

Unfortunately, the take-away lesson learned by the medical profession seems to be that all governments are not to be trusted.

The rhetoric of medical leaders does not distinguish between conservative governments, which at best have only ever been reluctantly accepting of a universal system, and Labor governments, which are viscerally committed to the scheme that their predecessors implemented, protected, and nurtured.

This was most recently evidenced in an extended piece in Inside Story, by veteran journalist Mike Steketee, where the current president of the Australian Medical Association, Professor Steve Robson, was surprised at the current Government’s response to the need to strengthen Medicare. “Something unexpected happened,” he said. “Government listened.”

Dr Nicole Higgins, President of the Royal Australian College of General Practitioners, however, recognised the importance of political context: “For the first time in decades we have a Government that’s committed to strengthening Medicare and general practice care.”

Challenges ahead

However, the mess Labor inherited will take longer than a few months to fix.

The architecture of Medicare has remained essentially unchanged since the 1980s; indeed its lineage clearly dates from the 1970s. Since then, there have been major epidemiological transitions with the rise of chronic disease and an increased prevalence of mental illness.

The supply-side has also changed with fewer small medical practices structured as partnerships, and more corporate ownership. Primary medical care in rural and remote Australia is mostly in a parlous state despite a revolving door on National Party Ministers for Rural Health.

No contemporary service, business, or organisation can survive almost a decade of malign neglect.

The legacy left by Liberal health ministers Peter Dutton, Sussan Ley, and Greg Hunt is a Medicare scheme sorely in need of repair, because of the slow erosion of the value of rebates, and the failure to respond in any meaningful way to changed circumstances other than to commission a talkfest of reviews, task forces and committees. These appear to have been established to create a semblance of activity, provide photo opportunities, and distract attention from the subtle, ongoing undermining which was at play.

Labor’s recent changes – especially trying to strengthen the affinity between patients and practices – will provide the basis for future changes, including strengthening multi-disciplinary teams, which must be the basis for care for people with multiple chronic diseases, and preventive interventions to improve health.

Under these changes – the marketing label is ‘MyMedicare’ – people will be able to ‘register’ with a practice.

This will give practices a picture of those who see the practice as their main source of care and identify opportunities for the practice to reach out to those patients for preventive care.

Initially the focus of MyMedicare will be patients who are ‘frequent hospital users’, with the exact definition of that term still being refined. The idea is that better primary care services might have helped avoid some of these admissions, benefiting both patients and the hospital system.

Further announced changes include increasing the bulk billing rebate to help arrest the decline in bulk billing. The decision to increase the prescription quantities that can be dispensed by pharmacies to 60 days’ supply rather than 30 days’ supply for a number of common medications will free up time of general practitioners to respond better to demand, as well as reduce costs for consumers.

Development of urgent care centres will improve access to care but it’s still too early to tell what impact they will actually have.

Good as these changes are, there is much that still needs to be done.

Workforce supply is one of the top issues, but this cannot be disentangled from workforce roles and relative remuneration. The former is under review, but the latter appears to be still a policy black hole.

Part of the Medicare promise is about access to public hospital care, yet few would say that people can get the right care, on time, every time. And the ‘D word’ – dental care – remains unmentionable.

What gives one cause for optimism, however, is that the context is a sympathetic government, one committed to equity, not one trying to undermine equity and return to a residualist mindset.

• Stephen Duckett, an economist, is an Honorary Enterprise Professor in General Practice and in Population and Global Health at the University of Melbourne, Chair of the Board of Eastern Melbourne Primary Health Network, and a member of the Strengthening Medicare task force.


See this recent Croakey article, 50 years on: legacy and lessons from Whitlam’s landmark community health program

 

 

 

 

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