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Mixed reactions for National Health and Hospitals Reform Commission report

Croakey welcomes feedback from readers on the report, which is available here.

The consumer emphasis is welcomed by Merrilyn Walton, Assoc Prof of Medical Education at the University of Sydney.

She writes:

“At last the consumer voice is on the agenda. Rather than being silent recipients of care, the NHHRC Report recommends their voice be an equal partner in both health care policy debates and health care delivery.

The recommendations around health literacy are pivotal to enabling patients to become partners in their own health care.

Missing in most reports and health care debates to date has been the need to prepare and enable patients to make real choices about their doctors or hospitals. Many patients do not make genuine choices in relation to their treatments either because of the nature of their disease or because the scope of the informational needs of patients and their obligations to provide it is under recognised.

Things have to change before patients are to have genuine choice in their health care. The current system – its structure and organisation relies on patients being passive receivers of their health care; patients are not at the centre; professionals are in control.

Most hospital organisations and health services are not patient-centred and not designed to take patient perspectives into account. Over the last century hospitals are better organised and professionalised and more complex, yet the patient’s role has remained relatively unchanged. They are admitted to wards in much the same way as a hundred years ago; they are told what is wrong with them, how, where and when their condition will be treated and by whom.

Patients are not expected to make decisions other than whether they will have the treatment or not; and sometimes this is not fully considered. If all patients being admitted to hospitals were to make inquiries about hospital infections, peer review requirements and credentialing, hospital staff would not be able to cope with the increased demand on their time.

The system is just not designed for questioning patients. If we are really going to include patients as partners, the system will need to be restructured and reorganised; this will require a major cultural change, but one worth the effort.”

***

The Public Health Association of Australia has given the report a big tick, calling it a “blueprint for significant improvement in the delivery of health services across the nation”.

“We welcome especially the emphasis on prevention and on other important issues such as mental health, Indigenous health, dental health and palliative care.  PHAA is particularly pleased to see strong support for the establishment of a new National Preventive Health Agency,” said Professor Mike Daube, President of the PHAA.

“We also welcome the clear outline by the Prime Minister of a timeline for discussion and further decisions by the Council of Australian Governments.  PHAA looks forward to taking part in further discussions on implementation of the reform agenda,” said Professor Daube.

***

But the rural doctors are not at all happy

The National Health and Hospitals Reform Commission has wasted a ‘once in a lifetime’ opportunity to fix the rural health crisis by ignoring the need for urgent initiatives to entice more doctors and other health professionals to the bush, the Rural Doctors Association of Australia (RDAA) said today.

“After the Commission released its interim report in February, we expressed our strong disappointment that the number one priority for fixing the rural health crisis—improving access to local healthcare by getting more health professionals into rural and remote Australia—was largely being overlooked by the Commission” RDAA President, Dr Nola Maxfield, said.

“Consequently, it is extremely unfortunate and frustrating to us that the Commission has not heeded our advice when developing its final report on health reform.

“The Commission’s final report was meant to be a report for the whole health system, but unfortunately it has a gaping hole in it—rural health. The crucial element missing from the report is any recommendation for substantial new initiatives to get more doctors and other healthcare professionals to the bush.

“In particular, we are extremely disappointed that a critical Rural Rescue Plan put forward by RDAA and the AMA has again been overlooked by the Commission. Implementation of this Plan would be a very cost-effective (and we believe hugely successful) way to get and keep more doctors in rural practice by providing real incentives and supports for them. We have already seen this type of Plan introduced in Queensland by the state government, and the ensuing increase in rural doctors there has been staggering.

“At the end of the day, the real issue for rural Australia is not about whether our nation has one health system or whether the states or Commonwealth control it, but whether there is a health system at all in the bush. The continuing, chronic shortage of health professionals in our country communities means that rural Australians are simply not able to access the healthcare they need and deserve.

“It’s all well and good for the Commission to talk about equity payments to ensure health dollars reach those who need it most, but until we get enough health professionals into rural and remote Australia it is going to be virtually impossible to translate those payments into the delivery of extra local services.

