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The Health Wrap: Looking back at 2019 – and predictions for 2020

In the first Health Wrap of 2020, Dr Lesley Russell looks back at the issues on the health agenda in 2019 (and sadly for many years, if not decades, before this) and provides an overview of the successes (few) and failures (many) of the Morrison Government to date. 

She provides a comprehensive overview of possible areas for reform this year including obesity, prevention and the Medicare Benefits Schedule (MBS) and outlines the inquiries and reports which may also drive changes, including aged care, mental health and Indigenous health and welfare.

While not overly confident that the current government will make substantial progress in any of these areas, Dr Russell concludes with a useful list of six essential components which will need to be in place if we are to address these ‘wicked’ problems which underpin the growing health and social inequalities in Australia. 


Lesley Russell writes:

In the first edition of The Health Wrap for the new year I am looking what we can expect for 2020, on the basis of the key health and healthcare issues and policies in 2019.

Over the year, the focus of The Health Wrap and that of other writers for Croakey was overwhelming on a common handful of issues – primary care, mental health, Indigenous affairs, dental health, prevention, the social determinants of health, and climate change.

These are the issues that underpin growing health and social inequalities so that for too many, Australia is no longer the country of the fair go. They are all wicked problems that will require sustained effort and resources to solve, but they become only more costly in terms of lives and dollars if the can is kicked down the road.

My initial overarching, overwhelming and overly depressing assessment was that the Morrison Government plans business as usual – protecting the status quo and the budget surplus.

My pessimism about the possibilities of meaningful change and reform was further reinforced when, in a Marie Kondo-inspired cleanout of my papers, I came across a folder of the opinion pieces I had written at the turn of the century: I was writing then about the value or otherwise of private health insurance (in the days then the PHI rebate was only $2 billion); on the need to do more in prevention and the management of chronic disease to keep people out of hospital; on how penny pinching in healthcare spending will lead to cost blow-outs elsewhere in the budget.

Oh, and a piece on the torture that government policies meant for asylum seekers. These pieces, so old that they are not available on the internet, remain terrifyingly current day – only the dollar figures need updating.

Despite the obvious, exemplified by the failures of the Prime Minister and his government with respect to the climate crisis Australia is facing this summer, I have decided to adopt a (slightly) more positive approach to this summary.

This is predicated on several factors:

  • There are several major reports due in areas like aged care, mental health and primary care that will outline what must be done and will be hard to ignore.
  • I’m anticipating concerted campaigns for change and action from voters and those working at the coalface.
  • There are many small-scale examples of initiatives that are working well and these will grow in numbers, scope and impact as their success is made public and their leaders come forward to work with their peers.
  • The Morrison Government will be anxious to redeem itself in the eyes of voters.

 


The April Federal Budget and the May election

Sadly, these both must be written off as lost opportunities in health and healthcare – may we not see their like again. My overall sense about both the Government’s election commitments and the Budget was that there was no strategy and that dollars were dribbled out to win votes rather than deliver health outcomes.

I wrote about election commitments on 28 January and again on 28 April and 13 May. It’s really insightful to go back and read the #AusVotesHealth Twitter Festival (perhaps better described as a Twitter storm) that was led by Croakey on 8 May, with a huge number of participants.

It is a most remarkable and on-target assessment of what is needed for a health and wellbeing system that is fit-for-purpose in the 21st century.

I wrote about the 2019-20 Budget on 5 April – and cross-referenced Croakey’s excellent and much more complete coverage.


(Possible) reform initiatives on the horizon

In August, at a speech at the National Press Club which was focussed on mental health, Health Minister Greg Hunt also released a document grandly titled Australia’s Long Term National Health Plan.

Sadly, as this article in Croakey highlighted, it is nothing of the sort. I wrote about it on 16 August. Interestingly, Hunt has barely mentioned this Plan since announcing it.

Primary care

It is undisputed that primary care one of the essential foundations of an effective and efficient healthcare system. Sadly the current Government pays only lip service to that, and to date has made a little more than a paltry push to move Medicare services beyond general practice to primary care.

The Health Care Homes initiative, once touted as a new approach, is no longer on the Minister’s radar. The program has some 10,000 people enrolled (considerably less than the 12,000 target) and will continue until June 2021.

