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adverse events
aged care
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chronic diseases
co-payments
Cochrane Collaboration
complementary medicines
conflicts of interest
death and dying
diabetes
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disabilities
e-health
emergency departments and care
Equally Well
euthanasia
evidence-based issues
general practice
genetics
health & medical marketing
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health ethics
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hospitals
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international medical graduates
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medical marijuana
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men's health
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MyHospitals website
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non communicable diseases
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organ transplants
out of pocket costs
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palliative care
paramedics
pathology
Pharmaceutical Benefits Scheme
pharmaceutical industry
pharmacy
Pregnancy and childbirth
primary health care
Primary Health Networks
private health insurance
quality and safety of health care
rural and remote health
screening
sexual health
social media and healthcare
suicide
surgery
swine flu
telehealth
tests
TGA
trauma
women's health
youth health
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#CTG10
#NTRC
Acknowledgement
cultural safety
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social and emotional wellbeing
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consumer health matters
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HealthElection16 checkup part1: what can we learn from a ‘health history’ of the Abbott/Turnbull government

The Prime MInister at Sydney Children's Hospital
The Prime MInister at Sydney Children’s Hospital

The focus on health in the lead up to the 2 July federal election has become bogged down in the politics of whether or not Labor is running an unwarranted scare campaign on Medicare privatisation, and whether or not the Coalition can be trusted this time around to keep its promises on health.

None of this of course is helped by the Coalition’s failure to agree to a head to head debate between Health Minister Sussan Ley and her Opposition counterpart Catherine King.

With little light emerging, Croakey has asked a range of health experts across a number of fields to see if, like a clinical consultation, taking a detailed “health history” of the Abbott/Turnbull Government’s performance may be more useful for predicting the Coalition’s future performance in health than relying upon its election promises alone.

In a separate post, they also conduct a “screening” test to see how healthy Labor and the Greens look by comparison.

As Dr Lesley Russell said in her responses:

At their best, election platforms and policies are aspirational – their translation from fine words on paper to development, funding and implementation is a long journey that requires leadership and commitment. At their worst, they focus on high profile issues like medical research and electoral pork-barrelling like hospital handouts. This election is a tipping point. Will the next government perpetuate the further erosion of public healthcare services and the retention of a very medicalised focus on hospitals, doctors and prescriptions? Will we get tinkering at the margins of reform? Will a change in government bring more upheavals in the health sector?

What is needed is a focus on national health and wellbeing as well as on healthcare services and a government brave enough to see this as an investment in equity, productivity and prosperity.

We thank the many individuals and organisations who have taken the time to contribute to this #HealthElection16 check-up on the major parties.

See also this post which is compiling scorecards on public health related policies ahead of the election.

Q1: How would you rate the Coalition Government’s performance to date in health care and the wider determinants of health?

Alex WodakDr Alex Wodak, Emeritus Consultant, Alcohol and Drug Service, St Vincent’s Hospital; President, Australian Drug Law Reform Foundation

I’m trying to be as fair as I can but I find it hard to identify positives for the Coalition Government in health and very easy to rattle off many examples of serious vandalism plus a lot of major concerns for their future policies. We know that the polls show that the community judges the Coalition Government the same way. I am mindful that the Rudd/Gillard/Rudd performance wasn’t brilliant in health but there were some major advances (eg plain packaging).

I can’t remember a new government stumble in Heath as badly as Senator Fiona Nash defunding the Alcohol and other Drugs Council of Australia (ADCA), siding with the food industry against public health, trashing the arrangements that Labor had made to reduce the impact of chronic disease, protecting her advisor who turned out to be associated with  the lobbies. The increasing inequality (which had been growing under Coalition and ALP governments for many decades), plus the health impact of climate change denialism, the continuing failure to significantly improve health outcomes for Indigenous Australians, the failure to act on alcohol and drug policy and obesity policy. How much worse can it get? Given the record of previous Coalition Governments,  I don’t see Labor’s Medicare stand as a scare campaign. Kicking the can down the road on same sex marriage while wasting $160 million on a plebiscite? Disgraceful and for so many reasons.

Alison Verhoeven, Chief Executive, Australian Healthcare & Hospitals Association

The Coalition’s performance in health has been mixed, with some policies that are very innovative and show positive promise for the future, and others which have challenged affordable health care and public-funded services.