“Rural Australia is already suffering from a shortage of 17,000 health professionals including doctors, nurses and other health professionals—and this shortage will only get worse in the absence of genuine government action.

“As Prime Minister Kevin Rudd undertakes his consultation around the Commission’s final report, we urge him to get out of the cities and the big metropolitan hospitals, and instead get into the bush to talk to the healthcare professionals working on the ground there. He needs to visit many rural hospitals, rural general practices and Aboriginal Medical Services to see for himself the problems surrounding access to healthcare in the bush and what must be done to remedy the situation before it is simply too late.

“Rural health is a bit like a paddock—once the topsoil has eroded away from lack of care it is very hard to bring it back to life. Now is the time to be investing in this paddock so it will provide the harvest of rural health professionals and better access to healthcare that is so desperately required in the bush.”

***

The emphasis on equity is welcomed by Professor Gavin Mooney, University of Sydney

‘How good it is to see such emphasis on equity and on Aboriginal health. That has to be the firm foundation for a good report. We hear so much about hospitals but normally so little about issues of access and fairness. The NHHRC also clearly believes in trying to ‘close the gap’ in Aboriginal health.

Let’s hope that desire rubs off on Rudd and Macklin and gets them stirred up to move beyond rhetoric and take some real action to take Aboriginal health problems seriously. The NHHRC report certainly gives me hope in that direction!”

****

Consumers Health Forum happy about consumer focus

“Reforming health in Australia towards ‘a health system that places the needs of patients first’ will take enormous courage from government” according to Ms Carol Bennett, Executive Director of the Consumers Health Forum of Australia (CHF).

Ms Bennett was commenting on the release of the National Health and Hospitals Reform Commission (NHHRC) report today in Canberra at which the Prime Minister, Kevin Rudd, and Minister for Health and Ageing, Nicola Roxon, again highlighted the critical role to be played by health consumers in reforming the current health system.

“This report again emphasises the enormous economic and human costs of continuing with our existing health system.  The report also offers solutions, and thankfully these solutions are about much more than the Commonwealth simply taking over hospitals or putting more money into the current system,” Ms Bennett said.

“It is refreshing to hear the Prime Minister talk about access to the services people need, rather than the services that the health system wants to offer.  To make this happen, we are going to have to measure the experiences of people who need health services as well as measuring the access to, and quality of, the health services provided.

“If patients are to be the centre of the new health system, it is health consumers who need to be at the centre of further discussion and consultations.  We don’t want the health reform debate to continue to be dominated entirely by existing health service providers and system lobbyists” Ms Bennett said.

“Now that the Government has this report, it is essential that it doesn’t get sidetracked into compromises that maintain the interests of those who benefit most from the current health system.  This is an opportunity to find solutions that provide the best possible health services for all Australians.”

***

What about the wasteful, unfair private health insurance incentives? The Doctors Reform Society asks…

The Doctors Reform Society welcomes the many positive ideas presented in the report from the National Health and Hospitals Reform Commission,” said Dr Tim Woodruff, President, Doctors Reform Society, “but we wonder how their stated commitment to the principles of equity and efficiency has allowed them to ignore the inequitable and inefficient Private Health Insurance (PHI) rebate. Is choice more important than equity?”

“The belated recognition that dental care should be a universal entitlement is a huge step forward for many Australians who until now have had no choice but to live in pain, unable to eat properly, waiting years for treatment,” said Dr Woodruff. But the Denticare proposal is at odds with the Commission’s comment that ‘we want to translate universal entitlement into universal access’. Denticare will encourage dentists to stay in areas of relative affluence, supported by taxes. Those without teeth unfortunate enough to have limited mobility and live in poorer areas will remain toothless. Denticare also guarantees that those who have the money for private insurance can get faster access. That’s choice before equity. It should be the opposite.”

