Get rid of the private health insurance subsidies and focus on primary health care and prevention, mental health, rural health and other under-served areas.
Listen to the wisdom of regional communites rather than central bureaucrats, and rethink some elements of the national health reform agenda.
And it would be wonderful if you could help kick start a national conversation that moves us beyond a focus on hospitals to tackling the social determinants of health.
Those are some of the tips for the new PM when she gets a chance to turn her attention to a portfolio she knows well.
Thanks to the Croakey contributors below for helping compile a health briefing note for Julia Gillard.
Dr David Atkinson, Broome, WA:
Rural, remote and Aboriginal health need a regional approach with strong voices for the different community groups. Central to this in many regional areas is ensuring Aboriginal people have a voice in determining where regional resources are spent.
Make more use of existing on the ground structures and listen to regional communities and not just to urban based bureaucrats in both the Commonwealth and State departments of health. Allocate resources according to need but let the regions work out how best to allocate resources.
The expensive and inequitous health insurance rebate needs to be dismantled. This uncapped subsidy is a major impediment to improving public health in Australia and minor changes to the means test are not the answer.
The reliance on fee-for-service as the primary means of health funding in Australia is a major problem that needs to be addressed systematically so that a reasonable proportion of funding is per capita needs based. The current system encourages procedures and discourages public health and evidence based approaches. The Government has made some timid steps in this direction but needs to have a plan to create a sizeable shift in the funding mix.
Margo Saunders, public health policy consultant:
In addresses to the National Press Club in 2004 and 2006, you stressed the need for investment in preventive health and for prevention to be moved from the periphery to the centre of the health system. I urge you to revisit the excellent observations and recommendations that you made then and to consider how the momentum can be regained to ensure their implementation.
You have noted that arrangements under Medicare fail to provide the right incentives to encourage regular checkups and screening and the provision of health advice.
The problems, however, are not only on the health care delivery side. For too many Australians, a low level of health literacy stands in the way of better health. The incentive of ‘better health in the future’ is, for many, an insufficient incentive to adopt healthier lifestyles today, especially when pervasive and sophisticated advertising, promotion, pricing and cultural norms urge us to (over-)consume products, the longer-term health impacts of which have no chance when viewed against short-term gratification.
There are many important and practical measures that can be undertaken to address the obesogenic environment, tobacco use, and excessive alcohol consumption; other health issues such as food safety and road safety also deserve attention.
In terms of reforms directed at preventive health, the Government has failed to adequately support the recommendations of the National Preventative Health Taskforce.
As you have recognised, addressing chronic disease and the overall burden of disease and injury in Australia will not be achieved by simply throwing more money at treatment. Making health, in all its facets, easier, cheaper, more convenient — and ensuring that the ‘default options’ are more supportive of health — should be regarded as a priority.
Regulatory approaches have been responsible for significant advances in public health and should not be shunned, especially in cases of market distortions.
You have noted the importance of integrated strategies. The Health portfolio is full of aspirational, strategic, motherhood, fatherhood, and all manner of other statements whose impact will amount to little unless they are reflected across in other relevant policies and in how things are done on the ground. The new National Male Health Policy and the forthcoming revised National Women’s Health Policy, for example, need to be reflected in other strategic policies at the national and State/Territory levels and in the orientation and delivery of health policies and programs.
Dr Rod Macqueen, an addiction medicine physician from rural NSW:
Dear New PM,
Congratulations, and I hope this job is not a poisoned chalice.
My first tip for a healthier rural Australia – listen to the local community, and their health workers. Use their strengths, help them overcome their deficiencies. Health maintenance and improvement is not an issue solved by masterstrokes from a central government, no matter how sincere they are.
Sincerity means little – learn from the NT “intervention” that these steamroller approaches frequently do more harm than good.
Good health comes form a more devolved community building model. I think Mark Latham talked about this, and it did not go down well with the centralised power accretion mob, but he may just have been right.
