Memo to Rudd, Roxon et al: Here’s how to win some cred on health reform

Croakey recently had a rather depressing thought. What if all the money, effort and carbon emissions that have been invested in health reform planning to date produce nothing more than an election policy for Rudd and co? What if the sum total of health reform in the Rudd Government’s first term amounts to a big fat zilch?

Health ministers are meeting today, and apparently workforce issues are high on their agenda. Here are some suggestions from Croakey contributors about what else should be on the table.

They were asked:  What is one thing the Rudd Government could do right now to convince you that they are genuine about achieving meaningful health reform?

John Menadue:

Clear away all the political obstacles to the full and early introduction of e health.

Robert Wells, Director Menzies Centre for Health Policy, ANU:

The one thing that would show serious reform intent would be to agree the NHHRC recommendation that the Commonwealth take accountability for the primary health care system and deliver a strategy reflecting that in the 2010 Budget.

Prue Power, Executive Director, Australian Healthcare & Hospitals Association:

The Federal Government went to the last election promising reform on health. It put into place a comprehensive reform process followed by extensive community consultation.

AHHA supported this approach as we believed that it was essential that all stakeholders had input into the future of our health system.  However, we now believe that it is time to move on from consultation to action and we are calling on the government to put a reform plan on the table.

Dr Lesley Russell, Menzies Centre for Health Policy:

Two crucial things:

1. A concerted and coordinated approach to Indigenous health.  So far  we have seen funds dribbled out in isolated programs, a focus on the
NT that has achieved nothing in terms of better health, little to address workforce shortages, the needs of the Aboriginal Community  Controlled Health Organisations ignored, and nothing done to help  those Indigenous people who live in metropolitan and regional areas.

2. Reform of the funding and delivery of mental health services in the  primary care sector.  The Better Access program has been poorly
designed from its inception, and the current situation for people with  mental health problems would never be tolerated for people with with a
physical problem.

George Rubin, Professor of Public Health, University of Sydney:

The Government established the National Health and Hospitals Reform Commission in its first year of office.  The Commission submitteed it final report in June 2009. We await the Government’s  response to the recommendations and an indication of what they accept and don’t accept and then an action timetable to detail plans to achieve specific priorities.  So, “In my view the Government should move quickly now to indicate which of the recommendations it accepts from the National Health and Hospital Reform Commission Final Report and indicate an action timetable with specific milestones, deadlines and resources.  We don’t need further enquiries or reports.”

Professor Ian Hickie, executive director of the Brain and Mind Research Institute:

The one and perhaps only thing that would convince the health community that we are on the threshold of major reform would be a clear statement by the Rudd Government that it intends to take over the financing of all Government-supported health services in Australia. Having only one level of Government responsible for the money, as distinct from the delivery of health care, would effectively end the historic Federal-State divide and allow us to build a more equitable and responsive system. Once the Feds took responsibility for the costs they would also then be able to move towards real accountability systems. As long as the States are left to pay for and operate the bulk of the public hospital system, the system will remain stuck with its 19th century focus on hospital-centric care and fail to build those more effective collaborative models of care that are essential for better management of chronic disease and other major challenges such as mental health and dental health care.

Dr Tim Woodruff, Doctors Reform Society:

Meaningful health reform cannot just focus on efficiency. Everyone except stakeholders supports efficiency. Equity is the forgotten principle in policy so far. Targeting gross inequity is easy and has been done by all governments. Addressing the structural changes which promote inequity is more difficult, more substantial, and more controversial. It is about social inclusion and the recognition that everyone is entitled to quality health care. This is not the same as addressing gross inequity with programs. That’s called charity. So it’s a matter of often well intentioned charity through targeting gross inequity or social inclusion through structural change aiming for equity.

The first structure which currently promote inequity is fee for service medicine which leads to patients missing out if they live in areas where health providers don’t choose to work and also leads to patients missing out if they can’t afford the private copayment which many specialists, psychologists, and some GPs charge. The second inequity promoting structure is support for the private health insurance industry, means tested or otherwise. It takes specialists out of under-resourced public hospitals to look after those who can afford PHI and subsidies those queue jumpers.

Thus, for the Federal Government to demonstrate it is interested in meaningful health reform it needs to look at needs based regional fundholding which would decrease the reliance on fee for service medicine and it must  re-examine its support for private health insurance.

