The Health Wrap by Associate Professor Lesley Russell returns for 2022 with a BANG!
Don’t miss her analysis below of pressing health reform concerns, including primary care, aged care, the health workforce, mental health, telehealth, hospital funding, prevention and pandemic lessons.
Plus, what might the Federal election mean for health reform?
Lesley Russell writes:
It’s a tradition that in the first edition of The Health Wrap each year, I look back at the past year and look ahead at what potentially lies ahead. So here goes…
But first, it’s interesting (and, given that little has changed, somewhat depressing) to read what I wrote in my look-backs in January 2021 and January 2020.
Over the past two years the big issues in health and healthcare have all centred around the impact of the pandemic. Given that these issues are well covered by so many others, I will not attempt to rehash them. In particular, I refer you to the COVID-19 Wraps from Alison Barrett and COVID SNAPS from Professor Kathy Eagar, and this link to archives all of Croakey’s COVID coverage.
I’m putting forward my review of 2021 and proposals for action in 2022 in the context of the looming Federal election. And I’m being very pragmatic about what I think the major parties will propose for health and healthcare during the campaign and what I think they will deliver if elected.
In other words – there are no grand hopes from me for bold visions and transformative reforms.
To be bluntly political – I think if the Coalition wins, it will be business as usual (likely with Dr Katie Allen MP from Victoria as the next Minister for Health) with pandemic spending used as justification for no further efforts. If Labor wins (I think Mark Butler will keep the health portfolio), there will be action on election commitments but no appetite for tackling the wicked problems.
These prophesies may be modified (for the betterment of health policy outcomes) if the very strong field of mostly-female Independents do well and perhaps end up with the balance of power in the House of Representatives.
Workforce
This is the central issue: nothing happens in health without the right people in the right place at the right time. Workforce is essential, not just in terms of numbers but also composition and training.
The pandemic has served to highlight the long-known, long-ignored pressures faced by the healthcare workforce and the problems with maldistribution.
Health Workforce Australia was abolished by the Abbott Government in 2014 and the task of workforce planning and distribution is now managed very inadequately by the Department of Health. Health Minister Greg Hunt’s solution to the healthcare workforce crisis is a proposal to import nurses and doctors from overseas, a short-term, short-sighted Band-Aid fix that is yet to eventuate.
It is imperative that an independent health workforce planning agency is re-established at the national level.
Two issues are key to boosting the healthcare workforce:
- A focus on multidisciplinary teams where everyone is working to full scope of practice – and these capabilities are respected, utilised and rewarded.
- Recognising the value of caring and cultural safety and outreach at the community level. To this end there are important roles in health and healthcare for community health workers, Aboriginal health workers, peer workers and trusted and respected community members.
It is time for the powers and controls of the speciality medical colleges to be reined in and redirected to better meet a public benefit test and to support and mentor young healthcare professionals.
In 2019, such changes had the backing of the Council of Australian Governments Health Council and it was reported that proposals for implementation were being developed by a high-level committee and the Federal Health Department.
This is such an important measure but apparently, with the demise of COAG, there has been no action to advance it.
Towards primary care
The pandemic has highlighted the central role of GPs, the importance of primary care (see THW, 17 May 2021), and the imperative to move to primary healthcare – the sort of wholistic care, encompassing the social determinants of health, that is delivered by Aboriginal Community Controlled Health Organisations and Victorian-based co-health.
However, despite the increasing responsibilities that Prime Minister Morrison and Health Minister Hunt have placed on GPs, the Morrison Government’s move towards implementing primary care reforms is painfully slow (the move to primary healthcare is not on their agenda)
The final version of the Primary Health Care 10-Year Plan, first announced in 2019 and due for release last year, is yet to see the light of day. I wrote about my concerns about where this was headed in the THW, 28 June 2021 and in an article for Croakey Health Media that analysed the discussion paper that was released last June.
What will we get from primary care reforms?
Judging by the submissions from the Australian Medical Association and the Royal Australian College of General Practitioners, the push is on for more and better paying Medicare items and keeping other potential members of the primary care team as subordinate to GPs – which is last century’s approach. I think most young GPs are more forward looking than this.
We need to actively move from general practice to primary care; the current system has been found “not fit for purpose”. I am pushing for models that deliver primary healthcare and look more like Community Health Centres and Aboriginal Community Controlled Health Organisations.
(For definitions of primary care and primary healthcare (and how these terms are used, see the 2010 debate led by Melissa Sweet here and here and here.