I wrote about reforms needed in primary care on 18 October, when Hunt announced the Primary Health Reform Steering Group – touted as the first step in the development of a Primary Health Care Ten-Year Plan (as part of the Long Term National Health Plan).

If you’re really into mining the archives, you can also read what I wrote on this topic on 19 October 2018. You might also appreciate the paper I wrote with Dr Paresh Dawda in early 2019 on the possible role for Primary Health Networks in primary care reform.

The media release announcing the Steering Group and its membership stated that its first business would be the provision of advice about the implementation of the $448.5 million provided in the 2019-20 Budget to support doctors to provide more flexible care to Australians aged 70 years and over. 

But to date – silence about this (due to be implemented in July 2020) and the establishment of a broad-based Consultation Group.  In fact, on 5 January 2020, I can’t find any reference to this on the Department of Health’s website; have I missed it?

In my search I was shocked to discover that the webpage on the COAG National Primary Health Care Strategic Framework has not been updated since April 2013, and it still includes reference to the Primary Health Care Research, Evaluation and Development Strategy which the government ceased to fund in late 2015.

So maybe my optimism about primary care reforms in 2020 is misplaced?  On a positive note, the Australian Institute of Health and Welfare is developing a National Primary Health Care Data Asset.

Medical Benefits Schedule reforms

The work of the MBS Review, which has been underway, with multiple committees and extensive analysis and consultation (see here) since 2015, should be a major point of reform, revitalisation and modernisation of Medicare. Sadly, the inherent possibilities in this work have been undermined by self-interest from organised medicine.

On 28 January I wrote a piece asking “will these reforms ever see the light of day”, based on a detailed analysis of the recommendations from the General Practice and Primary Care Clinical Committee.

As far as I am aware, none of these recommendations for GPs has been implemented. And I have little or no hope for others.

 The anaesthetists lashed out against the MBS Review recommendations for this specialty (made by a clinical committee that included seven practicing anaesthetists) and Hunt has given in to their demands. 

There is an (ongoing?) battle raging about recommendations that optometrists and nurse practitioners be allowed to do intravitreal injections.

Just recently it was revealed that Hunt has given in to lobbying from orthopaedic surgeons who protested plans to stop them billing Medicare for spinal fusions to treat uncomplicated chronic low back pain (a low-value procedure). This was not a recommendation from the MBS Review, but I understand was supported by the experts on the Review.

I’m sure I’ve missed a few other failed recommendations. When you consider the time, expertise, and endless consultation involved for what is impossibly slow progress, and then the Minister wimps out when there are protests based on self-interest, I wonder how much longer this work will continue.

It’s time for the Minister to make public (1) all the changes to Medicare items recommended to date; (2) which of these have been implemented: (3) which of these have not been implemented and why.

Prevention

It did feel like a victory of sorts when the Morrison Government finally agreed to the development of a National Preventive Health Strategy. 

Given that to date all we have is a steering committee, that it appears much previous work in this are will be ignored because it was done under a Labor Government, and that the whole approach is very clinical, narrow and short-sighted, there is a long way to go before anything concrete and meaningful is delivered. And will this include addressing the social determinants of health and climate change?

I wrote about this and cross-referenced some great work by Croakey contributors on 7 October. On 16 August I wrote about the excellent systematic review of the Australian evidence of the economic burden of preventable diseases which was commissioned by the Australian Prevention Partnership Centre.

You can read the communiques from roundtables on the prevention strategy (by invitation only) that have been held here. Note that the first phase of public consultation on the Strategy (the Living Well for Longer Survey) closes 31 January 2020.

Obesity

At the 12 October 2019 COAG meeting, the development of a National Obesity Strategy through the Australian Health Ministers’ Advisory Council (AHMAC) was agreed.

 A consultation paper was developed based on information gathered from two evidence reviews (Population level strategies support healthy weight and Addressing social commercial determinants healthy weight), and the outcomes of the Senate Select Committee Inquiry into the Obesity Epidemic (2018) and a National Obesity Summit. It was released 4 November. Community forums were held around the country in November and December.

This all seemed a little rushed and not very well publicised. What happens next? The Department of Health website says, “Information gathered during these consultations will help to inform the new national obesity strategy to be considered by COAG Health Council later in 2020.” 

