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Some expert advice to help Rudd & Abbott’s prep for tomorrow’s health debate

Is the PM’s campaign for health reform a case of six of one or half-a-dozen of the other? On one hand, you could argue that it’s a plus for health when the PM (or a Premier) takes a strong interest in the portfolio. It certainly gets bumped way up the agenda, and new opportunities are created for some serious policy action.

On the other hand, as we’ve seen in recent weeks, there are also major downsides to a PM outfitted in the Health Minister’s clothes. Thus far Rudd has given every sign of being more committed to serious political action than to improving Australians’ health and health care.

Perhaps tomorrow’s debate will prove me wrong.

In the meantime, Croakey’s contributors are conscious that the PM and Opposition Leader have much on their plates today, and hope that the following advice will help their preparations for the big debate. Read on for some debating tips from Professor Pat McGorry, Professor Ian Olver, Professor Kerin O’Dea and plenty more…

Professor Pat McGorry, psychiatrist and Austraian of the Year:

• What advice do you have for the PM?
WHO states there is no health without mental health. Mental health reform must be front and centre of any reform process. Health is much more than hospitals and we are already far too reliant on them because of the failure to invest upstream.  All we have heard about so far is hospitals and waiting lists.  In mental health, we don’t even have waiting lists as people are totally locked out of care. Nowhere is the lack of upstream investment more evident than in mental health where there is sparse investment and meagre coverage of those with mental health disorders.  Much worse than in elective surgery where all the photo opportunities seem to lie. Acute beds in mental health are a disgrace in terms of therapeutics due to the over-reliance on acute services and the under-investment across the board including the lack of haven-style beds. The community are slowly becoming enraged and momentum building re the neglect of mental health. Politicians are behind on this one but it is a sleeper which will surface more this year.

• What advice would you give Mr Abbott?
Same advice. Plus why have you not made an issue of mental health so far?

• How should we assess their performances?
Financial commitments and structural reform promises in support of the NHHRC recommendations

• What do you want to hear from them?
Need to raise taxes to pay for this!! Federal government to rescue and invest in community mental health system.
Strengthen existing headspaces and expand with an extra 60 sites.
Early psychosis roll out of 10 –20 comprehensive centres to back up the headspace model on the specialist end

• And what do you want them NOT to say?
No more comprehensive cancer centre, children’s hospitals and waiting list focus. This is ambulance at the bottom of the cliff thinking. This is same old, same old.

****

Professor Ian Olver, Chair, Australian Chronic Disease Prevention Alliance:

Prevention must be part of the health reform debate.

Increasing levels of largely preventable chronic diseases such as cancer, heart disease, stroke, diabetes and kidney disease are set to place an unaffordable burden on future hospital services, making preventive health programs and strategies a critical part of the solution for a more effective health care system.

We challenge Mr Rudd and Mr Abbott to tell us what they will do to reduce smoking, alcohol abuse and the burgeoning rates of obesity and overweight that are driving our increasing rates of chronic disease.

Will they implement the comprehensive evidence-based strategies recommended by the National Preventative Health Taskforce? Are they prepared to put the health of Australians ahead of vested interests by taking the tough decisions, such as restricting unhealthy food advertising to children? And when will they actually start to do something? With an additional 10,000 Australians becoming overweight or obese each month, we simply can’t afford to delay preventive action any longer.

The Government which campaigned vigorously while in opposition on its disease prevention agenda now seems to have fallen silent on this issue. More than eight months after the Taskforce’s report they have yet to provide a response to the report’s recommendations.

Nor do we know the Opposition’s position on the Taskforce recommendations.

The health debate provides the perfect opportunity for both parties to lay their cards on the table and demonstrate their commitment to providing a comprehensive solution to the issues facing our health system, a solution that addresses not just hospital reform but improved preventive health and primary care as well.

****

Professor Kerin O’Dea, director, Sansom Institute for Health Research, University of SA:

I am not optimistic about either side on this, as the whole issue has been politicised out of all proportion. I am particularly worried that population health and prevention do not seem to be on the agenda at all – the Health and Hospitals initiative seems to be entirely about illness and hospitals.

