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Health reform: it’s incremental and a work-in-progress

This post continues a series of reflections on health reform, marking the recent two-year anniversary of the release of the National Health and Hospitals Reform Commission’s final report, A healthier future for all Australians.

In previous posts in the series:

Philip Davies suggested we’d been having “cappuccino-style” health reform – an approach focused on the milky froth of health sector institutions while leaving the underlying, thick, rich espresso of health care delivery largely untouched.

Bob Wells and others looked at the missed opportunities of the reform process to date.

(The comments below – which largely emphasise the incremental nature of progress – were written before yesterday’s release of the latest COAG health reform agreement).

***

Primary health care needs more work

Professor Mark Harris, Executive Director Centre for Primary Health Care and Equity, UNSW

To continue the Philip Davies coffee analogy, and quite apart from the failure to integrate primary and hospital care, there is only half a shot of coffee in the primary health care cup.

This arises from the failure of the COAG to come up with a way of bringing Commonwealth and state funded primary health care services together with integrated funding and accountability.

There is a lot of hope and expectation put on the newly establishing Medicare Locals to address many of the key problems.

However, the lack of integration with state funded community health services is a real handicap to needs based local health service planning and development.

This has two serious risks.  One is that state community health services will become even more oriented towards post acute care and less focused on preventive care.

The other is that cost shifting will occur between local health networks/districts and Medicare locals with allied health services simply being shifted from one to the other with little net improvement in access and equity or quality of care.  This could also tend to undermine the development of trust and partnership between the two local organisations.

At the current impasse, it is the development of fledgling partnerships at the local level between primary health care and the local community and hospital system which hold out most promise for at least some incremental improvement.

***

Missed opportunities

Professor John Wakerman, Director of the Centre for Remote Health in Alice Springs, a joint Centre of Flinders University & Charles Darwin University

Two years down the track, I have a strong sense of missed opportunity with respect to health care reform in Australia.

The one consistent theme of the NHHRC’s extensive consultations was the desire to have one health system; or in Mr Rudd’s words, Australians expressed the desire ‘to end the blame game’, to ensure clear governmental accountability within the health system.

Whilst a number of very positive initiatives did result, this fundamental reform did not. We have replaced one complex system with another complex system. And we feel this most acutely in more remote areas.

Continuity of care for our patients will continue to be bedevilled by split Commonwealth/ State responsibilities for primary care (at least most of it) and hospitals. This is entrenched in the Local Health Network (LHN) and Medicare Local (ML) structures.

In the NT, for example, there are two LHNs and one ML. You’d think we could get those numbers right.

From my conversations with protagonists in at least a couple of states, hospitals will still be very much the creatures of state health authorities, with LHNs playing variable roles in terms of governance. The rapid development of MLs is less than clear and is fraught with risk.

Even a modest initiative such as bundled payments & voluntary enrolment for diabetes care has been pushed back into pilot territory by entrenched interests. Some of our ideas about regionalized, integrated primary & secondary care services in rural and remote areas, grounded in natural geographical regions, characterised by strong community input and equitable funding haven’t seen the light of day. The relatively poor health outcomes and inadequate access in non-metropolitan Australia and for Indigenous populations have not been well enough served by these reforms.

But there have been some very positive developments.

For the first time, we have a National Primary Health Care Policy, which may guide a much-needed emphasis on primary care and wean us off our hospitalisation habit.

We have a National Preventive Health Agency, which can at least provide a greater focus on upstream determinants.

And there is promise of improved monitoring though the National Health Performance Authority.

This government has also had a strong policy focus on physical infrastructure development – including GP Super clinics – and this has been welcome, especially in rural and remote areas.

I take comfort that we have a health system with features such as universal health insurance and the PBS that gives us some of the best health outcomes at a reasonable cost globally.

It’s back to incremental reform for another generation or so.

***

Let’s make the most of what we have

Professor Stephen Leeder, professor of public health and community medicine at the University of Sydney, Director of the Menzies Centre for Health Policy. and chair of the Western Sydney Local Health District Board

I meet many colleagues who are fed up with health reform. It feels to them as though they are extras in an unending reality TV show – DisasterChef as one quipped.