So someone (a highly paid consultancy firm?) is writing the strategy which will (eventually) get considered (and maybe endorsed) by AHMAC and then…. (depends on the $s and the political will). Don’t hold your breath – but don’t give up hope!

Obesity in The Health Wrap:

5 April: Obesity in the news but not in the budget

10 June: The often-unrecognised costs of obesity

18 October: Tackling obesity in England

3 December: COAG National Obesity Strategy


Inquiries and reports that could drive reforms

The Productivity Commission’s final report on mental health is due to go to the Government on 23 May 2020. The draft report was released 23 October and public hearings were held in November. The closing date for public submissions on the draft report is 23 January.

However, arguably the final report from the Victorian Royal Commission will have much more impact: its interim report was very powerful in both language and findings.  I wrote about this on 3 December.

As a recent Croakey piece stated, “implementation not recommendation will be key to Productivity Commission success in mental health”. Mental health was declared a COAG priority on 1 November 2019 as the States and Territories pushed Hunt for more mental health funding.

But It’s quite possible Morrison, Frydenburg and Hunt will try to ignore the Productivity Commission’s work in favour of the Government’s 2030 Mental Health Vision that Hunt touts (although we are yet to envision it!), along with an adult version of the headspace program.

I wrote about the cost of not doing mental health reform (including not doing it properly) on 28 January. My colleague Jennifer Doggett did a magnificent job of outlining why mental health funds are so poorly targeted in an article The Personal and the Political for Inside Story.

She makes the case that “Australia’s provider-centred, episodic model of healthcare needs to be abandoned in favour of a coordinated consumer-focused system that works across jurisdictional and sector boundaries and prioritises patients with the greatest need.”

Aged care

The ongoing work of the Royal Commission into Aged Care Quality and Safety continues to deliver horror stories about the poor care in residential aged care facilities. An interim report was delivered at the end of October and the final report, originally due in April 2020, is now due by 12 November 2020.

Even before the interim report was received, there was a push for action (I wrote about this on 7 October) and the Government did respond in paltry part with the provision of $537 million over four years in November. Most of this funding will go to providing 10,000 additional high care places, but this will barely reduce the growing waiting list, already at 120,000.

It is not clear that, absent some real public outrage and pressure, the Government has any real intent to address the multitude of problems in aged care that the Royal Commission is highlighting – as indicated by the recent discovery that the Department of Health intends to privatise the Aged Care Assessments Teams (see here). 

Private health care and private health insurance

In October 2017, the Health Minister announced a package of reforms to private health insurance (PHI). In July 2019 he announced a fresh review of PHI with the aims of reducing  premiums and reversing declining membership.

Hunt said he was looking for stakeholders to come to him with suggestions for savings. In part this was driven by the fact that reductions in the Prostheses List benefits announced in February 2018 are unlikely to deliver the promised savings to PHI funds or consumers.  

It seems Hunt is stuck for ideas. Labor has pushed for a Productivity Commission inquiry, but that seems unlikely. So PHI continues in a death spiral.

Professor Stephen Duckett and his colleagues at the Grattan Institute get the credit here for being bold and taking the lead with two papers on Saving Private Health (Paper 1. Reigning in hospital costs and specialist bills. Paper 2. Making private health insurance viable.)  You may not agree with their premises, findings or recommendations, but there is substance here for discussion. My analysis was written on 3 December.

Personally, but maybe not realistically, I like what Ireland has done – limiting the use of PHI in the public system (I wrote about this on 4 September).

Out-of-pocket costs

The burgeoning of OOP costs continues unchecked and these costs are a significant barrier for many patients who need healthcare services.

A National Strategy to Tackle Specialists Out-of-Pocket Costs was announced by Hunt as part of the election campaign, but to date this consists of a website which will be of little value to most consumers and patients.

As Jennifer Doggett and I pointed out in our paper A Roadmap for Tackling Out-of-Pocket Health Care Costs, tackling this problem will require a multifaceted approach – and thinking outside the box. That means considering bundled payments for some treatments – as I wrote on 23 March and as Duckett et al have proposed.  