The guidance, the drive, the assessment of progress, the targets, and the funding can all be centrally managed, but the day to day running needs to be local, and cannot be micromanaged. I think this is a process your immediate predecessor got badly wrong. This approach would probably work in the cities, too, where problems (eg, surgery waiting lists) do not seem to be going away.
Second, mental health is part of health. Services need to be better funded both overall and as a proportion of total health spending. Mental health also needs to be better integrated into mainstream health, as does the management of drug and alcohol problems. People with mental health and drug & alcohol problems (and especially those who have both) are often overusers of the mainstream health system, but their underlying issues are too frequently ignored or glossed over. We would not tolerate this negligence if it were diabetes or cancer being overlooked, and we should not accept poor practice as the norm with mental health and drug and alcohol problems.
Third, we cannot train health workers to better manage the growing burden of chronic, complex health problems by teaching them about acute or rare problems in high tech tertiary referral centres. These facilities suit teaching staff, but poorly equip our doctors and nurses to address the real problems they will see daily. Far more community based training and hence, funded training places, are needed. Community based training is not the second best option when we have too many students for the hospitals, it should be the preferred option.
Fourth, where is the discussion, let alone the action, on the well documented social determinants of health? I find it hard to believe that a Labor government apparently cannot even discuss the issue. There are big health gains to be had if government is brave and does some serious, evidence based leading. Most people want happier, healthier, safer communities, but are not sure how to make that happen. Can we move away from law and order campaigns, longer sentences, more jails, more police, and higher walls on gated suburbs, and talk about equity, social justice and evidence based prevention strategies? Some leadership is needed here, please.
Your comments in your first press conference about the importance of quality education are germaine – early universal child home visits have been discussed for years, but only sporadically done. There is overwhelming evidence of benefit, it’s the single best place we could spend money.
If you pushed that, we could begin to close down juvenile detention centres, jails and psych beds within 10-15 years. Someone needs to tell the public this is TRUE, doable, and sensible.
Dr Yvonne Luxford, Chief Executive Officer, Palliative Care Australia:
Firstly I think that we should take the time to acknowledge the commitment that Kevin Rudd made to improving Indigenous health through signing the Statement of Intent to close the gap in Indigenous health equality, and to report on the progress annually. The true value of this commitment was that it had bipartisan support, but a Prime Ministerial signature carries a lot of weight.
He also deserves credit for prioritising the need for health reform, and giving a focus to prevention.
Julia Gillard was an excellent shadow health minister and has great experience in this field. She could use her new position to re-open discussion on the health reform agenda to provide a greater focus on health outcomes rather than governance and financing.
Revisiting the reform agenda could enable a focus on true integration of services rather than the distinct splitting of the system into primary care (largely interpreted as GPs) and hospitals. This would not mean that all the governance and finance work would need to be discarded, just that it be restructured to better centralise the needs of patients.
The result of all of the incredible work on this reform package should be better health outcomes for all Australians and the package details should be able to demonstrate exactly how this will be achieved.
Public health physician Dr Jan Savage:
Very briefly the areas that are important for Australia’s health and wellbeing are:
· Investing in preventative health – beyond tokenism
· Responding effectively and sustainably to mental health
· Reorienting our health services to be client centred, multidisciplinary, integrated and planned – not just services provided by hospitals and doctors
All require proper planning, funding and long term investment.
Ron Batagol, pharmacy consultant:
I think there is a desperate need to reform primary health in a way that better co-ordinates the intensive high-care management of people with chronic &/or life-threatening in hospital with their ongoing medical management in the community primary care setting.
Keeping people out of hospital and managing them better at home is the key to better community health outcomes, and it take a lot more than just setting up new bureaucracies as is proposed, to shuffle the available money around.
One important factor in this is to make better use of the available expertise of nurses, pharmacists and other health care professionals to assist this process. Critically, that must include better management of mental health issues!!
Professor Lesley Barclay, Director Northern Rivers University Department of Rural Health:
We need good advice from wise heads on how this reform will get played out – not single agendas. It will be opportune to see the health minister have an opportunity to lead and enact reform in light of the range of reports and reviews that have now reported.