In THW, 27 October 2021 I wrote about the issues revealed in the RACGP annual report on the state of general practice. This highlighted:
- The increasing role GPs play in managing chronic physical and mental illnesses in the community
- The steady decline in bulk billing of GP services, halted only by pandemic-specific measures
- The barriers many GPs face in using telehealth items.
Reforms in primary care will demand addressing all these issues and more. Moreover, as I wrote in THW, 12 June 2021, we know little about the quality and safety of general practice/primary care.
Telehealth
Despite the fact that Health Minister Greg Hunt consistently touts expansion and increases in telehealth services as a “revolution” in healthcare reform, from the very beginning there has been a Just-in-Time approach to this issue that undermines the Government’s stated commitment.
Telehealth MBS items were first introduced as temporary items in March 2020. In September 2020, just days before they were due to expire, they were extended to March 31, 2021 and then on March 14 they were extended again to the end of the 2020 – 2021 financial year. In April, an extension to the end of 2021 was announced. (You can read about this timeline in THW, 1 May 2021).
As far back as November 2020 Hunt has said these items would be made permanent. That did not happen until very recently, in a package of measures headed “Permanent Telehealth to Strengthen Universal Medicare” announced on 13 December and effective 1 January.
However, Hunt had not done his homework, and there was immediate outrage from oncologists and mental health professionals who have been providing telehealth services in rural areas for some years, well ahead of the introduction of specific pandemic measures. Within weeks, Hunt was forced to make changes to address these concerns.
I belong in the camp that sees telehealth and digital technology as both facilitating and disrupting healthcare, with the benefits, disadvantages and challenges yet to be fully evaluated.
There is a need to collect and use evidence to ensure that these MBS items are effectively targeted and appropriately financed so that they improve access and health outcomes and deliver value for money and patient satisfaction. As it currently stands, the Morrison Government simply refers only to the numbers of services delivered and the cost to Medicare when talking about why such items are important.
Deakin University academic Dr Anna Peeters makes the case that the shift to telehealth requires more than a few new Medicare items and the associated financial incentives. The Australian Healthcare and Hospitals Association has pointed out that the increased use of virtual healthcare requires consideration of patient-centredness and equity, and a digitally capable healthcare workforce.
Mental health
It’s so disheartening to see the Morrison Government blithely ignore the recommendations from the Productivity Commission and the Parliamentary Report on Mental Health and Suicide Prevention.
While considerable sums have been provided to mental health services as a consequence of the pandemic, these are short-term commitments that rarely in line with expert recommendations or even with the Government’s own response to recent reports.
As part of this response, the Morrison Government committed to a new National Agreement on Mental Health and Suicide Prevention by November 2021. That has yet to eventuate with wrangling continuing between the federal and state and territory governments.
Both the Roadmap to Mental Health Reform and Services and the Fifth Mental Health and Suicide Prevention Plan expire in 2022 and it’s not clear what work, if any, has been done towards replacing these.
Currently many people in need miss out on mental healthcare because services are not well targeted and resourced. Mental health experts speak out about the “missing middle” (people needing subacute care), acute care beds are scarce, and recovery programs are hard to access.
The NDIS struggles to deal with the needs of people with severe and chronic mental illness. (See my analysis of the AIHW report on mental health services in THW, 31 May 2021 and the very recently released Productivity Commission Report on Government Services 2021).
The focus in mental health policy and evaluation needs to shift from the amount of spending and the number of services delivered to ensuring that there is appropriate workforce across all demographics and geographical areas, needs are met, high value services are delivered, and patient outcomes improves.
In an article Dr Sebastian Rosenberg wrote for Croakey Health Media in September 2021, he looked back at 30 years of mental health reforms and concluded that even the best plans and policies “require a rare combination of factors if they are to be successful: political will for implementation; adequate resourcing; management support; local stakeholder engagement in co-design; technology; and careful, regular monitoring and reporting.
I might also add: it’s time for the psychiatry profession to step up (see THW, 6 December 2021).
Ageing and aged care
If the performance of the Morrison Government on mental health is disheartening, what can be said about their performance on aged care?
In short – nothing positive. Make sure to read this recent, heartbreaking article for Croakey Health Media by Julie-Anne Davies.
There has been no clear path ahead forged in the wake of the recommendations from the Aged Care Royal Commission (as outlined by the Grattan Institute) and the Federal Government has continually and consistently failed miserably to meet its responsibilities throughout the pandemic.
At the heart of the Royal Commission’s recommendations is the need for more funding to provide people in aged care the services they need. The Government has committed $17.7 billion over the next four years, but advocates have argued that $10 billion a year is needed. Labor has said they will do more, but have been coy about the funding mechanisms.
