Health and the Federal Budget – an overview of key submissions

The upcoming Federal Budget, delivered in the context of a health and economic crisis, provides both challenges and opportunities for health.

While spending is expected to be constrained overall, the devastating impact of COVID-19 across all sectors of our society has raised awareness among governments and decision makers of the importance of health to the economy.

This creates opportunities to address areas of under-funding and to demonstrate to the Government the broad social and economic benefits of increased health spending.

Below Croakey editor Jennifer Doggett highlights some of the main asks from the submissions of key health groups.

Jennifer Doggett writes:

While most of the proposals in the Budget submissions deal with specific areas of the health system, there are some suggestions for big picture systemic reforms.

Consumers Health Forum (CHF) has called on the Federal Government to fund and implement a Health In All Policies approach and consider adopting a wellness budget to ensure all government policy supports health and wellbeing.

The Australian Healthcare and Hospitals Association (AHHA) proposed moving from volume-based care to a system of value-based healthcare, where patients are at the centre and the outcomes achieved in the provision of this healthcare are the focus.

In relation to this, AHHA has proposed:

• Value-based healthcare training, supporting resources, mentoring and communities of practice, tailored to an Australian audience and context, for Australian health services.
• A web-based clearinghouse of quality-assessed evidence on value-based healthcare
• Resourcing to implement the National Health Information Strategy, enabling use of patient-reported outcome and experience measures for patient care, and performance benchmarking.

The Australian Nursing and Midwifery Federation (ANMF) also supported a move towards a value-based health system, including asking that the Government:

1. Commit to supporting a long-term, national, cross-sector policy and strategy for value-based healthcare.
2. Commit to supporting improved access to relevant and up-to-date data via the establishment of patient outcome and experience measures, clinical quality registries, improved health informatics infrastructure, international benchmarking.
3. Work with stakeholders to develop a national health workforce strategy that supports models of care that enable value-based approaches to healthcare.
4. Pursue the adoption of mixed funding formulae that appropriately utilise a blend of activity-, block-, and performance-related funding measures that incentivise the delivery of value-based healthcare.

The ANMF also proposed the establishment of an independent Health Performance Commission to be a specialist health data analytics and performance reporting body for both private and public health sectors. This body would be responsible for mapping and co-ordinating the collection, analysis and publication of health data across the public, private and aged care sectors to enable value-based health care.

Income support

CHF has called for a permanent adequate increase to JobSeeker and other income supports in line with the level of support paid through the addition of the COVID-19 supplement.

The ANMF proposed broad reforms of the tax system, including reform of tax concessions, and increased transparency and an increase to the current Newstart (now JobSeeker) allowance to a level that provides the support that it is truly intended to deliver.

Aboriginal and Torres Strait Islander health

Aboriginal and Torres Strait Islander people’s health was a high priority for most Budget submissions with groups highlighting the urgent need for action across the health, education, social care and justice sectors.

The submission from Uniting Care contextualised its proposals for Aboriginal and Torres Strait Islander health initiatives by outlining recent budget cuts to programs in this area and arguing that:

…the continual churn and restructuring of First Peoples’ policy and programs has created constant upheaval and uncertainty, undermining the stability and sustainability of Aboriginal-controlled community organisations, and eroding the effectiveness of programs and policies.”

Uniting Care acknowledged that some progress had been made in closing the gap but argued for  “deeper and sustained efforts” to deliver “real reform and lasting change”.

It describes the Government’s approach to Aboriginal and Torres Strait Islander health as characterised by “a reliance on top-down and paternalistic measures”, including “the proposed expansion of the cashless debit card, and the continuation of punitive interventions that disproportionately target unemployed First Peoples in remote areas, such as the Community Development Program”.

Uniting Care’s submission urges the Government to “move beyond this prevailing top-down and paternalistic approach and commit to measures that genuinely empower communities and affirm their right to self-determination.” It also supports the call a Voice to Parliament and the Uluru Statement from the Heart.