Indigenous health and welfare

On 14 February, the Prime Minister delivered to the House of Representatives his statement on Closing the Gap, 2019. This was the eleventh report from the fifth Prime Minister – but the news has not improved. The report itself seems to get glossier each year, but lots of photos cannot hide the fact that progress has not been made. I wrote about this on 22 February.

There is hope that the December 2018 COAG commitment to a genuine formal partnership with Indigenous people to finalise the Closing the Gap Refresh and a forum for continuing engagement throughout implementation of the new agenda and new targets will deliver real progress. But some see little reason for optimism.

As I wrote on 5 April, there was little in the 2019 Budget for Indigenous affairs, apart from an expansion and extension of the cashless debit card program, a move made despite evidence about its effectiveness and opposition from Indigenous groups.

Other reports throughout the year delivered gloomy news.

25 June:  ANAO Evaluating Aboriginal and Torres Strait Islander programs

4 September: Bob Debus on Indigenous incarceration

18 October: Closing the Gap assessment from the National Indigenous Australians Agency

3 December: AMA report card on Indigenous oral health

See also the Croakey analysis of the 2019 Family Matters Report.

While the Refresh commitment had been to focus on progress and achievements, we saw nothing of that from the Government.

However, reports on success stories in Aboriginal and Torres Strait Islander health in Croakey (#KTthatWorks) served to highlight the great work that is being done at the coalface. We need more of this!

A central issue in addressing the health inequality faced by Indigenous people is ensuring the provision of an appropriate health workforce. I wrote about this on 7 October. And commend to you a paper by Dr Chelsea Bond and colleagues that looks “beyond the pipeline”, arguing that focusing merely on workforce numbers is insufficient and that issues around how empowerment and racism are embedded in healthcare systems must be considered.


Social determinants of health

I’ve been around long enough to remember when no-one (except the fearless Professor Fran Baum) dared to utter the words “social determinants of health”. Now they are finally recognised as critical to improving health status and health outcomes and reducing health disparities.

Unfortunately, there’s a significant gap between recognising this and acting on it. I wrote about two US reports on what is needed to tackle the social determinants and how to integrate social care into clinical care on 7 October.

 I see housing as a key determinant of health (especially critical for Indigenous Australians) and that is reflected in The Health Wrap:

13 May: Tackling homelessness

5 July: The links between housing and health

18 October: Housing – a key social determinant of health. This includes a reference to the legal efforts to improve remote Indigenous housing in the Northern Territory.


Climate change and bushfires

These are Issues that are currently on everyone’s mind. Others have tackled this issue better than I, but here is a list of The Health Wrap articles on these topics for 2019:

13 May: Climate change and the environment

16 August: Climate change impacts in the region

19 November: Bushfires and climate change (and mental health)

3 December: Climate news

Most recently, in this new year, I have been trying to make the case that it is imperative we now begin a concerted effort, with appropriate expertise and sustained funding, to collect and analyse data about the health impacts of the bushfire crisis.

Why?

Because we know there will be short- and long-term health impacts, including mental health problems and PTSD. It seems that currently there is no national agency charged with doing this, and there is little or no opportunity for individual researchers to access research funds.

This is an issue we must continue to push; at the very least we need a register and a longitudinal study of the health status, fire exposure and medical issues of firefighters. [Ed: See here for Lesley Russell’s response to the Government’s announcement of some funding for research into the health impacts of the bushfires.]


What else is needed for health and health care reform?

This is like asking “How long is a piece of string?”. 

Here is my list:

  1. Workforce planning and the reinstatement of the independent Health Workforce Agency (see 7 October and 19 November)
  2. More attention for rural health needs (see 19 November)
  3. Affordable dental services (see 23 March)
  4. Integrated mental health and physical health services (in none of Hunt’s plans for 10 Year Plans is this the case)
  5. A focus beyond illness and treatment to health and wellbeing (maybe we could adopt the New Zealand model for a well-being budget? See 30 May).
  6. Leadership, bold ideas, and a willingness to make large scale changes (see 30 May).

I’m afraid this summary of 2019 and what is ahead for 2020 is not as rosy as I would hope or like.

If it’s all too depressing, then remember that I conclude every edition of The Health Wrap with a good news story. They make for happy reading!


Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.

Previous editions of The Health Wrap can be read here.

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