Introduction by Croakey: Many stakeholders in the health, disability and aged care sectors must be wondering about the implications of National Cabinet’s recent decisions around health reform, and how best to engage with these processes.
The news that reform recommendations will be developed by a First Secretaries Group, chaired by Professor Glyn Davis, the new Secretary of the Department of the Prime Minister and Cabinet, has raised concerns, says a former senior Health Department public servant Charles Maskell-Knight.
Charles Maskell-Knight writes:
The first National Cabinet meeting under the Albanese Government has decided to power up the health reform carousel for another spin.
The communique from the meeting on 17 June states that:
“To deliver a more cooperative streamlined approach to Federation, First Ministers agreed to identify practical improvements to the health system and specifically the connections between GPs and hospitals. This includes working together to identify practical ways to get aged care residents and NDIS participants out of hospital and into a more appropriate setting.
Following the Commonwealth Government’s commitments to increased investment in primary care, the Commonwealth will also work with states and territories, drawing on local knowledge, to determine the final locations for Medicare Urgent Care Clinics.
The First Secretaries Group, chaired by Professor Glyn Davis, has been tasked with developing these improvements to the way the health system operates and reporting back to the National Cabinet.”
In the media conference following the meeting, the Prime Minister elaborated a little, saying that the First Secretaries Group “will conduct a process of review of health funding and health arrangements, looking at health reform”. It would recognise that the hospital system is treating people who “should” be looked after by GPs or in aged care.
While there were some media reports that the review would be finished by the end of the year, the Prime Minister stated that there was no timeframe for implementation of any changes emerging from the review.
Reasons for concern
There are several reasons to be concerned at this process.
To begin with, First Ministers’ Departments are not the right people to conduct a policy development process.
Over many years I worked with numerous staff in the Department of Prime Minister and Cabinet (PMC) on health policy issues.
They were all hard-working, mainly because a team of half a dozen or so people were responsible for advice across the entire health and aged care portfolio, and there was no room for slackers. Most of them were highly intelligent and intellectually inquisitive, with a strong analytical bent.
But most of them had only a couple of years’ experience in health policy – often acquired on the job. To make up for their deficit in knowledge, they were usually prepared to have a sensible discussion about a topic in the course of preparing advice to the Prime Minister.
Given these properties, PMC do an excellent job in providing the Prime Minister with advice on the pros and cons of policy options put forward by other Ministers, as well as advice on how these options fit within a whole of government policy context. And I am sure that state and territory counterpart departments do just as good a job.
However, successful policy development requires more than reaction to other peoples’ ideas.
It requires a good understanding of the policy problem to be addressed. Staff in health departments are in regular contact with service providers and their peak bodies, as well as professional organisations, consumer groups, and numerous other bodies advocating for solutions to particular health policy problems.
In addition, the staff understand the range of health sector data sources (and their strengths and limitations) and have access to analysts who can extract the data to illuminate policy problems and evaluate possible responses. And finally, health staff have the corporate memory of health sector policy, including knowledge of past successes and failures.
Staff in First Ministers’ Departments do not have these advantages. While a review conducted by them could second or co-opt health staff to assist, it would be far more efficient to involve health departments as equal partners in the process.
Secondly, although on the face of it “a review of health funding and health arrangements” is extraordinarily wide, state and territory First Ministers clearly intend that it will focus on how to take pressure off public hospitals, as that is the hottest political issue facing them.
There are two ways to reduce pressure on public hospitals: stop people turning up who “shouldn’t” be there but should be seen by a GP; or discharge people who “should” be treated elsewhere. While both are unexceptionable in principle, there are problematic elements to both.
As I have written in an earlier article, there are many reasons why “GP-type” patients turn up in emergency departments.
Some of these are financial – while most GP services are bulk-billed, about one-third of GP patients are not. Co-payments of $60 can act as a barrier to attending a GP, and send people to emergency departments instead.
Some reasons purely relate to access: same-day appointments can be very difficult to obtain, meaning an emergency department is the only option to receive urgent care. And in many regional areas, GPs’ books are closed to new patients.
Some reasons relate to effective scope of practice. Few general practices have access to the diagnostic services that are widely available in hospitals to establish whether a fracture needs to be reduced, or to differentiate infant meningitis from a relatively harmless viral infection. GPs faced with such cases are quite rightly likely to err on the side of caution and refer the patients to an emergency department.
Any effective package of measures to reduce “GP-type” attendances in emergency departments will need to address GP remuneration, distribution, and infrastructure. These are complex issues far outside the knowledge of First Ministers’ Departments.
On the other side of the ledger, states have been complaining for decades about “bed blockers” – older people who are only in hospital because they are waiting for an aged care place.
While there is some merit to these claims, the impact is often overstated. The most recent publicly available data suggests that eliminating waiting for an aged care place would free up about a thousand hospital beds, expanding system capacity by less than two percent.
However, care needs to be taken to ensure that eligibility for aged care does not disqualify people from receiving appropriate hospital care. In particular, the states need to accept that they have a responsibility to deliver necessary sub-acute care to older people, even if they are eligible to receive residential aged care.
The Aged Care Royal Commission heard that only 18 percent of aged care residents who received acute care for a hip fracture received sub-acute rehabilitation, compared with 51 per cent of people living in the community. There is no evidence that residential aged care services have the expertise or time to offer rehabilitation for residents following a hospital stay. Residents missing out on sub-acute rehabilitation through the hospital system are likely to suffer an irreversible decline in mobility and function.
In other words, many people in residential aged care require more hospital care than they receive, not less.
The change of Federal Government has prompted a plethora of articles suggesting priorities for a new health minister (see for example, https://johnmenadue.com/category/public-policy/health/). Improving public hospital performance is an important issue, but after almost a decade of neglect by the previous Government there are many others.
While it is encouraging to see National Cabinet focusing on health, a process led by First Ministers’ Departments will not have access to the knowledge and expertise needed to generate the best solutions, and will concentrate on a very narrow range of issues.
The widespread problems besetting the health system require a more comprehensive approach.
• Charles Maskell-Knight PSM was a senior public servant in the Commonwealth Department of Health for over 25 years before retiring earlier this year. He worked as a senior adviser to the Aged Care Royal Commission in 2019-20.