Some of the policies the Coalition will take into the July 2 election will continue to exacerbate issues of access, equity and sustainability. While the Turnbull Government has made some amends for the damaging cuts to health funding in the 2014–15 Budget, including some restoration of growth funding to public hospitals, funding uncertainty continues beyond 2020.

At the heart of the matter is the level of Coalition commitment to bipartisan, multilateral partnership with the states and territories to achieve agreement on hospital funding beyond 2020. Commonwealth leadership on health funding reform is critical because all Australians depend on a well‑resourced public health system, particularly if they require emergency or complex care, and if they are unable to afford private care.

The challenges to Medicare over the past three years, including some which have been reversed such as co-payments, and others such as the general practice rebate freeze and removal of bulkbilling incentives for pathology and diagnostic imaging, have shaken public confidence in Coalition support for Medicare. However, recent proposals for new models of primary care through the Health Care Home trials and the Turnbull Government’s anticipated responses to the multiple review processes across the health sector have the potential to drive positive change if implemented in a coordinated and collaborative manner.

Julie LeaskJulie Leask, Associate Public Health Professor, University of Sydney; visiting Senior Research Fellow at the National Centre for Immunisation Research & Surveillance

In immunisation, three carrots and one big stick:

The carrots: expanding the Australian Childhood Immunisation Register into the whole of life, which is great for helping adults and their providers keep track of their own vaccinations. Paying doctors $6 each time they catch-up children overdue for their vaccinations. Expanding their communications to address vaccine hesitancy. (Disclaimer: I have received funding from the Department of Health for research to inform this area of activity.)

The stick: The No Jab No Pay policy – an expansion of the existing rules linking vaccination to family assistance payments and the removal of an exemption for parents who didn’t fully vaccinated their children due to objection.

Dr Megan Williams, Senior Research Fellow, Centre for Health Research, University of Western Sydney

Good to see the National Aboriginal and Torres Strait Islander Health Plan but lacks an implementation plan or evaluation strategies.

Poor progress meeting Close the Gap targets.

Backwards steps in funding arrangements.

lesleyDr Lesley Russell, Adjunct Associate Professor at the Menzies Centre for Health Policy, University of Sydney. 

Healthcare issues are always at the top of voters’ minds during election campaigns and never more so than when there is a perceived threat to Medicare. In the lead-up to this year’s federal election, the actions of the Abbott/Turnbull Government once again indicated a lack of conservative commitment to the universality of Medicare. This was most obviously expressed in budget measures that would increase the already substantial out-of-pocket costs for patients  and cut public hospital funding; less obviously, via Cabinet documents, the work of the National Commission of Audit, the Harper Competition Review, and the Productivity Commission review of public services, there was a push to privatise the operations of Medicare and the PBS, expand roles for private health insurance, and increase competition and contestability (code for privatisation) in the delivery of a range of public healthcare services.

Reforms to the healthcare system are essential to address coordination of care, increasing pressures from non-communicable diseases and an ageing population, and financial strains. But the inability of the Coalition to present a strategic vision and cogently argue their case for change beyond the usual mantras (budgetary restraint, the supposed moral hazard of supposedly free services) has left the Australian public sceptical about their agenda. A recent poll shows the majority of voters are concerned about the privatisation of Medicare as well as the possible end of the federal health insurance program in its current form.

This Coalition Government has shown a great reluctance to undertake the hard work of evidence-based policy development. Needed reforms in critical areas like primary care, mental health and Indigenous health have to date involved little more than disruption (of the non-innovative kind), budget cuts, short-term funding and transfers of responsibility. Most egregiously, this has led to the axing of primary health care research, development and evaluation with the loss of the PHCRED Strategy and BEACH; mental health reforms floundering between Primary Health Networks and the National Disability Insurance Scheme; and efforts to Close the Gap on Indigenous disadvantage making little progress due to significant budget cuts and program delivery increasingly removed from Indigenous organisations.

Dr Dennis Pashen, Medical Coordinator Tasmania, Ochre Health

Substantially they have devalued General Practice and failed to live up to the expectations of rural doctors and rural communities.  They have chosen to attack the precise areas that offer substantial opportunities for cost savings in the health sector long term. They have given token support to the National Rural Generalist Training Program but not followed up with any appropriate policy and strategies for implementation.