***

Associate Professor Peter Sainsbury, public health expert, University of Sydney:

• What advice would you give the PM?
Let the principal factors influencing the ‘shape’ of the Australian health system be:
1) the underlying values on which the system should be built – eg compassion, quality health care, health promotion, equity, efficiency and
2) evidence of what works and what doesn’t at the policy and system level

• What advice would you give Mr Abbott?
As above

• What do you want to hear from them?
That they will abolish the private health insurance rebate.
That public health will be adequately funded to promote better health for all Australians.
That a social determinants approach will be adopted rather than a complete emphasis on personal behaviours and responsibility.

• And what do you want them NOT to say?
That the private sector offers many of the answers, that it is anything more than an adjunct to an equitable, efficient, appropriately funded public system.
That private health insurance is an essential part of the system.
That the private health insurance rebate is here to stay.

***

Dr David Briggs,  Editor, Asia Pacific Journal of Health Management:

• What advice would you give the PM?
Despite the political risk move to seek a bipartisan approach with the opposition on health reform, particularly as it is the States and their bureaucrats that are being difficult. In other words demonstrate some leadership for a change, instead of sniping. The two policy approaches have much in common about the need to go to/revert to a more manageable scale of organisation and delivery. At least agree on that and then argue around the periphery. While the health reform has strong community support and the PM has gained traction, elections will not be won on single issues. This reform if supported by both sides of politics would  be a powerful alignment to oppose the intransigent states and do much to begin to reform our federal/state system.

• What advice would you give Mr Abbott?
Abbott can be given credit for recognising when the Minister for Health the need to increase health professional training places, particularly medical students and in rural universities. The challenge that this initiative brings and the more recent similar announcement by Rudd of increased training is the difficulty in finding sufficient places for clinical placements and experience. Abbott should push this agenda because if we do not get the students trained and in the workplace the reform will not be achieved. He should make this challenge a central plank of his policy and force the governments hand to deliver.

• How should we assess their performances?
Performance can be assessed by:
1.       Leadership and statesmanship
2.       A policy that defines and differentiates the roles of funders, purchasers and providers
3.       A policy approach that recognises the specific additional needs of Indigenous, rural and marginalised urban groups.
4.       A clear statement that repudiates the centralist bureaucratic control of health care of the last two decades that has been a failure.

• What do you want to hear from them?
A recognition and commitment that this health reform will require an investment in high quality health management at the local service delivery level that at the moment has been decimated by the systemic centralised political and bureaucratic control.
A system of alignment and incentives that encourages the networks and PCHO (Divn GP) and the aged care sector to cooperate and deliver integrated services across their organisations.
A system of transparent accountability and performance review for State health bureaucrats to ensure that their failures of the past are no longer supported.

• And what do you want them NOT to say?
Blame game commentary, even though there are plenty to blame

• Anything else you’d like  to raise?
What mechanisms would they put in place to ensure that recalcitrant State bureaucracies effectively implement the networks and adopt an appropriate role for the health department(s).
How would they ensure that the significant resources now spent on middle order area health bureaucracies is quarantined and returned to the health delivery system and not to State treasuries.

***

Health economist Ian McAuley:

• What advice would you give the PM?
State your policy principles.

• What advice would you give Mr Abbott?
State your policy principles.

• How should we assess their performances?
High marks – articulation of clear choice between policies.
Low marks – obfuscation, hedging all positions, vague statements, statements in passive voice, goals without timelines

• What do you want to hear from them?

  1. We will always want more health care than can reasonably be supplied.
  2. Perhaps we should pay more from our own pockets for health care.
  3. Private insurance is not part of the solution; it’s part of the problem.
  4. We will bring private hospitals into the same funding base as public hospitals.
  5. Our health care structures and policies place the interests of providers, professional groups and insurers above the interests of users.

• And what do you want them NOT to say?
“big new tax”

***

Professor David Penington, Senior Fellow at the Grattan Institute:

• What do you want to hear from them?
How will each of the separate ‘silos’ of heath policy addressed by National Health and Hospitals Reform Commission be brought together so they interface effectively?  How will this be achieved without duplicating Commonwealth and State bureaucracies in each State?  What will be the role of the University-linked teaching hospitals in oversight of quality of health care, and of teaching and training across the many hospitals they need to relate to?