But change is in the air and it offers hope!

To take New South Wales as an example, its publicly-funded health system comprising 220 hospitals and 500community health centres, ambulance service and care given to special groups including prisoners and asylum seekers, has been reorganised with truly amazing speed.

For six years the hospital and community health services in NSW functioned as eight large entities. In late 2004, 17 smaller health areas were rolled into the larger areas that existed until March this year.  The pre-2004 smaller areas had boards overseeing them and connection through them to local communities of interest, including clinicians.  Their role in management was ambiguous because they were not governing corporate entities.

The post-2004 larger areas were established to cut down on the costs of managing multiple small areas, to enable clinical services to be more effectively networked, extending access to specialised services to communities that previously were underserved, and increasing the power of director-general, department and minister to manage the system. Several areas had been managerial nightmares and bad things had happened. Take the power back to the centre was the credo.

But the huge size of several of the post-2004 areas meant that the chief executive had a parish too large to manage effectively and for familiarity to be established between management and clinicians especially, and indeed with the communities that were to be served, characteristic of smaller areas, to ease tensions.

In NSW, there is now convergence among the Roxon-Rudd federal health reforms, the Tebbutt-Kenneally changes and now the Skinner-O’Farrell legislation in relation to size of managerial units for the publicly funded health and hospital services.  We have returned to the smaller health areas.

We have boards again, possibly with more autonomy and accountability than that pre-2004, and we await the effects of other federal changes.

There is hope that with greater public investment in primary care, partly managed through the formation of locality-specific organisations that bring general practice and community services together in Medicare Locals, better services will be offered to the community beyond the hospitals and greater harmony in care achieved between primary care and hospital/community health services.

The big challenges in health care today are two: first, we must come to terms with unsustainable cost rises due to new technology, population ageing and rising community expectations.  We need to be smarter, better informed and disciplined in the way we use resources.

Second, boring and uninteresting though it may be, the management of patients with multiple chronic problems is our core business for the foreseeable future.  The two challenges converge as we seek better quality ways of assisting people to cope with these long-term health problems.  Prevention in all its forms, beginning in the community and concluding in optimal palliative care, has much to offer.

The new arrangements open pragmatic possibilities for better deals for patients, communities, clinicians and managers. It is up to us to take advantage of better structure with improved function.

***

Maximising the possibilities of incremental reform

Associate Professor Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity

What we have seen for primary health care is really an incremental step – larger than usual, but still incremental – in the role and function of Divisions.

To go beyond this would have required bolder reform: a single funder for health care, bringing the government’s investment public and private health care into a single frame, a thorough examination of the health care that people needed, rather than the health care organisation that might support this, giving organisations a clear mandate and the power to carry it out. That appears to have been too difficult a call.

This incremental step is assisted by widening the scope of Medicare Locals to include private allied health and some non-government organisations, and by building on organisations that have experience in this rather limited version of primary health care development. It is hampered by the compromises made along the way.

These leave Medicare Locals with an unclear role, limited power, and a very complex environment in which to operate.

Perhaps the important thing at this stage is to recognise what is happening for what it is, and not to pretend it is anything more.

This may be difficult for some of us who have been heavily invested in the reforms, but might leave us freer to take the good things, accept the bad and above all not imagine that we tried health system reform and it didn’t work.

It may also free local health care leaders from the weight of unrealistic expectations and give them the opportunity to do what they can with the opportunities they have.

***

Bowel cancer screening still missing in health reform agenda

Professor Ian Olver, CEO of Cancer Council Australia and a medical oncologist

In the two years since the National Health and Hospital Reform Commission’s recommendations were published, the Australian Government has introduced some groundbreaking initiatives in cancer control.

Allocating $560 million towards regional cancer centres, increasing excise and introducing plain packaging for tobacco products, earmarking $870 million for prevention partnerships with the jurisdictions – for these and other measures, Nicola Roxon should be commended.