Victorian Aboriginal Community Controlled Health Organisation (VACCHO)

The Coalition Government rates poorly in relation to health care and policies impacting the wider determinants of health for Aboriginal and Torres Strait Islander people. In particular, policy and funding allocation decisions which impact accessibility to, and sustainability of primary health care services have a disproportionate impact on Aboriginal and Torres Strait Islander people, who experience significantly higher rates of chronic conditions than the general population, and for whom cost is a much more substantial barrier to access than for the population as a whole.

Prime examples of this include the failed attempt to impose a $7 co-payment associated with GP consultation and subsequent extension of a ‘freeze’ on Medicare rebates.

There was no consultation with service providers on cutting $534.4 million over five years from the Indigenous Affairs budget through programme rationalisation under the Indigenous Advancement Scheme (IAS), including cuts to evidence-based  lifestyle prevention programs such as tobacco cessation.

It is clear from the IAS process that Commonwealth Departments require greater understanding of Aboriginal health and wellbeing needs and what ACCOs do (and achieve).

vacchoOur CEO Jill Gallagher’s quote on this year’s Federal Budget was: “We’re not fooled, the end result of all this is that ongoing, unnecessary slashing of health funding has serious implications for Aboriginal peoples.”

The framing and implementation of the Indigenous Advancement Strategy indicates the Coalition Government’s profound lack of  understanding of the social determinants of health for Aboriginal and Torres Strait Islander people.  This is illustrated by:

  • Reframing of Social and Emotional Wellbeing (SEWB) and Alcohol and Other Drugs (AoD)  as a legal issue, in the context of the IAS “Safety and Wellbeing’ Program, the key performance indicators of which include “crime prevention” and “violence reduction”.
  • Lack of recognition that an understanding of Aboriginal culture is critical to non-Aboriginal organisations that wish to engage with Aboriginal people as equals. This is evident in the failure to institute controls that would ensure the cultural safety of services provided to Aboriginal and Torres Strait Islander people by mainstream organisations funded by the IAS.
  • Specific failure to allocate funding to programs with demonstrable positive impact on social determinants such as food security and education – e.g. a VACCHO member applied for the continuation of a breakfast program for school aged children that had produced evidence of positive effects on school attendance over a 10 year period.  This program was unsuccessful in attracting IAS funding, despite the focus of the current Government on school attendance in Aboriginal communities.

And as aside: The IAS, through the strengthening organisations governance policy, overtly forces a large number of organisations to transfer their incorporation. This is not only discriminatory but it would also be a logistical nightmare, a financial blowout without discernible benefits.

Jennifer Doggett, Croakey moderator, Fellow of the Centre for Policy Development and  health sector consultant

Overall, its performance has been woeful.  There has been a lack of vision in its approach to the health system and political leadership characterised by a poor understanding of the health system and a naïve belief in the ability of the private health sector to solve complex and entrenched problems.

Promising reforms introduced by the previous Labor government were terminated before they had a chance to deliver on their potential with little or nothing put in their place.  Poor relationships with the States and the medical profession have crippled attempts to progress collaborative policies and infrastructure (both organisational and knowledge-based) vital to the future success of our health system has been destroyed.

Progress in a number of areas has been delayed through protracted and overly complex reviews (and in some cases, reviews of reviews). Where some clear policy directions have emerged as a result of these reviews and consultation processes, the Health Minister has been stymied in her attempts to achieve some progress by a reluctance to allocate any substantial funding to these areas.

Leanne Wells, Consumers Health Forum CEO

The Coalition’s performance changed for the better over the term of their government.

A number of 2014 Budget measures did not get a welcome reception from the health sector. Economic imperatives seemingly prevailed over health policy based on evidence and consultation with key stakeholders, particularly State governments, consumer and doctor groups.  The focus was to look at the health portfolio for savings to assist with budget repair. This brought cuts to public hospital funding and a proposal for a GP co-payment: hallmarks of policy measures geared around reducing health expenditure rather than impacts on people and what was best for the sustainability and effectiveness of the health system overall.

The Australian National Preventive Health Agency was dismantled as were Medicare Locals, some of which were already working well and before many others had much opportunity to prove their worth as community-based health entities.  The Government at first sought to block the healthy food stars initiative which has subsequently proved to be a driver of healthier food formulation.