****

Dr Rod Macqueen, drug and alcohol expert:

• What advice would you give the PM?
Do not play politics. At the same time, we need to acknowledge that playing politics, the blame game, and ensuring sinecures for the mates will not stop just because there is a new model. There may just be more money to squander. Do not overstate the “mess” health is in, as was done with the NT “intervention”. Some things are done well, and should not be destroyed to subserve some new unproven model. If we do not get prevention and health promotion right, we will go bust and experience worsening health. Why is there so little discussion here? Address the social determinants of health – heck, acknowledging them would be a start. Amongst rural and marginalized people, the social determinants are far greater than any choices they make. We cannot use an acute care/ hospital/surgical model to address complex (and complexly determined) chronic health problems. Read Illich “Limits to Medicine -Medical Nemesis (1976)”, it is still relevant today as we focus on new hospitals, bed block and the PBS.

• What advice would you give Mr Abbott?
Much the same as above. This needs to be a bipartisan issue. But try not to be bitter, and little minded, and encouraging of jealousy, fear and divisiveness, like the Howard government was. This is not healthy for the politicians or the country. We need confidence and optimism and hope, not the support of the radio shock jocks.

• How should we assess their performances?
This is not my field, so I would suggest we leave it to the experts. I would hope we look for hard content over style.  I tend not to watch this stuff anyway as it is about the spectacle and probably has little impact upon health. The cult of personality, when combined with micromanagement and spin, is actually antithetical to good evidence based health care (or anything evidence based), in any case. This is not about Rudd or Abbott, in the end it is about how long and how well we live, and how our kids will do. These two mortals will be gone before too long, but their legacy will  linger.

• What do you want to hear from them?
Certainly not a focus upon just those things politicians and their bureaucrats like which are all easily measured in short time frames but may not actually measure what we need to measure, like improving health  service efficiently (ie bang for the buck vs other ways to use those finite resources). Some words like complex, chronic health problems, social determinants, evidence of benefit, prevention, efficiency would all be nice. Some humility instead of hubris and spin would be good – health is a big issue and no one person has all the answers.

• And what do you want them NOT to say?
Spin, how much we spend, how the other team blew it last time, how only I will get it right, more on the cult of personality. We’ve done that and we’re tired of it.

• Anything else you’d like  to raise?
I’m not sure this will be much more than a spectacle and do much more than support the cult of personality. Both these contribute nothing to health. In the end, the processes we use in our daily lives make us who we are as individuals and communities, so pandering to the media for a spectacle with some quick sound bites may actually reflect and support the processes that support bad health! A series of local, community level discussions (as Mark Latham proposed) may be a better way to address this issue and promote healthy change by participation rather than passively watching.

****

Ron Batagol, pharmacy consultant:

• Advice to the PM
A lot more detail is required on the details of how primary care services in the community are to be improved.

Given the shortage of GPs, you have indicated you will utilise nurses for in some areas. Would you consider using pharmacists to assist in providing a uniformly-acceptable standard of primary care for a range of common ailments.

This could include advice and medical referral, working collaboratively with doctors, and incorporating  appropriate fee-for-service, instead of the current practice of “ad-hoc service and no fee” arrangements given in isolation, at individual pharmacies.

• Advice to Mr Abbott
If you are in favour of a co-ordinated national plan for hospitals, how will your network of local hospital networks differ from, and be better than, those proposed by Mr.Rudd, and will you avoid adding “just another layer of bureaucracy”.

3. How should we assess their performances?
The PM – a lot more detail on the effective co-ordination of community care and hospital care, and on how the skills of health professionals, such as nurses and pharmacists, can be effectively utilised to provide high-quality primary care, in an environment of a shortage of doctors at the GP level.

Mr Abbott – A detailed plan for a nationally co-ordinated hospital plan, integrated with primary care in the community, which will be better and more cost-effective than that proposed by the PM.

4. What do you want to hear from them?

The PM – needs to satisfactorily explain how  the “whole package of health reform  is to hang together”, so as to achieve a more  “seamless” transition of patients between hospital and the community. He also needs to explain how the “blame game” will end, given that the States will still, as is currently the case, be responsible for an albeit lower (40%) percentage of the overall costs, and a capping of hospital services in the form of an activity target.