But when it comes to “structural reform”, lack of progress in bowel cancer screening remains a disappointment.

To understand why, we should reflect on the original principles of the then new Labor Government’s health reform agenda when the National Health and Hospital Reform Commission was set up in 2008.

Key drivers were “ending the blame game”, responding to demographic change, reducing cost-shifting, cutting hospital expenditure by investing in prevention and early detection, re-invigorating primary care, centralising care standards and putting long-term population health interests before short-term politics.

A full bowel cancer screening program ticks all these boxes like nothing else in cancer control.

Australia’s annual bowel cancer bill is estimated at around $1 billion – most of it in hospital and pharmaceutical costs. A full screening program – which would cost around $150 million a year (the current, restricted version is costing $35m pa) – would cut hospital costs by picking up early-stage cancers and precancerous conditions when they are easier to treat. (The program is already detecting twice the rate of early-stage cancers as are diagnosed through symptomatic presentation.)

So why, three years after 50-year-olds joined 55- and 65-year-olds as targets for one-off testing with a faecal occult blood test, are we still waiting for the program to be expanded and to re-screen participants? (Everyone 50 and over should be screened every two years.)

If the answers are 1) it’s too costly in the short-term, despite the program’s long-term cost-effectiveness and 2) the savings are enjoyed by the states and territories, rather than the Commonwealth, then the question must be asked – weren’t these precisely the sorts of problems a restructured health system was meant to fix?

Structural reform can only translate to improved population health and system sustainability when applied to actual programs.

An expanded National Bowel Cancer Screening Program is an ideal vehicle for converting rhetoric into practice.

But Government has to back its intent with investment.

Perhaps next year’s federal budget?

***

On Tasmanian (and wider) matters

Geoff Couser Associate Professor of Emergency, University of Tasmania

The recent Tasmanian budget has confirmed the old saying that when the tide goes out you get to see who’s been swimming naked.

Yes, Tasmania is deeply in the red and serious budgetary cuts need to be made. The DHHS budget, rising at a rate faster than CPI just like all other health budgets around the country, is targeted for significant spending cuts.

There has been much outrage from the community and interest groups about such proposed changes, yet to date the government has shown little sign that it has the capacity to implement the necessary changes.

The state opposition has been calling for maintenance of full services and no job losses in the public sector despite there being no money in the bank.

This is on a background of a federal government floundering on what appears to be ill-defined health “reform” but really achieving very little true reform.

This is also occurring where state and federal politicians perennially promote the concept that the health outcomes of the community are related to large tangible projects, such as the redevelopment of the Royal Hobart Hospital.

As someone who works in the health sector I’m going to put my neck out and welcome these cuts in spending.

Additionally, having recently experienced a political campaign from the inside, I feel I can confidently say that no-one in politics really understands health.

We need to seriously examine the way healthcare is delivered in Tasmania and we need to support our political leaders to implement the necessary changes. I’d like to initiate this sort of conversation.

A bit of a background first – health inflation has been well documented to be in excess of 6% per year. With a CPI of less than 3% this is clearly unsustainable growth.

Total health spending is probably in excess of $130 billion dollars per year. Our health system is geared towards acute conditions, being reactive and healing illness – when it should be re-gearing itself towards dealing with chronic conditions, being proactive and maintaining wellness.

Whilst this might sound like a glib big picture statement, the future health needs of our community are indeed confronting: the massive projected increases in the incidence of diabetes and other chronic conditions and the well documented challenges coming in aged care are just two issues which will demand that our health system re-gears itself towards prevention and primary care.

The increases in costs are unsustainable and at this point in time our massive spending does not seem to correlate with improved health outcomes of our community. These are not new ideas nor are they controversial.

Put simply, the health system is a bubble and it’s set to burst in the next few years regardless of where you live and your insurance status.

And a warning: those of you who have “private health insurance” and think you’re immune from this think again – over 50% of your care is funded by public money, either through Medicare rebates or the private health insurance rebate.

Hence the community does have a say in how those dollars are being spent.