A change of Minister to Sussan Ley brought hope for potential advances in health policy. Minister Ley not only recognised there were health programs and areas of spending that were in need of an overhaul, but that, by taking a systematic look at where there is waste in health spending, better value could be derived and targeted spending achieved.

Leanne WellsStakeholders, including the Consumers Health Forum, expressed concern at the multitude of reviews she announced and the risk that they may result in poorly integrated policy.  At the same time, the reviews were widely welcomed because stakeholders were well aware of the fiscal pressures facing the government and the need to take a long-range view of spending priorities for health.  She embarked on a major project looking item by item at the services that should (or shouldn’t) be publicly subsidised under the Medicare Benefits Schedule,  as well as reviews into primary health care and private health insurance.  These raised prospects that the Federal Government was prepared to press for real improvements in areas that previous governments grappled with.  The result in the case of primary care has been a worthwhile report pointing to viable and much needed reforms such as the trial of Health Care Homes.  On health insurance, the Government has announced plans to make health insurance more consumer-friendly but the measures are still to be developed and will need more work to deliver simpler more transparent and competitive policies and also to meet the challenge of taking strain off public hospitals.

Q2: There have been so many cuts to health and related areas under this Government. What are the three most important cuts you would highlight?

LeederStephen Leeder, Emeritus Professor of Public Health and Community Medicine, Menzies Centre for Health Policy and School of Public Health, University of Sydney

On balance, dreadful. Cut and abolish have been their verbs – prevention, forward funding of hospitals and frozen Medicare. Then there was the copay debacle. Policy free, dull and unimaginative.

Dr Alex Wodak, Emeritus Consultant, Alcohol and Drug Service, St Vincent’s Hospital; President, Australian Drug Law Reform Foundation

That’s a really tough question. But defunding the hospital system to scare state and territory  governments to support an increase in the GST is so huge and still hasn’t been rectified.

Alison Verhoeven, Chief Executive, Australian Healthcare & Hospitals Association

While there will always be a need for, and opportunities to find savings in the health system, some of the cuts to health funding under the Coalition Government have bitten hard.  These include the reduction in growth funding to public hospitals from 2017, some of which has subsequently been restored; the reduced commitment to preventive health and the associated cessation of various preventive health programs; and the general economic pressure on primary care including the closure of many community-based services, along with the tight squeeze on general practice. A strong health system requires investment in prevention, community and primary care, and a well-resourced public hospital sector. Government responsibility for this cannot be totally outsourced to the private sector if we are to ensure all Australians have access to quality healthcare.

Julie Leask, Associate Public Health Professor, University of Sydney; visiting Senior Research Fellow at the National Centre for Immunisation Research & Surveillance

Cuts to primary health care research funding, including BEACH (Bettering the Evaluation and Care of Health). This took away the longest and most consistent source of data on service delivery in general practice, making it harder to evaluate effectiveness in future. This was part of a general pattern of reductions in primary care research.

MegDr Megan Williams, Senior Research Fellow, Centre for Health Research, University of Western Sydney

The overall $500 million cut, and merging of programmatic areas into the Indigenous Advancement Scheme’s limited categories.

Money being taken out of prevention.

NIDAC (National Indigenous Drug and Alcohol Committee) gone!

Also, it’s not just the cuts but the lack of progress needed to overcome inequity, and the lack of progress implementing plans and recommendations, eg Deaths in Custody.

Dr Dennis Pashen, Medical Coordinator Tasmania, Ochre Health

Failure to address the issues around specialist charges, and “beyond the gap” payments for specialist care has forced many patients onto public waiting lists causing them to blow out.

Failure to address the burgeoning costs of pathology and radiology when the industry has increased technology driven charges.

Failure to implement evidence based health planning in the approach to funding of health.

Failure to index GP payments. Both major parties have refused to index Medicare payments for GPs. Rural practices have communities with poorer health status, poorer socio-economic indicators and are less viable and able to access services, hence bear a triple whammy in health care. GP practices in rural areas need to be viable and many members of Rural Doctors Association of Australia have indicated that they have high bulk billing rates to compensate for their patients difficult circumstances: practice costs are still increasing, and hence the viability is being affected.  Many are contemplating having to charge patients an appropriate amount to continue their practice viability.  This will, in some communities, have the effect of driving patients inappropriately to the Emergency Departments for continuing Primary Care.  Seeing patients in EDs bears substantial costs over GP visits.

