Cross-posted from Crikey, Mark Bahnisch outlines why the Queensland Government’s Blueprint for Better Healthcare isn’t only important for Queenslanders….
After its first year was dominated by ministerial resignations and scandals on one hand and large scale spending and staff cuts on the other, Campbell Newman’s government has now revealed its hand. The findings of the Commission of Audit have set the direction for public policy, public management and service delivery.
On Thursday in Croakey, Michael Moore wrote about the Government’s “Blueprint for Better Healthcare”, outlined that morning by Health Minister Lawrence Springborg at a function which, controversially, was pay for access, with funds raised going to the LNP’s coffers.
The radical changes to the delivery of healthcare in Queensland make a lot more sense now that we know the Government looks favourably on the recommendations its Audit Commission made.
Unfortunately, the Commission, headed by former Liberal Treasurer Peter Costello, has not released its full report. Only the executive summary was released to the press in a ‘lock up’, and it is unclear at the time of writing whether even Government backbenchers have access. The Government, in a strange approach to consultation, has simultaneously called for a debate and indicated it will publish the report and its response in six weeks’ time.
The interim report attracted heavy criticism from independent economists such as Professor John Quiggin. This criticism was not just directed at the report’s ideology but at its financial and statistical assumptions and accuracy.
Yet we know enough to say that the report is a sweeping blueprint not just for privatisation of state assets, but also for outsourcing (“contestability”) of government services. Page 11 of the executive summary effectively protects only the courts, police and emergency services from the outsourcing drive.
So, it’s now no surprise to see that health is slated for “contestability”. This is spun in the Blueprint as agnosticism towards the ownership of service providers, but its implications are both more far-reaching and also not subject to the mandate the Government says it will seek for privatisations of assets.
Like the cuts to public health, no clue was given prior to last March’s state election that this approach would dominate health. Yet the straws have been blowing in the wind. In January, I wrote that it was clear that a privatisation agenda was set to dominate health policy in Queensland.
Politically, this time, the Minister has the AMA on his side, but unions are promising “the mother of all campaigns”.
Federal Treasurer Wayne Swan has vowed to fight, claiming that the moves amount to a dismantling of Medicare. There has already been controversy over payments not made to Queensland because of a failure to meet agreed upon COAG targets. In a classic exemplar of the “blame game” over funding, the State calls this money a “cut” while the Feds decry the State for breaking its promises.
In this game, the Commonwealth probably has the best of the argument, but – as with Gonski – it would be fair to say that a co-ordinated national approach to policy now lies in tatters. Minister Springborg’s document gestures to the role of Medicare Locals, but his own Federal counterparts promise to abolish them if elected in September. The report reads as if bureaucrats have tried to harmonise the Government’s direction with national objectives. But it’s far from clear how successful they’ve been, owing to the unfortunate rhetorical sludge which characterises the writing.
So those who advocate a national approach to health reform must see this Blueprint as a setback.
We don’t know much – as yet – about how the Blueprint will be translated into practice. The paper is heavy on rhetoric, and also trumpets the government’s achievements in several areas which it did foreshadow in the campaign; a ban on “ambulance bypass” for instance. And a lot of small operational initiatives are interspersed with vague generalities about how the Promised Land will be reached.
One worthy aspect is the emphasis on transparency. It will indeed be necessary to judge the strategy by patient outcomes and other meaningful indicators.
But there are at least two red flags that should be flying.
First, the third point in the table contrasting the “old” and “the new” on p. 8 significantly calls for streamlined awards and agreements. It’s correct to observe that the award and classification structures in Queensland Health are complex and unwieldy, and that this was one of the causes of the payroll debacle.
Work has been done in the past on a more logical structure, including workforce reform which many would welcome. But there’s little indication that a competency based approach to scope of practice has really been thought through. There certainly is reason to believe that reducing pay rates and conditions might be part of the picture, particularly when considering that remuneration is normally lower in the private sector for nurses, Allied Health Professionals and other health workers.
The Government has also weakened employee protections in legislation rushed through Parliament last year.
Whether a further drift of doctors to private practice will be a result is a legitimate question.
Secondly, the paper emphasises – rightly – accountability and results. But overseas experience shows that outsourcing often cuts standards, and that contract and performance management eats up resources that might more optimally be directed to service provision. Problems of co-ordination are also rife, with contractualism replacing cooperative management. Add contracts for service delivery to the mix of local hospital boards’ responsibility for purchasing services and you have a recipe for the sorts of bureaucratic confusion and empire building the Blueprint rejects.
Something might have been learnt from outsourcing the design of the payroll system.
Peter Costello is now trumpeting the Audit Report as a template for other States and a Federal LNP government to follow. Even if that’s blowing in the wind (and it probably isn’t), we deserve better than to be told by Lawrence Springborg to “get on the train or get under it”. Change of this magnitude ought not to be done by fiat. But the train seems to have left the station.
• Dr Mark Bahnisch is a Fellow of the Centre for Policy Development and a Postdoctoral Research Fellow in the Centre Medical Education Research and Scholarship, School of Medicine at The University of Queensland. A sociologist, he has for many years been active in policy debates and in social consultation. He has recently been researching and publishing on Health Workforce and Health Services.