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The viper’s nest that awaits Rudd, the paradox of primary care and other thoughts on reform

Professor Stephen Leeder, director of the Menzies Centre for Health Policy at the University of Sydney, is one of the great wordsmiths of medicine. His analysis of the health reform announcements, just published at The Drum, is well worth a read.

He writes that changing funding arrangements will not be enough to stop the blame games that are played out at all levels – between managers and clinicians, between politicians and manager and clinicians, and between the private and public sectors. He also cautions that funding hospitals according to national standards will prove difficult “because the health system is a viper’s nest of creeping and crawling competing interests”.

He says the plans are revolutionary: “Be ready for quakes if you tickle tectonic plates”.

Meanwhile, Jon Wardle, of the School of Population Health at the University of Queensland, writes about the “paradox of primary care”:


“One of the major problems with good health reform is that is just so plain. Hospitals, specialists and machines that go beep‚ may be sexy and win big with the punters (and draw a line of politicians for ribbon cutting ceremonies) but they are also far more expensive and far less effective than the low technology interventions of primary care. Rudd’s latest foray highlights this.

I am currently enjoying the sights and delights of Seattle as a visiting scholar at the School of Medicine at the University of Washington ˆranked number 1 in the US (in an untouchable mid-2000s Federer fashion) for primary care for the past 20 years ˆ and the experience is offering some interesting insights to problems that may come Australia’s way.

One of the physician academics here very sneakily broke her hip recently to explore the issues of primary care in the US health system. Her insurance is generous, provided by the Washington state government due to her tenure as a University of Washington employee. She mentioned that despite world-class facilities ˆreplete with chandeliers and artwork’ and the best doctor to patient ratios insurance could buy the primary care she received was sub-par. Despite being visited by a doctor and nurse every half hour she never once was asked about herself. The clinician’s obsession with pain scores (it was, after all, how their performance was being measured) meant that her overwhelming nausea was ignored. When she tried to mention this nausea she was told it simply wasn’t possible. Her solution to the problem – lie about her pain scores, it stopped her being pestered by doctors and nurses and the pain was infinitely more bearable than the nausea. Sometimes patients just get in the way of good healthcare.

One of Rudd’s strengths but also one of his inherent weaknesses is his obsessive attention to numbers and statistics. However, the details of how we measure this new health system by are important. The paradox of primary care is the fact that although primary care performs far more poorly than specialized care at the individual disease or outcome level, it works far better than anything else at the broad population level.

The problem is that although Rudd advocates for primary health care, we are still talking about measuring outcomes in terms more suited to hospitals and specialists. Right solution, wrong outcome measures. Are we dooming good primary care before it even begins?”

And Dr Michael Vagg, from Victoria, argues that the plans represent a missed opportunity:

“Having read the text of the speech I am struck by the typical stylish rhetoric and studied silence about the hard questions. So it seems the Rudd Government plans to alter the existing funding arrangements with the states, but I can’t even begin to comment about how this might work without seeing some of the details.

The large investments in sub-acute care and training are very welcome, but again this is not visionary, as the coming wave of new medical graduates have to be trained when they graduate or they’ll be driving taxis and pulling beers when they should be working in the public system or general practice as registrars. There are no details as to how the increases in allied health and nursing training will be achieved.

Sub-acute care has been ignored or patronized with health system funding for a long time, and infrastructure is badly needed in outer urban population corridors and regional areas, where dedicated rehabilitation or aged care facilities are often nonexistent. Recurrent funding of these services is needed, not just infrastructure.

The Superclinic idea seems to be very popular among policymakers who seem bent on ignoring the embarrassing evidence from overseas, particularly in the UK, that they are certainly not guaranteed to reduce excessive expenditure or fragmentation of care. In practice, the Superclinics will foreseeably force local well-run general practices to close or be absorbed by the Superclinic, which with its extra administrative requirements and teaching committments will be less efficient than simply expanding existing practices so they can provide an even better service than they currently do.

The models for how Local Hospital Networks will ‘work’ with State Health Departments are sketchy and have the potential to cause years of conflict as the States seek to unburden themselves of as much responsibility as possible, and the Commonwealth attempts to lean on the States to maintain responsibility for some areas such as procurement and proper management of the capital assets which the Local Networks administer. Imagine trying to plan long-term for the needs of a region with ageing infrastructure in a safe State Government seat (of whichever persuasion) when the State DoH has no political interest in spending their dollars there.

The reforms outlined may well improve the delivery of hospital services, and if this is all that achieved we will at least stop going backwards in terms of quality of hospital care. One would expect this from any vaguely competent government. Much of this statement is making a virtue of necessity and misses the opportunity for radical reform.”

**

Update (5 March): And in case you missed the piece from Bob Wells, director of the Menzies Centre for Health Policy at the ANU, in the March 4 Crikey bulletin, here it is:

“The Rudd hospitals reform is, hopefully, the first part of a broader strategy for health reform. While it’s disappointing that he has decided to tackle health system problems in a piecemeal way (hospitals, then primary care, then prevention and so on), it is a pretty good start.

Of course there are questions about the plan- will the states play ball? Are there enough super managers and clinical leaders to run 200 or so hospital networks? Will the system be even more fragmented than now?

These are all valid questions, but we should focus on the real reform underlying it all rather than the detailed implementation issues. The real positives in the Rudd plan include:

  • Clear accountability at the Commonwealth level for the system into the future including for the standards of the facilities and the teaching and research that they provide;
  • Much greater clarity for public hospitals about what is expected of them and certainty about their budgets which will be based on real measures of activity; and
  • Ability for local communities to compare the performance of their local hospitals against others and to deal with a local management group who can be expected to do something about it.

What could he have done better? He could have announced his primary health care reforms first. Fixing primary health care will have enormous benefits and affect nearly all of us at some point in any one year- there are well over 100 million GP consultations alone in any year whereas only around 7 million hospital admissions. Primary care of course is much broader than GP services and is more complex with Commonwealth, states and non-government organisations all major players yet very much uncoordinated.

What else is missing? The hospitals reform does not deal with the private health insurance mess. The opportunity has been missed to roll up the massive private insurance subsidy into the overall hospital funding pot and let the local hospital networks purchase the health services from private or public hospitals. People could still take out private insurance to meet their particular circumstances or service preferences.

Why would the states sign up to the plan? Ultimately the states are the winners from the plan. The commonwealth will carry the risk for the escalation of costs of an ageing population and ever-increasing technology for health interventions. The Commonwealth will take responsibility for building new hospitals and maintaining the ones we have. Best of all, the Commonwealth will clearly be in the firing line when the system fails to meet expectations.

So all in all the Rudd plan while not perfect is a positive step forward.”

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Summer reading 2020-2021
Tasmanian election 2021
Testing Croakey News category 1
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Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
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2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
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Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
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Population Health Congress 2015
2016 conferences
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2017 conferences
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#BTH20
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Australian Palliative Care Conference
2018 conferences
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