Victorian Aboriginal Community Controlled Health Organisation (VACCHO)

In their signing of the Statement of Intent to reduce Indigenous Health Inequality, in 2008, both Government and Opposition committed to achieve equality in health status and life expectancy between Indigenous and non-Indigenous peoples by the year 2030. Fantastic, however since then we have seen measures that limit access to culturally safe, high quality primary health care services, increasing health inequality experienced by Aboriginal and Torres Strait Islander People.

Consequently, cuts which are likely to have major negative impacts on health for Aboriginal communities include:

  • cuts to Medicare funding, including extended freezes to Medicare rebates and cuts to Medicare bulk billing incentives for diagnostic and pathology services announced in the 2015-16 Mid-year Economic Fiscal Outlook (MYEFO)
  • $534.4 M funding cuts to Indigenous Affairs budgets over five years, which has had impacts on the operations of Aboriginal community controlled health services, as well as reducing  funds to evidence based lifestyle prevention programs such as tobacco cessation.

Prime Minister Turnbull has failed on his Close the Gap promise of “it is time for Governments to ‘do things with Aboriginal people, not do things to them’.

We know all too well that you can’t have jobs and growth if you don’t have fundamental investment in health and education.

Jennifer doggettJennifer Doggett, Croakey moderator, Fellow of the Centre for Policy Development and  health sector consultant

The decision not to renew Labor’s funding agreement with the states on public hospitals. This decision not only took money out of the public hospital system but undermined relationships with the states making it difficult to make progress in areas with joint responsibility, eg dental care and mental health.

The freezing of Medicare rebates which has reduced resources available in general practice making it difficult to improve the prevention and management of chronic disease, one of Australia’s key health challenges.

The failure to fund a fourth phase of the Primary Health Care Research, Education and Development (PHCRED) Strategy. PHCRED funds a range of different primary health care research and support services, including the Australian Primary Health Care Research Institute (APHCRI) and the Primary Health Care Research and Information Service (PHCRIS).  While there may have been room to improve some elements of PHCRED, these organisations play a vital role in ensuring the provision of primary health care is informed by policy and research (and vice versa).  Without them our ability to improve the effectiveness and efficiency of our health system will be significantly compromised.

Leanne Wells, Consumers Health Forum CEO

Public hospital funding cuts, the indexation freeze on Medicare benefits and the dismantling of Medicare Locals.  CHF also remains concerned that the proposed PBS co-payment remains on the table.

Q3: What is the Abbott/Turnbull Govt’s most important achievement in health?

Stephen Leeder, Emeritus Professor of Public Health and Community Medicine, Menzies Centre for Health Policy and School of Public Health, University of Sydney

None

Dr Alex Wodak, Emeritus Consultant, Alcohol and Drug Service, St Vincent’s Hospital; President, Australian Drug Law Reform Foundation

The only achievement I can think of was to accept advice and fund treatment for hepatitis C.

Alison VerhoevenAlison Verhoeven, Chief Executive, Australian Healthcare & Hospitals Association

The Coalition Government is to be commended for exploring new models of primary care with its Health Care Homes trial program. With sufficient funding, Health Care Homes could be a positive force helping to integrate primary care as a cornerstone of the health sector, ensuring that patients with complex care needs receive better continuity of care and have greater opportunity of achieving better health outcomes. Importantly this represents an early step towards breaking down some of the silos that have existed for too long across the care continuum. Bringing this work under the auspices of Primary Health Networks could be a mechanism for enhancing integration across sectors, and could also assist in targeting the population groups of greatest need, with a focus on outcome-based care.

The shift to outcomes-focused commissioning of primary care by Primary Health Networks is in its early days, but represents a positive move to a focus on health outcomes rather than purchase of services.  Informed by community needs assessments, this will assist in targeting primary health services where they are most needed.

Dr Megan Williams, Senior Research Fellow, Centre for Health Research, University of Western Sydney

The National Aboriginal and Torres Strait Islander Health Plan being printed – although there is much to do. At least it is printed to be available to help guide future service planning. We must now hold them accountable to implementation and evaluation.

Dr Lesley Russell, Adjunct Associate Professor at the Menzies Centre for Health Policy, University of Sydney.