There is no doubt that aged care is an expensive and wicked problem, but it is not a can that can be continually kicked down the road as the ageing population grows and there is a looming dementia tsunami (see also THW 28 September, 2020).
Every politician should imagine their own aged care needs and fund services accordingly!
Data and stories that emerged from the Royal Commission, reinforced by the dreadful toll of the pandemic, highlight the need for a public debate about the role of for-profit entities in the provision of care for vulnerable Australians. Which political parties will be up for that task?
All the evidence points to an erosion of quality and safety standards and increasing costs when returns on investments come into play. (See for example this article for Croakey Health Media by Professor Anthony Scott and colleagues.)
Sadly, there is little focus currently on healthy ageing and addressing ageism (see THW 29 March, 2021). It’s a key issue that is lost in the furore about residential aged care.
Many older people are functioning well in the community and can continue to do so with some additional supports. These include not just home care packages but efforts to address physical and mental activities and loneliness.
As my own birthdays accumulate, these are themes I return to often in THW. The ALP policy platform recognises that loneliness is an issue that must be addressed and it was reported in November that Labor would take a policy on loneliness to the election.
Public hospitals and the public/private debate
Public hospitals were already under stress before the pandemic arrived and yet hospitals and staff have demonstrated an amazing capacity to respond to the pressures and demands of COVID-19. However, it is clear that this burden is not sustainable, and issues of staffing and resourcing must be addressed.
The Morrison Government has continually engaged in argy-bargy with the States and Territories over hospital funding. Morrison says he has “showered the states with money” and in October refused states’ pleas for further hospital funds.
The 2021-2022 Budget Papers show that federal contributions to States and Territories for COVID-19 under the Nation Health Reform Funding was $2.58 billion in 2020-2021, $410.9 million in 2021-2022 and nothing in the remaining years.
I think we can expect hospital funding to be a contested issue during the election.
What is also needed is a considered public debate about the level of federal support for private hospitals through the Private Health Insurance Rebate (PHIR) and better integration of the public and private hospital systems, building on what has been learned during the pandemic.
This is no-go territory for the Coalition and tricky territory for Labor, which, at the last election in 2019, promised to establish a Productivity Commission review into the private health sector.
A proposal from the Australian Greens to phase out the PHIR was costed in 2019 as delivering $20.88 billion in savings over the 2019-2020 Budget forward estimates period and $75 billion over the decade to 2029-2030. Such savings could ensure expansion and support of the public hospital system, and also enable the inclusion of dental services in Medicare.
The Grattan Institute has developed a number of approaches around reforms of private health insurance that are more pragmatic than abolishing the PHIR and that could serve as a starting point for public debate. (You can access the reports here and here.)
Prevention, climate change and an Australian CDC
It was encouraging to finally see the launch in December of the National Preventive Health Strategy 2021-2030 after many delays and some concerns about the draft strategy. You can read analysis in Croakey Health Media about the final document here and concerns about the draft document here.
As part of the Strategy launch, Hunt announced funding of $23.7 million over three years to 21 health groups across Australia. This paltry effort stands in stark contrast to the Rudd/Gillard Government focus on prevention, which included the establishment of a National Preventive Health Agency.
Issues central to Australians’ health and wellbeing – like good nutrition, addressing the obesogenic environment, excessive alcohol consumption, and climate change – are never mentioned by the Morrison Government. At the same time there is no evidence that the Government and the Federal Department of Health are working to ensure that Australia is well prepared for the next global pandemic.
There are calls for the establishment of an Australian version of the United States Centers for Disease Control and Prevention. Depending on how this is conceived, such a body could take responsibility for community health and wellbeing, prevention, the National Medical Stockpile, addressing the health impacts of climate change, managing antibiotic resistance (seen as a rising international problem), preparedness and the collection and analysis of relevant data.
Labor has already announced it will establish an Australian Centre for Disease Control. It will be imperative that this is independent of government and well-resourced over the long term.
Addressing disparities and inequities
The pandemic has served to highlight the large and growing disparities in the socioeconomic and health status of Australians. Most at risk of structural disadvantage are Indigenous Australians, the homeless, people with disabilities and serious mental illness, asylum seekers and refugees, and older women.
The decade of efforts to close the gap have seen few gains, but there is hope of better progress from the Closing the Gap Refresh, with new targets and priority reforms, and a greater willingness among governments to work in partnership with Indigenous communities and leaders.