“The report clearly identifies inequities in funding and recommends regional block funding for rural and remote areas, based on need,” said Dr Woodruff, “but the report ignores this issue for inner and outer regional areas where many more Australians regularly miss out on their fair share of Government spending. They have no choice”.

“The report targets areas of marked inequity, ie serious mental illness, dental health, rural and remote regions, and Aboriginal health. This is appropriate but it is charity rather than the removal of inequity which drives this targeting,” said Dr Woodruff. “Structural reforms to address the root causes of these inequities are clearly second order priorities. Fee for service funding will predominant in the new plan despite it guaranteeing that the inverse care law, ‘those who need the least get the most, those who need the most get the least’ will continue to apply. Private health insurance will be expanded despite its striking inefficiency and inequity.”

“Our public hospitals are struggling, burdened by inadequate Commonwealth funding. The drift of doctors from public to private hospitals and the inequity of access to public hospitals is clearly identified in the report but the contribution of the PHI rebate to this inequity is ignored. Choice remains a taxpayer subsidised option for the minority of Australians who can afford PHI and can queue jump public hospital waiting lists, whilst the most needy just wait. They have no choice. Vested interests remain untouched”

“Despite the many excellent ideas within it, this report is ultimately about entrenching those vested interests, about a long term vision for health care as a commodity to be subject to competition and the market,” said Dr Woodruff.  “Swine flu affects us all, We do not need a health industry, we need a health system for all. That will only happen with co-operation, not competition”.

Comments 1

  1. Budhmuni says:

    A bureaucratic temptation: shame other bureaucrats, create new bureaucracy

    Dear Prime Minister

    Sadly, it does appear that you may need to re-think your strategy.

    Yes, it is a great idea to have a single funder of health care. Does it have to be Commonwealth though! Why not give whole funding bucket to another funder – even to States, or to the local government. They might actually have systems to deliver, and can get the job done. You wanted decision with the local community, local clinicians and Local Hospital Network, isn’t it? Why centralise the system even further.

    Yes, what a good idea to have singular responsibility for funding and policy for GP and primary health services. But, why not a singular responsibility for funding and policy for entire health care? It does make sense you know – not to keep the primary and secondary care systems fragmented. I thought you were concerned about cost shifting. Perhaps with your preoccupation with cost shifting between Commonwealth and States, you seem to have forgotten that the problem is cost shifting between primary and secondary care systems not commonwealth and states. Will it change – certainly not. Have you eliminated moral hazard – definitely not.

    You do think handing control to Local Hospital Networks will enable gains in technical efficiency and allocative efficiency. I know you have given the reason over and over again – by pointing a finger at us and saying – “Let me tell you one thing, it will, because I said so”. It is good to look around. There are many countries that have tested and tried these models, had Boards and disbanded Boards, had small health services and amalgamated these to make larger planning and funding units. Why – to eliminate waste and duplication of effort, local politicking and bickering, to minimise inconsistencies and you want to have Local Hospital Networks for each hospital.

    So, having an arrangement for commonwealth to make a 60 percent “efficient price” allocation will be an incentive for states to also limit funding Local Hospital Networks to 40 percent of “efficient price”. What a great idea! Why wouldn’t states accept it, it is such a wonderful idea. Moreover, states shouldn’t worry about carrying this risk as there is no additional risk other than what they are carrying anyway. They have been trying hard for years to make the system more efficient and control costs. How foolish – why did they not think of Kevin’s solution – Give the funding to Kevin and he will pay 60% of efficient price and you pay the rest of it, even if the system becomes more inefficient and costs of maintaining Local Hospital Networks blows out in your face. It is so simple.

    Can I suggest that if a question is asked about health reforms, you ask your staff to reiterate the following points:

    Do you know why this reform will drive major improvements in service delivery? Because, the Government will dismantle the system in the name of building a new health and hospital system for the future. The “new” health and hospital system actually does not need anything more than a new pricing and funding arrangement. These state bureaucrats sitting in central offices are fools. Quite rightly they should be sacked. Bring in the Commonwealth bureaucrats. It just needs efficient pricing and going back to local Boards and every thing will just work out for the better. Introduction of similar systems has helped curb the cost of health care in the UK. Total NHS expenditure did multiply by three times in 5 years. I guess could have been worse.