After three years in office, the positive achievements of this government are few: a review of MBS items that is yet to deliver real changes but offers potential and agreement by most stakeholders to begin the implementation of a ‘medical home’ approach to delivering community-based healthcare for those with chronic and complex conditions. The Government’s biggest success may be that it has united constituencies as diverse as the Australian Medical Association, the Consumers Health Forum, the Australian Healthcare and Hospitals Association, and the National Aboriginal Community Controlled Health Organisation (NACCHO) in opposition to its policies.

Dr Dennis Pashen, Medical Coordinator Tasmania, Ochre Health

Recognition that ASGRA-RA (Australian Standard Geographical Classification – Remoteness Area) was hopeless and implementation of the Modified Monash Model.

Review of the PBS and its potential.

Review of the Medicare schedule and its potential to remove non-evidence based items.

Victorian Aboriginal Community Controlled Health Organisation (VACCHO)

We commended the Turnbull Government’s decision in the 2016 Budget to add new Hepatitis B drugs to the Pharmaceutical Benefits Schedule and continue implementation on Palliative care and National Blood Borne Virus strategies 2014-17.

We also congratulated the Government on its decision to retain the National Aboriginal and Torres Strait Islander Health Plan (NATSIHP) developed by the previous Labor Government and their development of a NATSHIHP Implementation Plan that recognises the central role of the Aboriginal Community Controlled Health Sector in driving improvements in the health and wellbeing of Aboriginal communities.  However, we are disappointed at the Government’s failure to resource this implementation plan.

Jennifer Doggett, Croakey moderator, Fellow of the Centre for Policy Development and health sector consultant

While poorly timed and often largely duplicative of previous consultation processes, some of the reviews initiated by the Abbott/Turnbull government have added to our understanding of key policy areas and provided useful strategic directions, for example, mental health and therapeutic good regulation.

Leanne Wells, Consumers Health Forum CEO

Steps towards pharmacy reform and a better deal for consumers in relation to the price of medicines and professional services delivered by community pharmacists have been an achievement. The Coalition Government continued and extended the price disclosure measures embarked upon by the previous Labor Government. This has driven down prices and freed up the PBS to fund innovator medicines such as the new Hepatitis C drugs.  Injections of additional funding for the professional service pilots have the promise of delivering more accessible, evidence-based primary health care style services to consumers as well as better integrating pharmacy and general practice. An independent Pharmacy Review Panel, which includes a consumer panelist, is currently examining future pharmacy remuneration arrangements.

Primary care reform is another area where promising steps have been taken. This occurred on two fronts. Firstly, the Coalition’s commitment to pilot the introduction of Health Care Homes for people with complex and chronic conditions is something of a watershed. For the first time, it will move us away from fee-for-service funding arrangements in primary care towards financing models better suited to integrated, coordinated care. Careful policy translation and implementation that pays sufficient attention to the scale of change management involved will be critical.

Secondly, the structural reform to primary care through the introduction of Primary Health Networks is also welcome. While many, including Consumers Health Forum, were critical of the costs involved in winding down Medicare Locals, there are aspects of PHNs that are an improvement. Most notably, to have their function as commissioning organisations and ‘system stewards’ clarified is a good move. Equally, the requirement that their planning and commissioning decisions must be informed by Consumer and Community Advisory Committees, on an equal footing to clinical advice, is also an essential step in CHF’s view.  The Government’s response to the Report of the National Mental Health Commission gives PHNs their first major commissioning task.  How they go about this will be a true test.

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Comments 1

  1. T Hannan says:

    All the previous replies are important and valuable contributions to this debate. There is political bantering and talk of remedies to correct the system. Despite these perspectives there has been and will remain for the foreseeable future a continued failure to improve health care delivery. This is because the current model of care in this country and for many OECD nations (apart from the USA) is inappropriate. There is very little accurate nor realistic insight into the core drivers of our costly and at times poor quality of care delivery. Apart from a dominant focus on hospital-based care there-more beds, more doctors, more nurses-there is no clear cut direction to reform prevention which has since the 1980s been seen as the best way to enhance the health of the nation. In addition there is a constant failure to openly address the roles clinicians have in the overuse, underuse and inappropriate use of health care resources. The changes in doctors incomes pales into insignificant when these factors are measured in their contribution to health costs and quality as well as the variations in health care.

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