Australia does little to collect and analyse data on health disparities to facilitate better targeting of efforts and refinements of programs. Even the efforts around the monitoring of Indigenous programs are often hampered by lack of appropriate data. These are efforts that must be better resourced and then maximally utilised (a task that could be assigned to the proposed CDC).
A key issue around health disparities and inequities is the burgeoning growth of out-of-pocket costs. These are serious barriers to treatment and care. They are surely a “kitchen table” issue for the election.
The Morrison Government developed a website that has little credibility with doctors and patients and has since abandoned any pretence of addressing the issue. Labor took a policy on out-of-pocket costs to the last election, but this was focused on those costs related to cancer treatment.
Tackling out-of-pocket costs needs a multi-focused approach that recognises the realities of many Australians’ low incomes. Jennifer Doggett and I have outlined a roadmap for addressing this.
We also make the point that there are units within DoH responsible for hospitals, the healthcare workforce, the private health insurance industry, and the pharmaceutical and medical device industries – but there is no one place where the issues of consumers, patients and carers are considered and championed. Perhaps there should be?
One simple solution that would address a significant aspect of the out-of-pocket cost problem would be the provision of Medicare-funded, bulk-billing specialist clinics attached to public hospitals. Yes, this would require new Federal/State and Territory agreements, but these could be set up as win-win situations for all stakeholders and so should not be major obstacles.
The pandemic not only highlighted the growing disparities in Australia but also how easy it is to fix many so-called wicked problems like poverty and homelessness (see THW 14 February, 2021 and THW 15 March, 2021).
Just a few more dollars a week in social welfare payments like JobSeeker can lift people out of poverty and finding homes for the homeless can turn their lives around. It just requires government commitment and willingness to fund these efforts on a permanent basis.
The pandemic provided a real life trial on the social and economic value of a basic income – and it worked.
Building a culture of innovation
I’m a big fan of initiatives like the US Center for Innovation that was set up under Obamacare within the Center for Medicare and Medicaid and is now celebrating its tenth year (see THW 23 August, 2021).
In Australia we need to get beyond the reliance on short-term pilots that are no sooner started than they are finished, and the funding disappears along with any evaluation. For example, where is the evaluation of the Health Care Homes pilot and what could we learn from this?
So I would like to see a push for the establishment of a permanent and independent Centre for Innovation and Health Reform – along the lines of the Australian Health Reform Commission proposed by Labor in 2019.
As a beginning, even a small pot of money would help with flexibility to do more of current unsung innovative initiatives that are underway. What is needed is a better communication system to spread the word about these, on-going evaluations and tweaking to improve them, and examination to see if they can be scaled up and transferred elsewhere.
This might also be one way to begin to over-ride the strictures imposed by state borders and federal/state divides.
Better integration
Everyone has a different idea of what integration means. The key aspect of any definition is that the patient is at the centre, although patient-centredness is also viewed in different ways by clinicians and patients (see THW 26 July, 2021).
We need better integration in several areas:
- Across mental health/substance abuse/physical health services – both acute and community-based
- Across primary care/acute care/subacute care/aged care
- Including oral health, hearing, and eyesight as essential aspects of healthcare.
One simple but valuable way to start this is to ensure that transfers of care are better managed, and seen as an essential part of care rather than a last minute, pro-forma add-on.
Moving forward
Earlier in this column, I promised to make pragmatic proposals about needed healthcare reforms – so I’m sure someone will be eager to point out that I have advocated for several new agencies and DoH responsibilities, thus potentially invoking more red tape and regulations in the health sector.
I would counter that these proposals will ensure there is someone, somewhere in the system that has responsibility and can be held accountable. And yes, perhaps I have allowed a little idealism to creep into this assessment and these proposals.
Under the current Government, issues like responsibility, accountability and transparency have become major concerns for those who look for these values in policy and funding. Increasingly attempts are made to hide information about policy development, submissions to government inquiries and reforms, and the mechanisms of funding decisions. That cannot be allowed to persist.
We have also seen a depressing lack of vision, leadership and commitment and not just in relation to issues around the pandemic. Health Minister Greg Hunt’s recently released assessment of the past two years of what he calls the “COVID fight” shows an extreme unwillingness to face the facts and for any introspection about what could have been done better.
That’s why, as part of the upcoming election campaign, there must be a concerted push for a Royal Commission into the management of the coronavirus pandemic. Labor has called for such an enquiry.
Most of us are dissatisfied with and worried about the current situation and are ready for reforms in health and healthcare.
These will need the best efforts of all stakeholders, new perspectives and cultures, and leadership at both the national and community level. Those are the criteria I will be looking for in the upcoming Federal election.
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.