    Do you know that the National Health Reform Plan will work. Why – because Kevin says on Page 2 that the Government has already delivered. What has the Government delivered – “a record funding for public hospitals, increased number of elective surgery procedures, taking the pressure off emergency departments and a record investment in training more doctors and nurses.” Be aware, some may think it was the pricing system and changing the funding arrangement that Kevin was delivering, not “record funding”. Just need to media manage this fluffal!

    Do you know, our rates of hospital admission are much higher than that in comparable counties. What have these silly state bureaucrats been wasting all this time mapping processes, changing culture, introducing innovations in clinical practice, implementing evidence based practice, etc. Just threaten them with efficient pricing and they will start behaving. In any case, if they don’t, we can blame the Local Hospital Network. They can sack the CEO or even get rid of the network, for all I care. If that doesn’t work, we’ve got it sorted anyway. Not our problem anymore! It will be a problem that states’ and territories’ will need to sort out. After all they’ll be paying anything over and above efficient price.

    You don’t understand, as Kevin has said “without reform, these challenges will put governments around the country under increasing fiscal pressure, add to the workload of already stretched staff and lead to longer waiting times”. Clearly, we can’t put governments under fiscal pressure, definitely can’t make staff work and waiting times look really bad as that makes it look we don’t know what we are doing. Never mind the patients, they will find somewhere to go. Kevin as clearly said on Page 2 “In implementing its reform, the Government recognises the importance of continuing the role the private hospitals and other private health care providers play in delivering strong health outcomes.”

    Did you not realise, “sustaining funding model of health and hospitals – must involve reform of the nation’s finances.” That’s it. You just needed an accountant to run hospitals. You silly clinicians, don’t you understand if we haven’t got thousands of politicians and bureaucrats on Local Hospital Networks to sort out all our funding woes, a few of you won’t be able to do anything anyway.

    Lets talk about problems with our health system today. The system isn’t prepared for future challenges. You clinicians and health bureaucrats haven’t got a clue that the population is ageing, growing, there is burden of chronic diseases, new technologies are expensive, we haven’t got enough people in our workforce, system is fragmented, poorly coordinated and so on. As Kevin says on page 4 “New arrangements that fundamentally change the way hospitals are funded and run are needed to ensure additional hospital capacity, greater efficiency and better services.” Now, no one should doubt that, changing the funding arrangements, adding another layer of bureaucracy at the Local level and having local politicians rather than state politicians, is the answer. They can fight it out at local level. At least no one will be blaming commonwealth bureaucrats or politicians. As Kevin has said about a whole lot of his number one priorities, his number one priority is to pay “efficient price.” Now, don’t even try to blame him if the efficient price is not right. Blame that silly, bureaucratic independent pricing commission that set that inefficient price.

    Do you know that cost of providing health care is continuing to increase. Even Kevin has suddenly realised, in the last five years public hospital expenditure has grown at an average of close to ten percent per year. If we take the GST bucket from the states and give you exactly the same amount of funding, but now from the commonwealth, that will magically make funding sustainable. Why – because this is an election promise, that Kevin must deliver.

    Did you not know why there is so much inefficiency and waste in our health system. This is because “the Commonwealth Government currently funds states with block grants for public hospitals” and I am not blaming anyone but as Kevin said, “Part of the problem is overly centralised and bureaucratic administrative arrangements for hospitals in some states, which sap the innovation and drive of local clinicians and managers and reduce incentives to improve performance.” Again, I am not blaming anyone but do you also know that the problem is that there is not enough local or clinical engagement. Real technical efficiency will be gained not by improving our systems and processes, removing waste and double handling, duplication of care delivery between primary and secondary care systems but “by appropriate clinician and community engagement concerning service mix and delivery options.”

    Yes, Prime Minister

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