Remember the National Health and Hospitals Reform Commission? Here’s a pointed refresher

Introduction by Croakey: Health Minister Mark Butler has been talking up his planned primary healthcare reforms as “the greatest reform since the start of Medicare” – but this is far from the first time a government has attempted to make changes to Australia’s universal health insurance scheme.

Over a decade ago, the previous Labor Government embarked on a comprehensive approach to health system reform via the National Health and Hospitals Reform Commission (NHHRC). Despite a comprehensive consultation process and extensive involvement from the health sector, most of the NHHRC recommendations have not been implemented.

With the Strengthening Medicare Taskforce report due for imminent release, Croakey editor Jennifer Doggett and columnist Dr Lesley Russell revisit the NHHRC recommendations and highlight some that remain a high priority all these years later.

Jennifer Doggett and Lesley Russell write:

Calls for reform to Medicare have been going on almost as long as Medicare has been around.

Stakeholder groups and experts have pointed out the limitations of the Medicare model, which was designed in an era when our healthcare needs were very different from today. Successive governments have attempted to address the need for reform with limited success.

For over a decade (as also highlighted in the National Health and Hospitals Reform Commission’s final report), there has been general agreement around the main problems with an out-of-date Medicare, in particular its inability to adequately support a team-based, comprehensive and long-term approach to chronic disease prevention and management; previous attempts at reform have failed to deliver substantial gains in this area.

These attempts include COAG’s two rounds of coordinated care trials (1997-2005) and more recently the Health Care Homes trial (2017-2021).

The most comprehensive approach to systemic health system reform was the NHHRC, which was established by the Rudd Government in 2008 and delivered a final report with 123 recommendations in 2009.

This process involved an extensive consultation process with health groups, industry and experts and two rounds of submissions. It represented a significant investment of time and resources, from the Government as well as the health sector, which participated in the consultation processes through meeting with the Department and Commissioners, and preparing submissions.

Unfortunately, due to a range of factors, including Labor’s leadership instability, leading to the departure of Rudd in 2010, there was no systematic response from the Government to the NHHRC report. Almost a decade and a half later, most of the recommendations have not been implemented.

Of course there have been major changes to the health system landscape since then; for example, advances in our understanding of the social, cultural, commercial and environmental determinants of health, as well as developments in information technology –not to mention a global pandemic.

However, despite these changes, many of the NHHRC recommendations remain relevant today.

Rather than allocating additional resources for yet another consultation process on overdue Medicare reform, the Government could revisit these outstanding recommendations and prioritise them for its planned $750 million spend.

Some suggestions for key outstanding recommendations to revisit are outlined below. (The italicised sections are the authors’ comments on relevant NHHRC recommendations).

Equity

If we are serious about addressing inequalities and inequities, then we must collect the data that track this over time, in particular for groups who experience reduced access to healthcare and poorer health outcomes. We also need to do better in targeting funding to these groups, in particular to Aboriginal and Torres Strait Islander people.

Key NHHRC recommendations in this area include:

• A regular report that tracks our progress as a nation in tackling health inequity.
• To promote greater equity, universal entitlement needs to be overlaid with targeting of health services to ensure that disadvantaged groups have the best opportunity for improved health outcomes.
• A dedicated, expert commissioning group be established to lead this investment. This could be achieved by the establishment of a National Aboriginal and Torres Strait Islander Health Authority within the Health portfolio to commission and broker services specifically for Aboriginal and Torres Strait Islander people and their families as a mechanism to focus on health outcomes and ensure high quality and timely access to culturally appropriate care.

Data

Fragmentation and gaps in data on primary healthcare make developing and implementing needed reforms much more difficult. We need to improve both the collection and use of data across the spectrum of primary healthcare to drive improvements in quality, equity and access. The case for a National Primary Healthcare Data Set – and analyses and use of the data to improve services – has never been stronger. This work is underway but progress is slow and not publicly obvious.