Very few people can actually afford true private health care, where the entire cost of healthcare is met by the patient.

So, when you have an operation in a private hospital think of it as being the federal public system. The feds can’t keep paying for this forever either because the costs will ultimately catch up. I think they’re short of cash too at the moment.

So what’s the answer?

We need to have a good long hard look at ourselves and realise that health is not just provided by the health department – social, environmental and economic factors play a dominant role.

We need to have a conversation about what we’re prepared to pay for and what we’re not. We need to look at the whole health system and ensure that it is providing health outcomes acceptable to our community as whole.

Pockets of public spending that contribute little or nothing to the overall health of the community need to be identified and stopped.

Bear in mind that this applies across the entire health system and principles of equity need to be considered. However, with rights come responsibilities, and the transition to a whole-of-community-focussed and patient-centred system could be hard for some.

We can actually learn from business as how best to run an efficient organisation: this may sound harsh, but when US companies were hit by the GFC in 2008-9 they laid off many staff.

With the initial shock over they didn’t re-hire. Why? They were forced to be more efficient, lift productivity, and trim their structures. They then realised that they were able to provide a similar or even better service with less.

In the short term our health system needs to do the same while it re-positions itself for the long term. When times are tough, whether you’re a family, a public institution or a private company, it’s essential to examine spending and decide what’s essential and what’s not. It’s a matter of bankruptcy or survive.

But such change seems impossible in such a huge system.

I seriously doubt whether our politicians or health bureaucrats are able to do this – I believe they lack both the political courage and the capacity for genuine innovation to proceed in the re-tooling of the major consumer of public monies in this state.

I’m not saying this in a bad or critical way – it’s just not what they’re trained or able to do within the constraints of such an enormous entrenched system.

To her credit, Lara Giddings raised this issue when she was health minister and attempted to initiate change but a laudable plan lacked follow through.

I wonder if our health system needs an external body or administrator to come in, work out what we need as a community based on evidence, and then enact the changes to ensure that the community is indeed getting an acceptable return for what it’s paying a rather high and ultimately unaffordable price.

Real patient-centred care demands no less.

Some examples as to where attitudes and practices must change include:

the provision of high cost medical services for little ultimate benefit

a shift to broad-based preventive health and primary care

workforce reform, cost containment (for example, a federal approach to awards would circumvent the current practice of each state out-bidding each other for scarce staff and driving costs forever upwards)

and, ultimately, each of us taking direct responsibility for our health.

Unfortunately the best time to plan for the future is when there’s money in the bank, not when you’re breaking up the furniture to keep the fire going.

But Tasmania now has the opportunity to reconfigure its health system and take the lead in preparing for a true 21st century health system that is evidence-based and will provide for our community in a sustainable way. The current budgetary situation is the ideal catalyst for such change. We all have a responsibility to make it happen.

• This article was first published in the Hobart Mercury

Disclosure: A/Prof Geoff Couser is Associate Professor of Emergency Medicine at UTAS and a staff specialist in emergency medicine and retrieval medicine at the Royal Hobart Hospital. He was the Greens candidate for Denison in the 2010 federal election where he tried to talk about this to no avail. These views are his alone and do not reflect any institutional or political policy.

***

Engage the consumers

Sally Crossing AM, Co-Chair, Health Consumers NSW and Chair, Cancer Voices NSW

An area gently passed over in the NHHRC was meaningful health consumer engagement.

The report and nearly “everyone” think it’s a good idea, but few put their minds, or their money, as to best practice advice and assistance.

Patient focus is all the go, but only on clinicians and bureaucrats terms again?

Here in NSW, under the banner of the new Health Consumers NSW, and in partnership with the national peak, Consumers Health Forum of Australia, we are having a go at addressing this through the new structures.

Wish us luck!

****

Meanwhile, the Australian Institute of Health and Welfare has today released a report on dental decay in Australian children, which found that young children from the lowest socioeconomic areas have about 70 per cent more dental decay than children from the highest socioeconomic areas.

It’s one of many reminders that health reform is very much an unfinished business.

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