Mr Abbott needs to fully explain why the Government’s  proposed national coordinated plan will not work, and what specific plans he has in mind that will achieve better healthcare delivery and service at all levels.

5. What do you want them not to say?
When addressing issues, The PM must stop the ”segue” to the failings and past history of the opposition when they were in Government, ad nauseam, at every opportunity, and concentrate instead on what he is aiming to achieve with his propose national healthcare plans.

Mr Abbott should acknowledge the good points of the Government’s proposed national health care plans,  indicating where he is in agreement, and suggest an alternative plan, if he has one, that would improve on the weaknesses of the proposed Government plan.

***

Margo Saunders, Public Health Policy Consultant, Canberra:

To the Prime Minister:

Quick – who said this?

“We need to change the mindset which currently sees billions being spent on managing diseases rather than preventing them in the first place. … It is time to move PREVENTION from the periphery to the centre of the health system. … Australia desperately needs an integrated primary health care and prevention strategy.”

It was Julia Gillard in an address to the National Press Club in February 2006, reiterating many of the themes of her previous Press Club speech in 2004.

Your Party entered Government with an important focus on preventive health.  Your name and the name of your Health Minister appear on the front of the policy document, Fresh Ideas, Future Economy: preventative health care for our families and our future economy, issued in June 2007.  (Perhaps tellingly, this document has been removed from the Labor Party’s website.)  Fresh Ideas, Future Economy notes the imperative of finding ways to keep more people healthy and out of hospital and is critical of the ‘piecemeal approach to prevention.’  It is also critical of the disproportionately small amount of investment directed to prevention initiatives, especially given the evidence about rate of return on these investments.

Your Party has also recognised that preventive health – all of those things that help keep people well – is not just about the healthcare system, but is, to a large extent, about the myriad aspects of day to day life: how we eat, drink, travel, work, and relax.

Echoing many of the themes of Fresh Ideas, Future Economy are key statements in the National Labor Party Platform.  For example, Chapter 6 includes a key paragraph stating that:

38. Labor recognises that health maintenance, promotion and illness prevention will have vital roles to play in combating the rise of preventable chronic diseases, and that the responsibility for this rests primarily with governments. Progress will, however, also require substantial changes in personal behaviour, which can only be achieved and sustained with the active participation of all levels of government, the non-government sector, health professionals, local communities, and individuals.

This is prefaced by other key paragraphs, including:

7. It [health reform] will also require a far greater focus on prevention and wellbeing. Keeping people well and out of hospital will deliver benefits not only to individuals but to the entire health system, taking pressure off our strained hospitals and allowing governments to use existing resources more effectively.

36. Labor believes that primary care and prevention must play much greater roles in the Australian health system to address the rise of preventable chronic diseases like type 2 diabetes, cardiovascular disease, and some cancers, which are placing a growing burden on our health system.

37. Labor believes that we cannot allow to go unchallenged a situation in which our children may have a lower life expectancy than adults currently enjoy. Labor believes in national leadership to improve the health of Australians and particularly Australian children. This is a vital social priority as well as an urgent economic priority. …

So…given that the legislation to establish the National Preventive Health Agency has stalled in the Senate, and that the Government has not provided a formal response to the recommendations of the National Preventive Health Taskforce, can the Prime Minister indicate:

–  what the Government’s intentions are in relation to chronic disease prevention in the light of the Preventative Health Taskforce’s recommendations in the key areas of tobacco, alcohol and obesity, and

–  specifically, in relation to initiatives outside of the healthcare system, how the Government intends to move forward on measures such as plain packaging and tax increases for tobacco products, and more effective controls on the advertising and marketing of alcohol and of ‘junk food’?

****

Retired GP, Dr Peter Arnold:

• What advice would you give the PM?
1. The major stumbling block is the shortage of nurses. Not enough nurses -> not enough hospital beds -> not enough patients admitted and treated -> not enough training of doctors and nurses. Make nursing an attractive profession, with apprenticeship and practical training in hospitals instead of theoretical university studies.

2. Train health care workers for rural and remote Australia. Defy the AMA’s insistence on rural and remote primary health care being the preserve of medical professionals.