Key NHHRC recommendations in this area include:

• Embedding a strong focus on quality and health outcomes across all primary healthcare services. This requires the development of sound patient outcomes data for primary healthcare. We also want to see the development of performance payments for prevention, timeliness and quality care.
• Regular monitoring and public reporting of community confidence in the health system and the satisfaction of our health workforce.
• Public reporting on health status, health service use, and health outcomes by governments, private health insurers and individual health service providers which identifies the impact on population groups who are likely to be disadvantaged in our communities.
• Accessible information on the health of local communities. This information should take a broad view of the factors contributing to healthy communities, including the ‘wellness footprint’ of communities and issues such as urban planning, public transport, community connectedness, and a sustainable environment.
• A national approach to the synthesis and subsequent dissemination of clinical evidence/research, which can be accessed via an electronic portal and adapted locally to expedite the use of evidence, knowledge and guidelines in clinical practice.
• To drive improvement and innovation across all areas of healthcare, a nationally consistent approach is essential to the collection and comparative reporting of indicators which monitor the safety and quality of care delivery across all sectors.

Services and infrastructure

Many Australians in rural and remote areas struggle to access even the most basic health, mental health, pharmacy and dental care and on-going specialist care is almost impossible to find. Even in the cities, people can struggle to access the care they need due to a range of cultural, financial and geographic barriers.

Improving primary healthcare infrastructure and services, in particular to currently under-served communities, will require a range of strategies including workforce planning, changes in workforce practices and the increased use of technology.  It will also require ending the turf wars between the organisations representing healthcare professionals.

Strengthening the Aboriginal Community Controlled Health Organisations and setting up equivalent community controlled and comprehensive health centres for non-Indigenous communities, especially those that are disadvantaged and currently under-served by traditional general practice is another important strategy which should be considered. 

Key NHHRC recommendations in this area include:

• That young families, Aboriginal and Torres Strait Islander people, and people with chronic and complex conditions (including people with a disability or a long-term mental illness) have the option of enrolling with a single primary healthcare service to strengthen the continuity, coordination and range of multidisciplinary care available to meet their health needs and deliver optimal outcomes. This would be the enrolled family or patient’s principal ‘health care home’.
• Care for people in remote and rural locations necessarily involves bringing care to the person or the person to the care. To achieve this, we recommend:
  – networks of primary healthcare services, including Aboriginal and Torres Strait Islander Community Controlled Services, within naturally defined regions; and
  – expansion of specialist outreach services – for example, medical specialists, midwives, allied health, pharmacy and dental/oral health services.
• In its expanded role, the Commonwealth should encourage and actively foster the widespread establishment of Comprehensive Primary Health Care Centres and Services. We suggest this could be achieved through a range of mechanisms including initial fixed establishment grants on a competitive and targeted basis.

Funding

It’s clear that more funding is required to meet the needs of the Australian community for high quality primary healthcare. But it’s also important to ensure that any new funding delivers the maximum possible value to the community. This means addressing current cost barriers to accessing care, such as high out-of-pocket costs, and ensuring funding mechanisms support a comprehensive and team-based approach to primary healthcare.  

Key NHHRC recommendations in this area include:

• A review of the scope and structure of safety net arrangements to cover a broader range of health costs. We want an integrated approach that is simpler and more family-centred to protect families and individuals from unaffordable out-of-pocket costs of healthcare.
• Priority areas for new capital investment should include:
  – the establishment of Comprehensive Primary Health Care Centres and Services; and
  – an expansion of sub-acute services including both inpatient and community-based services.
• Medicare rebates should apply to relevant diagnostic services and specialist medical services ordered or referred by nurse practitioners and other health professionals having regard to defined scopes of practice determined by recognised health professional certification bodies.
• Pharmaceutical Benefits Scheme subsidies (or, where more appropriate, support for access to subsidised pharmaceuticals under section 100 of the National Health Act 1953) should apply to pharmaceuticals prescribed from approved formularies by nurse practitioners and other registered health professionals according to defined scopes of practice.
• Where there is appropriate evidence, specified procedural items on the Medicare Benefits Schedule should be able to be billed by a medical practitioner for work performed by a competent health professional, credentialled for defined scopes of practice.
• The Medicare Benefits Schedule should apply to specified activities performed by a nurse practitioner, midwife or other competent health professional, credentialled for defined scopes of practice.

Also read this article by Dr Lesley Russell, analysing the National Health Reform Agreements 2020-2025 

See Croakey’s extensive archive of articles on the NHHRC