AHHA’s submission also stresses the importance of an Aboriginal and Torres Strait Islander-led approach to improving the health outcomes of First Nations peoples. It proposes training Aboriginal and Torres Strait Islander people as health coaches to be employed in very remote communities, to support primary healthcare efforts.

The AHHA’s submission describes how this project would use locally recruited, trained and managed Aboriginal or Torres Strait Islander people as health coaches to intensify primary healthcare efforts in very remote communities, targeting the health needs of approximately 20,000 people. Their role would be to intensively support patient compliance with primary healthcare treatments/recommendations.

The Australian Medical Association (AMA) submission included a comprehensive section on Aboriginal and Torres Strait Islander health, which called on the Government to deliver two key initiatives:

1. Allocate Indigenous health funding in the 2019-20 budget based on the much higher health needs of Indigenous communities, recognising that chronic disease is inextricably connected to the social determinants of health; and
2. Implement the recommendations of the AMA’s recent Report Cards on Indigenous Health, in particular:
   • commit to achieving a minimum standard of 90 percent population access to fluoridated water;
   • systematically identify, cost and fund unimplemented parts of the national Aboriginal and Torres Strait Islander Health Plan 2013-2023;
   • implement a coordinated national response to address chronic otitis media in Indigenous communities;
   • fund and implement a strategy to eradicate rheumatic heart disease from Australia; and
   • appropriately fund services that divert Aboriginal and Torres Strait Islander people from prison.

The ANMF’s submission covers a broad range of Aboriginal and Torres Strait Islander health proposals, including:

1. Provide increased ongoing funding to CATSINaM
2. Establish a caucus of Aboriginal and Torres Strait Islander health organisations and representatives to provide regular and ongoing consultation on policies and activities that affect Aboriginal and Torres Strait Islander health and wellbeing.
3. Support the increase of the Aboriginal and Torres Strait Islander nursing and midwifery workforce to five percent of the total Australian nursing, midwifery, and assistant in nursing workforce across health and aged care.
4. Provide funding and support for the development, implementation, and evaluation of Birthing on Country programs in urban, regional, and remote locations.
5. Substantially increase funding to community-controlled, targeted, evidence-based strategies for Aboriginal and Torres Strait Islander healthcare across the life course.
6. Endorse and support the implementation and roll-out of nurse- and midwife-led models of care that address Aboriginal and Torres Strait Islander health concerns and challenges.
7. Support the inclusion of cultural safety training into the annual registration and continuing professional development requirements of all healthcare professionals.
8. Support the inclusion of measures of cultural safety with all health and aged care service providers into the National Safety and Quality Health Service Standards.
9. Expand the Closing the Gap initiative by adding additional targets linked to incarceration, community violence, disability, aged care, and children in out of home care.

Aged care

Aged care is in the political and media spotlight at the moment due to the tragic deaths of over 600 residents of aged care facilities from COVID19.

It is an area overdue for reform and one of the few sectors in which the Government will be looking to spend significant amounts of money in the Budget.

For these reasons, the proposals from stakeholder groups in Budget submissions this year are particularly important.

CHF’s proposal included three main measures to support the delivery of high quality and consumer centred aged care:

1. An increase in the supply of Home Care Packages to ensure the maximum wait time for a package is 60 days.
2. Improved medication management for older people by funding dedicated pharmacists in residential aged care facilities and community-directed medication management packages.
3. Changes to the MBS rebates to create better incentives for GP services provided to residential aged care facilities including the provision of after-hours care.

The ANMF’s submission included a strong focus on the nursing workforce and included the following specific proposals:

1. Introduce mandatory minimum staffing levels and skills mix in residential aged care in accordance with the ANMF’s evidence, i.e. a national average of 4.3 hours of care per resident per day with a skills mix of 30% RNs/20% ENs/50% carers.
2. Commit to full implementation of the above mandated staffing and skill mix model for residential aged care by 2025 (in accordance with the ANMF’s implementation plan.
3. Commit to implementing legislation requiring all RACFs to publish current staffing levels and ongoing up to date information regarding staffing levels and skills mix.
4. Determine and fund (as required) staged staffing increases required in RACFs commencing 1 July 2020.
5. Support the regulation of unregulated aged care workforce staff to ensure adherence to minimum education and training standards and ongoing adherence to safety and quality standards.
6. Fund 10-15% wage increases for all aged care workers to assist with recruitment and retention of quality workers.
7. Establish an appropriate education and training framework to support the development of skills and workforce numbers needed to achieve minimum staffing requirements, in collaboration with the Aged Services Industry Reference Committee.
8. Provide funding to educate nurses on their clinical leadership role in RACFs and home-based care and train carers in the assessment and management of the deteriorating resident.
9. Provide better funding support and incentives for specialist health professional in reach services to be delivered on-site at RACFs, including incentives for GPs to attend those facilities.
10. Fund further home care packages, in particular Level 3 and 4 packages, to significantly reduce the increasing waiting list, while ensuring the allocation of available home care packages are appropriately triaged through clinical assessment by suitably qualified clinical professionals.

Many of these proposals were also supported by the AHHA, which called for extra funding for home care packages, a phase out of supply caps and an investment in increased workforce capacity within the sector.

The AHHA also proposed investing in data development to measure and monitor unmet need and equity of access to aged care services and improving care and accommodation options for younger people with complex care needs, including those in residential aged care and via appropriate support through the NDIS.

The AMA’s submission included support for an increase in registered nurses and also called for increased funding for medical and allied health services in aged care facilities. Specifically it called on the Government to:

• stop the abuse and neglect of older people through enhanced quality and safety by increasing overall investment in aged care;
• introduce mandatory minimum staff to resident ratios that reflect the level of care needs and ensures 24-hour, on-site, availability of registered nurses;
• prevent older people from prematurely entering RACFs and hospitals by increasing the number of home care packages to reduce waiting times;
• significantly increase Medicare rebates by at least 50 per cent for services in RACFs to adequately cover the time that doctors spend with the patient assessing and diagnosing their condition and providing medical care;
• take responsibility to ensure quality of, and timely access to, specialist support and allied health in all aged care settings. This includes palliative care, mental health care, physiotherapy, audiometry, dentistry, optometry, and occupational therapy;
• provide better funding support for services being delivered on site (such as mobile radiology services), which can save on costly hospital transfers; and
• introduce new telehealth Medicare items that compensate GPs, and other medical specialists, for the time spent organising and coordinating services for the patient, and the time that they spend with the patient’s family and carers to plan and manage the patient’s care and treatment.

Boost prevention

Prevention was a theme of most submissions, which highlighted the low levels of spending on prevention in Australia, compared with most other OECD countries.

CHF’s submission focussed on two key areas: obesity and the National Preventive Health Strategy.

It called on the Government to fund and take a leadership role to implement the actions outlined in the National Obesity Strategy currently in development, including introducing a price mechanism to reduce consumption of sugar-sweetened beverages and high sugar snacks.

CHF proposed including actions and funding to address the social determinants of health in the National Preventive Health Strategy, including specific measures to mitigate and address the health impacts of climate change.

The Public Health Association of Australia (PHAA) argued for a greater investment in prevention on the basis that on average Australians live for around 13.2% of their lives in ill health, one of the largest ratios of any OECD nation, exceeded only by people in Turkey and the United States. The PHAA’s submission argued that despite this poor outcome, at present public investment mechanisms fail to take up opportunities that are already available to make investments in health and wellbeing.

PHAA called for:

a clear, strong and national commitment to investing in illness prevention and wellbeing, implemented through the creation of an ongoing mechanism by which the Government can assess proposed illness prevention programs, and followed up by means of an automatic system for ensuring that the best programs are quickly and consistently assessed and where appropriate, funded.”

PHAA proposed a three-pronged new ‘mechanism’ to ensure that governments are making an efficient and effective investments in illness prevention, at a scale sufficient to make a major impact on economic vitality, and significantly ease long-term pressures on government budgets.

These three prongs are:

1. Balance – Setting a serious national target for a balance of illness prevention investment against illness treatment expenditure, with that balance being five percent prevention to 95 percent treatment in national public expenditure.
2. Assessment – Establishing an institutional mechanism for independent, expert-led, evidence-based assessment of the efficacy and efficiency of public health investment programs.
3. Delivering – Combining the above two elements into a system where funding for the delivery of assessed and approved public health programs flows quickly and effectively to providers in response to need.