• What advice would you give Mr Abbott?
Expose the practical nonsense of most of what Mr Rudd has said so far. Doctors cannot be trained other than ‘on’ patients in hospitals – medicine is a practical profession, not learnt from books. How on earth does Mr Rudd propose to ‘supply’ enough patients for all these new doctors to learn from? Is each patient going to have ten students each insert a finger? How can private patients in private hospitals, with ‘choice of doctor’, be ‘persuaded’ to let students ‘have a go’ at them?

• How should we assess their performances?
Regrettably, the electoral cycle is too short for that. By the time any sensible measures yield useful outcomes, there’ll be another government in power. At the very least, any suggested remedies must be shown to be practical, not airy-fairy theory. We’ve all suffered enough from that, especially under Wooldridge with his mythical doctor surplus and the inappropriate business of training nurses in universities instead of where the sick people are.

• What do you want to hear from them?
That they are taking the advice of practical doctors and putting practical doctors (safe from political interference) in positions of authority throughout our health care systems. Becoming Director-General of Health now means being the ‘fall guy’ for the Minister. Such positions should have tenure and be remote from Ministerial control.

• And what do you want them NOT to say?
That they are being advised by bureaucrats who tell them what they (the politicians) want to hear.

**

Senior health service manager:

At the time of writing I have yet to hear the outcome of the state elections in Tas and SA. Notwithstanding this I am feeling pessimistic about the possibility of real reform.

This is for two reasons. First, because what Rudd has offered is partial in scope and limited in vision. This approach is particularly weak because it has potential negative synergies with his apparent difficulty in operationalising policy as demonstrated with the insulation, schools, intervention, greenhouse etc. In addition to this weakness in policy, this difficulty with operationalisation must also reflect on the capacity of the Commonwealth to manage health services. This is not to say that I think Abbott is any better, it is just that being in opposition he is spared the requirement of being judged on what he delivers as well as what he says.

Second, it seems unlikely that Rudd will be able to deliver what he proposes. He must have known this when he proposed it, which leads one to speculate cynically about what his real motives are.

However, both experience and common sense suggest that, as a nation we only have a limited number of bites at “health reform”. I am one of the minority who question whether the system is as broken as people think, or, more properly, believe that the first step in determining whether the system is broken it to have some data, and that those data are currently insufficient.

Both leaders have each now called “wolf” once: Abbot promising health reform in the last years of the Howard government and Rudd being at risk of doing so now. My question to both then is, how are they going to ensure that appropriate and meaningful health reform is happens once they have stopped using healthcare reform as their favourite football and moved on to some temporary new topic? The real risk is that their mutual wanking will spill the seed on infertile ground and that there is no baby.

***

Dr David Atkinson, a doctor in the Kimberley, WA:

The main issues relate to the primary care/hospital care interface.  This includes:

(1) how to prevent expensive hospital services sucking up all the resources that should be allocated to prevention, particularly secondary prevention (early diagnosis and management of chronic disease to prevent or delay complications); and

(2) cost shifting between the sectors (cost shifting occurs at many levels in the health system including between budgets within the various departments of health – it is not by any means limited to Commonwealth/State division.  Includes cost shifting from hospital budget in regional area to budget that funds RFDS for patient transfers, cost shifting from primary care to hospitals on weekends and after hours, cost shifting between OATSIH budget and mainstream health budget, cost shifting between State population health budget and hospital budgets).

Would they consider a trial of regional fund holding for Rural/Aboriginal health (including buying in the needed tertiary services outside the region)?

The Kimberley would be good trial region and I am sure the Aboriginal Community Controlled Health sector and the WA Department of Health would be keen to be involved.  The Kimberley shares many similarities with the NT, with Aboriginal health being the overwhelming priority, but did not receive the ‘Intervention’.  The Kimberley has a quarter of the Aboriginal population of the NT but with much less than a quarter of the resources they have for health services.

***
Professor Ric Day, University of NSW:

• What advice would you give the PM?
– we need a national PBS system to cover all medicines
– we need to establish a national health data evaluation service & expertise to understand the results of our investment in health e.g. a data linkage capability that can help us answer questions quickly and powerfully about matters of safety in particular
– we need a strong, national, eHealth framework and protocols so that all the ‘bits’ fit together
– we need focus on prevention, primary health care, indigenous health care
– bring on health technology assessment for all interventions proposed especially if they are expensive
– we need to examine how to reduce ‘defensive’ and thus unnecesary, expensive medicine.

