If 2009 was the year of health reform talk, will 2010 be the year of health reform action? I wouldn’t bet my Christmas stocking on it.
The mental health sector is watching the state of play in health reform closely, and no wonder. The sector potentially has the most to gain from reform – but it may also have the most to lose, being one of the least powerful players within our procedurally-focused institutions and systems.
When push comes to shove in the perennial battles for funds, they’re usually the ones being shoved.
Professor Alan Rosen, a prominent psychiatrist and longstanding advocate of community-based care, has investigated some of the potential risks and benefits of various health reform options for mental health.
He writes:
“The CoAG festive season talk-fest of December 7th 2009 came and went without anyone finding any neatly wrapped health reform package in their stocking.
Maybe Mr Rudd is right. While we are all frustrated with the glacial speed of arriving at a practical proposal for sustainable and real health reform, we are just not ready yet.
On the basis of funding proposals currently being bandied about by state and federal governments and other prominent bodies, if we were to adopt any of them, we could be in danger of inheriting the worst of all possible worlds.
Public vs Privatized Purchasers:
Some states, eg NSW, want a single national funder to pick up the tab while they allow regional health authorities to extend what most of the existing traditional area health services have been doing habitually and shabbily for many years: confounding the roles of purchaser and provider, making a hash of mental health services, spreading them too thin, and recentralizing them on hospital sites, while siphoning off dedicated mental health resources to pay for medical and surgical procedures.
The only possible exception is Victoria, which already has specific mental health service objectives and operates a fairly tight contractual purchaser/provider split to achieve them.
Meanwhile the AMA “…wants the Commonwealth to be the single national funder of public hospitals, with the States to continue the day-to-day management of the hospitals”. Surely this would just replicate the poor management and rampant managerialism of the current regimes in most of the states.
The authors of the National Health and Hospitals Reform Commission report advocate for the option of a “meso-level” bunch of health insurers to take over as purchasers. They unfairly contrast this option with the spectre (or “straw man” argument) of traditional and inefficient regional health authorities,compromised by having to do both purchasing and providing.
Regional Health Authorities have been demonstrated over extensive periods to be effective overseas, eg UK and New Zealand, but only if they are strictly arm’s-length purchasers andcommissioners only, not providers as well.
In New Zealand, these regional purchasers worked better than smaller scale district health boards, which have sometimes become too cosy with the district general hospitals, at the expense of alternate providers.
The NHHRC-favoured “Medicare-Select” and related Netherlands style insurance options involving the Health Insurance Funds should be further questioned and explored carefully before considering implementation, because of a) the distortion produced by the profit margins expected, b) their history of cherry-picking of more profitable diseases, clinical procedures and populations, and c) their lack of a track record in working with and integrating both health and human care, and all phases of care from emergency to longterm or even life-long care.
The main concerns of the mental health community about the Netherlands model are strong indications of perverse outcomes such as over-hospitalisation of mild disorders, and its siphoning of resources away from complex conditions like severe and persistent mental illnesses.
While some of the main proponents of these proposals have long and distinguished experience in the public sector, most have declared links to the Australian health insurance and private provider industries, and have not yet allayed the basic concerns of the health community.
The nation cannot be expected to implement such models on trust without unambiguous evidence of effectiveness elsewhere. Once they overcome these concerns and difficulties, involvement of the Health Insurance Funds could possibly be welcomed as subsidiary pilot projects to integrative regional purchasing models.
Regional Health Purchasing and Commissioning Authorities (RHCA’s) should be purchasers only completely independent of providers, working at arm’s length from them all.
If the RHCA was the organising, integrating and commissioning mechanism, traditional Area Health Services which both purchase and provide services could become obsolete, as purchasing could occur directly with facilities, their governing boards or companies, or with groups of practitioners.
Australia’s mental health services are so fragmented and uncoordinated that they are “ripe for takeover”. This presents either opportunities for integration, streamlining and systematizing more effective practices, or otherwise risks of being ignored and glossed over for bureaucratic or political expediency, and ultimately being exploited by private interests.
Most models for purchasing and organising services which are already out there are not fully developed (and some are not even half-baked), and need a lot more working up.
The ideal model needs to be locally integrative of all public, private and non-government sector providers, as independent as possible from political or bureaucratic meddling, and immune from gaming for personal or private gain (arguably the 3 “I’s” of real health reform).
This is a tall order, but achievable if the political will is there.
The danger is that the building momentum in the Australian community for long-overdue health system reform will be allowed to ebb away.
The mental health community is hanging out desperately for real reform. We can only hope that Mr Rudd and Ms Roxon aren’t trying to lower expectations that they will ever deliver on it.”
