Health reform: is it a disappointment or should we be grateful for any crumbs?

On June 7, the head of the Department of Health and Ageing, Jane Halton, and her colleagues Rosemary Huxtable and Graeme Head were grilled by the Senate Finance and Public Administration Committee as part of its inquiry (recently published here) into COAG health and hospital reforms.

The transcript (available here) is quite illuminating (although obviously some comments have been outdated by subsequent events, such as the axing of plans for a National Funding Authority) and also entertaining at times, with more than a few dry asides.

We learn, for example, that the Federal Budget papers were wrong to say there would be 150 local hospital networks. “That should have said ‘up to 150’. This is not a document that health produces,” Halton told the committee.

We also learn that DOHA expects private hospitals will be part of the local hospital networks if they are providing public services, and that some wits have nicknamed Medicare Locals as “mellows”.

Halton strenuously rejected an Opposition Senator’s suggestion that the reforms were not significant because the power of the states over hospitals was unchanged. She said: “The bottom line is that this is a fundamental change to how these services are operated. Everything from the creation of the local governing councils, the funding on an ABF (activity based funding or casemix) basis, the greater level of transparency, the greater focus on performance, emergency services targets and elective surgery targets; these are all fundamental differences in the way this system will work.”

The Committee’s report found that the Government’s hospital plan was “hurriedly put together” between 5 February and 3 March, with the Department of Finance and Deregulation conceding that it only started the formal costing process for the plan on 17 February 2010.

The report is overtly partisan, as you’d expect from an Opposition-dominated committee. This is annoying as it seems such a wasted opportunity for a rigorous, independent investigation of the reforms, and tends to undermine some of the legitimate concerns and questions raised. As well, many individuals and organisations put considerable time into making submissions and it would have been nice for these to have been put to more constructive use.

But, as to the report’s diagnosis of the Government’s claims of “historic” health reform as a bad case of overblown rhetoric, here Croakey must admit to feeling quite confused.

Some days, I have a fire-in-my belly anger that it has all been a terrible, missed opportunity that is unlikely to bring a real return to the nation’s health for the large investment of time, resources, and energy. It seems unlikely to correct the power and funding imbalances that contribute to inequities in access and outcomes.

Or, as one Australian Health Care Reform Alliance representative told the Senate committee inquiry: “The reform package and associated dollars focus very heavily—almost disproportionately—on hospitals at the expense of some other areas, especially primary health care and the social determinants of health, as we noted earlier. Consumer involvement in the reform package is minimal. We believe there is some token gesture of consumer involvement in the governance and operational details of the local hospital networks and the primary healthcare organisations. There was no recognition of the importance of health literacy and the need to build active partnerships with the consumers of healthcare services. Consumers are still viewed as patients receiving passively health care from providers who hold the knowledge and therefore the power to dispense their services.”

As well, there seems to be no big-picture vision of the overall objective: is it a healthier population, a fairer, better health system, or simply a more efficient mechanism for funding hospitals and enabling local governance of health services?

And there seems little acknowledgement of the need to transform our public conversation about health, to acknowledge that we can’t afford everything (and nor should we want to, given that quite a lot of what is on the market is ineffective, inefficient or even harmful) and that we need more explicit, values-driven and transparent decision-making around resource allocation that engages the broader community.

On those days when I am lamenting how little real progress has been made in the past few years, I wonder whether the mammoth effort involved in the proposed changes to structures and governance will do anything to change professional and institutional cultures.

I look with envy to this new document from a UK charity, the 2020 Public Services Trust, Improving Health Outcomes – a guide for action, which takes a big-picture, visionary approach, suggesting social solutions for health and care problems, and a need to shift the power “from the centre to citizens”.

It says: “Smarter, more democratic and citizen-driven commissioning is the best way to give people the means to build care around their own and their community’s needs”. Health and social care systems should be seen as a set of shared values, and not as a set of buildings or institutions. “The starting point,” it says, “should always be: what does the problem look like to the patient or citizen?”

It says that future primary health and care interventions should be delivered at home, and in more local community hubs (such as social clubs or pharmacies), facilitated by remote connectivity with primary health providers.

The hurdles to this vision, according to the document, include transient political leadership, over-centralisation, media culture, layers of mistrust between clinicians, managers & politicians, strong professional interest as a barrier to change, the lack of power within the social care workforce, and lack of awareness over the costs of care.