****
Justine Caines, Secretary, Homebirth Australia Inc:

It seems the health reform debate is shaping up to be who has the biggest… Pile of cash. Little has been mentioned of reforming practice that is not evidenced based and is costly. Maternity care is a good example. The caesarean section rate in Australia is now higher than the U.S. 30% of babies born by caesarean section to mothers with no risk factor end up in special care or Neonatal intensive care. Despite a maternity services review and a plan to fund midwives through Medicare there has been no investigation of the appropriateness of obstetric controlled maternity care and the huge cost to taxpayers as the largest volume area of health that accounts for the greatest number of hospital bed stays.  How can you justify such spending and proceed with major reform when there has been no analysis of safe and appropriate practice?

***

Mental Health Council Australia statement:

As the leaders begin their first election debate, millions of Australians will be hoping that the words ‘mental health’ are not only mentioned, but real commitments are made to change the ongoing tragedy and desperation facing many Australian families.

There is a reason why the National Health and Hospitals Reform Commission devoted a whole chapter to mental health – the only other area that received this level of attention was oral health. This year alone, there will be over half a million presentations at Australia’s hospital Emergency Departments by people seeking urgent attention for their mental health problems.  Less than a third will gain admission, most will not receive treatment.  Those who do gain a bed have a one in seven chance of being discharged and readmitted within 28 days.  Over 40% of those currently occupying a hospital acute mental health bed would not be there if there were appropriate community based services available.

Given these facts, there are three fundamental questions we would like to see put to both leaders on Tuesday:

1.      Are you aware of the ongoing suffering and frustration at the lack of access to appropriate health care for hundreds of thousands of people with a mental illness and their families in Australia?
Although both parties talk about mental health as an issue, neither has committed to addressing the problems currently being experienced in most Australian communities.

2.      Will you acknowledge the need to look beyond hospital beds and invest in more effective and appropriate community based mental health care?
We could provide an extra 1000 mental health beds in hospitals tomorrow and they would be full and effectively blocked within a month.  Until appropriate community based care is provided, our hospital centric responses are doomed to ongoing failure.

3.      Will you give a commitment to implementing the 12 mental health specific recommendations of the National Health and Hospitals Reform Commission?
There has been no response from the government or the opposition regarding these long discussed and seriously considered recommendations.

If you have cancer in Australia, you can expect high quality care and a responsive health system that would not turn you away until your cancer is more life threatening.  Yet everyday in Australia, hundreds of people with a mental illness are turned away from health care and wait until their mental health problem poses a real risk to themselves or others.  Australia’s mental health consumers and carers are tired of platitudes and running out of patience.  Mental health reform is critical to health reform and must be addressed by our leaders in any debate about health in Australia.

****

Simon Burrow, pharmacy industry consultant:

The ASX suspension of trading by Sigma Pharmaceuticals, and the bottomed out API share price has been mostly attributed to low margins on generics and the inability of the wholesalaers to make a profit. However, the pharmacists are enjoying large discounts, incentives and government pressure to dispense generics. If these two giant wholesalers were allowed to ‘collapse’ due to protectionism of the pharmacist, where would the distribution of medicines to both pharmacies AND hospitals and clinics be?

Comments 1

  1. jenauthor says:

    While there are some common themes, the above shows why reform is so difficult, everyone sees the problem from their individual point-of-view, thus they push their barrow accordingly.

    I agree that the system ain’t as broken as people would like us to think — good news rarely gets a headline, but an individual’s bad experience sells papers and allows the shock-jocks to confect outrage and get their audience mobilised.

    Prevention is a must — and the government paying people’s private health insurance is obscene (and I am one of those privately insured — but that’s my choice so I should be paying the premium, not the taxpayer).

    What I want to hear the PM say? That the bureaucracies in all states will be dismantled and rebuilt, removing excess.

    What do I want to hear Tony Abbott say? Something other than NO. We need policy and ideas, not naysaying.

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