Hopefully this will mean listening to people who have experience and knowledge of systems to make sure we go forward not backwards.
I personally am concerned that primary health care comes back on the agenda and we create health rather than hospital networks. These incorporate leading local GP organisations and other primary health care services with acute care, particularly in rural and remote areas.
It is the juxtaposing of these where we have much opportunity to reform and improve. We have potential – if the area and resource base of boards is big enough, to regain rebalance between competing agendas in ways that reduce long term acute care by working on early intervention and prevention.
Health care rather than illness care can incorporate safe and supported experience of patients across a continuum of services that makes a difference locally. This leaves people supported and cared for across all elements of the health continuum in a way that improves safety, minimizes non essential hospital admission and makes good decisions about local targeting of resources and effort.
Professor David Penington, Senior Fellow, Grattan Institute, University of Melbourne:
I would hope Julia would accept a commitment to continue the reform process recognizing that there is a huge amount still to be done in working out how the different sectors are to inter-relate one with another.
These include hospitals with primary care, primary care with aged care at a community level giving support for people to stay in their own homes and for the sub-acute hospitals to be seen as Rehabilitation Hospitals, not just as a point to offload older people from Acute Hospitals.
Hospitals themselves need to develop clinical governance processes with medical involvement to secure safety and quality of services. There is a huge amount to be done for mental health which will require considerably more funding, as well as more explicit processes for management of services.
She needs to acknowledge that the Commonwealth’s statement that it is taking over all primary care is not, in itself a solution to anything.
Officers of DoHA cannot manage community services around the country and there is an urgent need to review how these services are to be managed effectively with interface with GPs, participation by Community Nurse Practitioners and Physiotherapists. ‘Medicare Locals’, said to be able to do everything for everybody, do not yet exist.
Acknowledging that the next three years will require extensive consultation following the election, to get sensible process in place, would be a good start.
Jon Wardle, NHMRC Research Scholar, School of Population Health, University of Queensland:
Gillard certainly brings a lot to the table as prime minister. She appears less controlling, more consultative, certainly has a lot more friends within the government and is generally a more effective communicator than her predecessor.
However, a major problem is that although Gillard brings a breath of fresh air to the parliament, the same powerbrokers and apparatchiks remain at play behind the scenes. Whilst Mark Arbib and the Right factions have recently distanced themselves from the (now former) Prime Minister Rudd and played a large part in getting Gillard to the job, the fact is that they were not only responsible for instilling him there in the first place, but also largely responsible for many of the recent disastrous policy decisions and backflips that drove the popularity of both Rudd and Labor into the red.
As Mark Latham wrote, the NSW Right can “tell you what the focus groups said last night but they have no idea about political trends six months from now”.
Australians can be a fickle lot – and focus groups can pick up and run with this fickleness if not contextualised properly – yet by and large the population yearn for true reform and a bigger picture government. Hawke once said that we should never underestimate the intelligence voters, yet no-one’s been talking to them like adults on health reform (or anything else for that matter) for years.
The fact is that governments simply don’t lose elections on issues like promising to fix the health system – it’s only the failure to deliver and the incompetence in doing so that do them in – and in this regard recent backflips have done Labor no favours.
On the face of it Gillard certainly seems to have the courage to make reform happen, but the question remains – will Labor or the Right faction more specifically actually let Gillard be Gillard?
Unless the Labor party stops its ridiculous and clearly ineffective tradition of listening to the NSW (and now Victorian) Right and focusing on short term spin rather than long term substance, whilst lacking the courage to go ahead with the real reform it promised, we may soon have to contend with a new prime minister from a party with virtually no policies at all rather than worrying what Gillard is all about.
And that’s also a concerning thought for health reform.
Carol Bennett, Consumers Health Forum:
Health consumers have been very supportive of your reforms to date, but we would like clear support, practical and financial, to ensure that consumers have an significant voice in the new health bodies being established under these reforms. Health reform will only be fully effective when the experiences and opinions of the people who use and pay for the health system are properly recognised and taken into account.