It is exactly these sort of issues – the immense barriers that health reform faces – that on some days has me rethinking my cynicism about the current reform agenda. On these days, I think perhaps we should be grateful for every weensy bit of progress that is made.

There are, after all, so many hurdles. Here are just a few of those that I’ve heard discussed around the traps recently (including at an off-the-record roundtable on health reform convened last month by the Institute of Public Administration Australia).

• Media
There have been a number of pertinent comments recently about how the nature of 24/7 media coverage and its susceptibility to the influence of powerful lobbies mitigates against real reform. Journalism academic Professor Matthew Ricketson gave a lecture last week (you can download it here) that spoke of journalists and governmental PR being locked in a “crocodile’s death-roll”, and Miriam Lyons wrote about related issues in the Sydney Morning Herald on the weekend. These issues are, of course, not peculiar to health reform but perhaps they are more acute in this area because of the power differentials (doctors and professors wield more clout in the headlines), the lack of transparency and complexities.

• It’s the culture, stupid
Many argue that real change comes from cultural rather than structural change. It is possible, as some researchers have noted, to get “reform without change”, and “change without reform.”  We haven’t spent much time talking about how to achieve the latter. Or how to address cultural and communication barriers to avoid the former.

• Implementation challenges
These are huge. There are so many uncertainties, and so much room for good intentions to go horribly astray in the implementation – and also for some on-the-ground corrections to policy gaps and errors. As Halton told the Senate committee: “There is no point in designing the micro features of these things in an ivory tower in Canberra because it does not work. You have to make sure that the people who will give this life, who will drive it and run it, are part of the implementation and roll-out.” There are also many questions about the reforms, not least being what will the overall impact of the new hospital funding arrangements will be on health costs? Are they about to blow out? The national implementation of casemix funding for hospitals – described by some as “the least worst option” – will certainly hit some bumps. Some experts have called for a more open discussion of the potential pitfalls of casemix funding (including around the likelihood of “casemix gaming”)  to help reduce the severity and frequency of these bumps.

• Capacity
It is widely acknowledged that the Commonwealth’s central agencies lack the capacity necessary to drive the reform process and that DOHA, for example, will need to develop new expertise and new ways of working. But it’s not only the capacity of health departments that will come into play, but also of local health services, health practitioners and communities. Do allied health professionals and nurses, for example, have the skills and support to play an effective role in the governance of new primary health care organisations? And what about the local communities themselves?

• Innovation roadblocks
This blog on 56 reasons why most corporate innovation initiatives fail seems uncannily relevant to the health reform agenda. We’ve heard little about how such barriers will be addressed, although perhaps Graeme Head’s transition office is addressing some of these. If so, wouldn’t it be nice if we could all be in on the conversation? Where is his blog discussing these challenges, and crowdsourcing ways around them?

• Cynicism rules
Related to the above suggestion for a more genuine engagement and multilateral communication process is the widespread level of cynicism about reform, not only amongst clinicians, but also amongst service managers, and bureaucracies. National health reform comes on top of an unending cycle of restructuring and reform within the various jurisdictions, and a deep seated mistrust between federal and state health departments, and also between health administrators and head office in each jurisdiction. There is not a lot of good will for reformers to draw upon.

• Governance questions
If health ministers can still ask for hospital network ceos or Medicare Local ceos to be sacked, or determine the makeup of these organisations’ governing boards, then will anything really change? If decision makers, even those who live and work locally, are still unable to talk to their local media and local community, will anything really change? Geoff Simmon’s recent post about New Zealand’s experience with elected hospital boards suggested that local governance in itself does not cure problems of policy and resource allocation being driven by the squeaky wheel, rather than the population’s needs. How will these issues be addressed?

Of course, all of these issues may be rendered redundant if the outcome of the forthcoming election is to wipe health reform off the political agenda. The Opposition leader, Tony Abbott, was not famous as a reformer during his time in the portfolio, and we are still waiting for a sense of Prime Minister Gillard’s priorities in health.

But if the national health reform agenda survives, then I reckon Jane Halton’s prediction that the “work program will extend over several years” is grossly optimistic. The job could go on forever…

Update, 7 July. In one of those timely coincidences, DOHA has just released an implementation road map. You can also sign up to receive email updates of how well the reform journey follows the map.