Professor Stephen Leeder, Professor of Public Health, University of Sydney:

Recently, I went to Melbourne to the launch of the Social Inclusion Framework by Julia Gillard, Jenny Macklin and others. I found it refreshing.  One of the features of it was that they presented a genuine framework into which various initiatives fitted.  It bore the imprint of thought.  Indeed, perhaps with the possible exception of employment, the Gillard portfolio performance has been deeply impressive.  They understood what the stimulus package money was for – to stimulate the economy now – and hence rolled out a lot of fairly small projects in education that would engage a lot of people in work. In health we will be using stimulus money for five or more years to build things, long after the recession is forgotten but the debt is not.

In health, there is no discernible framework for reform. There are dozens of suggestions but they do not mesh. While the many NHHRC recommendations stand waiting in the cold for attention, the seduction of the truly ridiculous Medicare Select distracts.

So, how about a framework for health?  How about Rudd saying where he thought we should get to with health and health care in five years? Has he a goal? If not why not?  What kind of a health care system might we expect for five, ten and fifteen years hence, over and above the fatuous froth of the Intergenerational nonsense, so brilliantly demolished by Gittins recently?  We need from him an inspiring vision of where we are going, what we need to do, how we are going to get there. It is called leadership.

Dr Sue Page, Northern Rivers Department of Rural Health:

More students only works if you have more placements the whole way through to independant practice – so for all disciplines we need more Intern places and Voactional training posts created at the same time. The new national registration system will require students to be registered as well, which creates a bureaucratic nightmare as students notify their new address each time they move house and drop in and out of the system as they defer for a year.

Nearly half Aboriginal people live in NSW, yet grants like these consistently go to remote areas. Is this so we can pretend the issues have more to do with remoteness than with having services that are culturally inadequate and poorly integrated? One report I read had 4% of antenatal care at one metropolitan AMS being delivered to girls under 14, another that if you increase Aboriginal school attendance by one year you reduce perinatal mortality by 7-10%. So why not work harder in school retention programs?

What would convince me?

1. Defining a basic set of health care to be provided to populations, as we do for education by setting the school leaving age. Establish regions of a geographic size that is cost effective but also not too large in kms – perhaps 200,000 pop – then allocate health dollars by where people live. Ideally funding pool should combine state and federal buckets in a transparent per capita amount. Then accept a bit of lost accountability (and possibly some $ wastage) through less micromanaging in exchange for greater local autonomy as local regions broker their own service delivery deals.

2. Put proportionate representation at any Ministerial Advisory group – if 1/3 Aussies are rural then 1/3 advisors should be, and if a clinical group is appointed then mixed disciplines rather than all doctors or all nurses so as to break up the factions.

3. It wasn’t put as an option, but I would remove all the highly expensive hospital units from state budgets so they can concentrate on the population based incidence patterns. That is, federally fund your research units, transplants, major burns and certain specialty services like extremely premature infants as if they are the nation-wide services that they are. States should specifically divert their new savings into disease prevention models.

Other general comments:

Make a decision as to whether you want top quality care (for the top quintile) or health equity across the population. Because the strategies are quite different so without a whole lot of extra money we can’t do both.

Governments should stop obsessing about fancy machines and pilot projects and free up funds for the ongoing bread and butter stuff. Focus on what clocks around more often even if it isn’t sexy – including mental health, addiction medicine, and chonic disease. You need to treat people not headlines.

Don’t commission any more research until we apply what we have already – as an academic I can count no less than 3 grants over $1mill given out by different govt departments within a 5 year period to develop culturally appropriate resourses for Aboriginal people to stop smoking. As a clinician I never received one, so what is the point? Instead evaluate the cost-effectiveness of services and develop ways to increase the uptake of evidence based care.

Forget about elective surgery – the only people who really care are the private surgeons and the media. Altering market forces by anything other than acuity will see hips and eyes done at the expense of coronary bypass surgery (including one of my patients who was bumped 24 hours to achieve a target and unfortunately didn’t survive the night) or at the expense of the small yet common stuff like ENT operations.

Carol Bennett, Consumers Health Forum:

• reduce the number of people being forced, needlessly, to use our public hospital system
• invest more in better integrated, more flexible and comprehensive primary health care services
• invest more in preventative health measures including health promotion
• review the current workforce limitations, both in terms of numbers of professionals and role delineation
• refocus measurement on the health consumer rather than the system to improve real outcomes.

Health policy expert Yvonne Luxford:

If I could only choose one thing it would be the development of a comprehensive, evidence based plan of action to address the significant gap in health outcomes between Indigenous and non-Indigenous Australians. Such a plan must be developed in partnership with Indigenous Australians, include clear targets and allocate accountability for achieving outcomes. This government has shown true commitment to improving the health of Indigenous Australians and deserves to be commended. However, without a long term national plan developed in partnership there will be no true reform in this vital area.