The AMA also called on the Government to increase spending on prevention to five percent of total health expenditure and for this spending to be accompanied by mechanisms to ensure funding is allocated appropriately to ensure multi-generational benefits. This  and increased investment in health prevention must be consistently resourced, implemented, and independently evaluated and reported on.

The ANMF also supported an increase in spending on prevention to five percent of total health expenditure. It also called for the Government to:

1. Re-establish a national dedicated preventive health body.
2. Increase incentives to encourage changes in both health provider behaviour and individual behaviour, which will lead to better health outcomes.
3. Establish preventive primary care systems that encourage people to enrol in wellness maintenance programs as is now occurring widely throughout the world.
4. Ensure that primary health networks focus on disease prevention, health promotion, equity and social determinants of health.
5. Investigate better and more efficient ways to fund and manage chronic conditions
6. Establish funding arrangements which support the use of a wider range of health professionals in chronic and complex care in preventive and primary care including NPs.
7. Ensure that private health insurance companies are restricted from operating in primary care.

The AHHA had a more modest target for preventive health funding, of 2.3 percent of recurrent expenditure on health.

It suggested this spending be focused on implementing the National Preventive Health Strategy, including though:

• Addressing risk factors and determinants including overweight and obesity, alcohol misuse and abuse, tobacco consumption, inequality and immunisation; and associated data development.
• Supporting Primary Health Networks and Local Hospital Networks to develop shared regional needs assessments, priority setting and funding for regionally targeted preventive health initiatives that respond to local community needs.
• Investing in evidenced-based strategies to discourage the consumption of sugar-sweetened beverages, including introduction of a 20% ad valorem sugar-sweetened beverages tax, with revenue hypothecated for preventive health measures.
• Implementing a five-year transition period to shift from voluntary to mandatory implementation of the Health Star Food Rating System.

Rural health and wellbeing

The National Rural Health Alliance (NRHA) made two proposals targeting rural, regional and remote Australian communities.

The first proposal is to create six place-based health and wellbeing networks (PBHNs) to test the efficacy of alternative funding and service delivery approaches to address under-servicing of health, aged care and disability services in rural and remote communities.

The aim of the PBHNs is to help people in rural Australia attain a fairer and more equitable standard of health and wellbeing – one that is more consistent with that of people in the major cities.

The second proposal is a package aimed at integrating national digital health strategies and increasing the uptake of digital health initiatives, digital health literacy and connectivity, to increase digital inclusion, awareness and participation in digital health solutions for health consumers and health practitioners.

Overall the package provides a blueprint for rural digital health, to complement and consolidate existing national digital health strategies, including COAG’s National Digital Health Strategy and the Australian Digital Health Agency’s National Digital Health Workforce and Education Roadmap.

The AMA’s submission includes a number of measures to support the rural medical workforce, including increasing the targeted intake of students from a rural background into medical schools to 25 percent, expanding the Specialist Training  Program with priority given to training places in regional areas, and funding for additional rural GP infrastructure grants.

The AMA also called for an expansion of telehealth MBS Items to regional areas and funding for a dedicated rural medical research stream through the NHMRC or Medical Research Future Fund.

The ANMF’s submission focuses on supporting the role of nurses and midwives in rural areas and calls on the Government to:

1. Fund designated salaried positions for NPs in small rural and remote communities.
2. Provide scholarships for RNs in rural and remote locations to undertake postgraduate midwifery education.
3. Remove the restriction on rural and remote scholarship applicants by allowing access for those employed by State/Territory governments.
4. Require the Health Workforce Agencies to establish a national advisory committee, which includes nursing and midwifery professional organisation representatives, to provide oversight for the Health Workforce Scholarship Program.
5. Ensure health workforce scholarship data is collected by the Health Workforce Agencies and made publicly available by the Australian Government.
6. Support the establishment of an Australian Rural Health and Medical Research Network.