Meanwhile, a senior health industry insider with long experience in the public health bureaucracy now gives us ten tips for driving health reform in a useful direction. Because of the usual political and bureaucratic sensitivities our correspondent’s identity cannot be revealed.
“1. The proposed reforms are a reasonable start if all we were dealing with was hospitals. As Bernard Keane noted in the Crikey blog of 15 March ‘The irony is that health reform is — at least in terms of the primary target, hospitals — a sort of confected issue. Australians aren’t crying out for a more economically efficient hospital system. Instead, they’ve been convinced by politicians and the media that the current system serves them poorly.’ But the proposals fall down in one minor detail: the Commonwealth couldn’t run a root in a brothel. Just look at their attempts at service delivery in other areas – the latest fiasco with roofing insulation (run by a department headed by Robyn Kruk, a former Director General of NSW Health, who should know something about services). Though in some areas they aren’t too bad – Centrelink, for example.
2. Rudd made a serious mistake in personally attacking bureaucrats because it is an unnecessary diversion but he does raise the valid related issue of how those who built the system are perhaps not the best equipped for reforming it. Why should they be? They think they have done a good job – and they have, if you consider their brief. Really, can you imagine Deb Picone (the survivor of NSW Health), Tony Sherbon (who has now done stints in three States), Mick Reid (two states plus the WA inquiry), or Chris Brook (not a successor in sight) really wanting to change anything? Their problem is they think they know everything and they belittle all new ideas. And they have been running against the National Health and Hospital Reform Commission recommendations since before they were released (and have convinced Ministers and Premiers). Mind you the NHHRC’s muddle headed thinking didn’t make that too difficult.
3. Australian hospitals in comparison to those overseas are not in crisis. The Wodak blog makes that quite clear.
4. There is considerable scope for reform that would lessen the pressure on hospitals if we were able to do two things. First, identify those services hospitals should not do. In most advanced systems there are a common range of these that are variously labelled as bed blockers but which are more complex, usually based on historical craft behaviour or lack of development of alternative services. Second, identify “appropriate care” standards. Australia does not measure this data but Rand has had a tool for over 20 years and many countries do. The results are generally terrible and I don’t expect they would be any different here.
5. Set targets for reform outcomes for the hospitals based on this “real” data, not the demand data of the suppliers eg the doctors who just want more beds or cash for waiting lists (that’s a failed strategy we have been employing for many years now with no lasting results).
6. Use standards to set the targets, and identify likely “savings”, not for Treasuries but for the system as a whole. As soon as Treasuries hear the word “savings” they think they are theirs. They have absolutely no concept of reinvesting within a system, or of the time lags that savings also entail. You just can’t take money out without investing in alternatives or abatement services.
7. Let the States run the hospitals – they are quite good at it – certainly better than the NHS in the UK, but within the context of the proposed reforms – 60/40 Commonwealth/State funding, local boards and add in state-based quality commissions charged with appropriateness of care and evidence-based services. And the aforementioned bureaucrats might just be up to this task if they could accept some advice.
8. The Feds should take over not only primary health care, (and not use Divisions of GPs because they are not real organisations. They are partnerships of independent small businesses that spend half their time turf protecting from the threats of nurse practitioners and other self-perceived threats to income maintenance) as well as Public Health.
9. The Feds should set up a national Public Health Agency to run the evidence and regulatory sides of Public Health and maintain the National Prevention Agency (if it ever gets up) for social marketing. They should be required to work collaboratively eg have a single chair with two separate boards.
10. We need a rigorous independent analysis of public health and prevention spending. NSW and Vic (and probably also Qld) spend virtually nothing other than Commonwealth funds, though they will deny that. But it’s true, and now the State Treasuries have even managed to get rid of what protected funding there was by rolling them into the National Health Care Agreements. This means instead of that money coming directly from DoHA to State Health departments tied to public health, it goes from Commonwealth Treasury to State Treasury, they skim it for “efficiencies”, then send it untied to health departments where again it is skimmed – subject to the power of those same hospital centric bureaucrats who set up the system. This year public health has had more funding cutbacks if we are to believe the AIHW.”