In the first of a series of articles unpacking current health policy concerns, a long-term rural health advocate, Gordon Gregory, argues that “health reform” is a term that is much over-used and inappropriately applied.
In particular, he queries the usefulness of Health Minister Greg Hunt’s characterisation of three “waves of health reform”.
However, Gregory, former CEO of the National Rural Health Alliance (NRHA), does offer the Minister a way out of the froth and boil of crashing waves – with a list of 16 areas where “real and desirable” reforms could be made.
Surfing the ‘waves of health reform’ in Australia
Gordon Gregory writes:
Health Minister Greg Hunt has made no secret of the personal and Ministerial motivations he brings to his work, nor of the portfolio priorities as he sees them.
On his appointment (18 January 2017) he paid tribute to his mother and his wife, both nurses. And his grandmother was a pharmacist – one of the first women to take up pharmacy in Victoria. Despite this, as Minister his focus seems narrow. On his homepage one reads:
As Minister for Health and Sport, Greg is committed to ensuring all Australians are able to see a doctor when they need to and can receive medicine when they are unwell.”
And he has made a virtue of his very close attention to the views of the medical profession:
The very first call that I made, I think about 10 minutes after the Prime Minister’s announcement, was to Michael Gannon, the very capable leader of the AMA, and shortly after that to Bastian Seidel, who is the head of the Royal Australian College of GPs.”
Some people fear that this is code for ‘looking after the doctors’, and for what the Australian Health Care Reform Alliance (AHCRA) has called a ‘drugs and doctors’ policy environment.
Since his appointment the Minister has developed and consistently promoted “four pillars” of what he calls “a long-term national health plan” (the quotes in this piece are all taken from the Minister’s published speeches or interviews):
First, a rock solid commitment to Medicare and universal access to doctors and to medicines.” (“We listen to the Australian public. When you boil it down, can they go to the doctor, can they get their medicines, and when they need to, can they go to the hospital?
The second pillar is the hospitals, and the funding for hospitals is increasing every year by a billion dollars.
The third is mental health, which is a deep personal passion, and above all else perhaps on my watch I want to deliver more frontline services and work on preventive health.
The fourth is medical research.”
Some might argue that these four constitute less of a ‘plan’ and more the underpinnings and fixed financial arrangements in health care set constitutionally for the Australian Government.
Greg Hunt subscribes to the view taken by too many Health Ministers of the day that the Government’s plan for health care, and evidence of a successful commitment to that plan, is provided by the fact that rates of bulk billing are rising and expenditure on Medicare and hospitals is going up:
– bulk billing rates under the Turnbull Government are 3.5 per cent higher than they were under Bill Shorten’s Government. – – in the last half-yearly figures that are just out, we’ve gone from 84.7 per cent, to 85.4 per cent. So in other words, Medicare funding is up and bulk billing rates are at their highest ever on a half-yearly basis. What does it mean? More funding, more investment in Medicare and more people being able to go to the doctor without having to put their hand in their pocket.” (Greg Hunt, Sky News Agenda interview, 19 March 2017.)
The Government of the day doesn’t need to ‘plan’ to increase expenditure on Medicare. It merely needs to let time pass and the eligible population and number of doctors increase, while hoping that the Department of Finance doesn’t get its way in somehow capping the program.
And as for what Greg Hunt – like so many Health Ministers before him – has described as “our absolute commitment – core, fundamental, unbreakable commitment, to universal access and to Medicare”, we still don’t know for sure how many people have no access to Medicare because they have no GP within effective logistical reach or because they can’t afford the out-of-pocket costs they fear may be involved with a visit.
The number is certainly substantial, and is increasing. (On 4 May 2017, Chief Medical Officer Brendan Murphy said that out-of-pocket costs were actually the highest they have ever been. Non-government payments on health, largely private individual expenditures, are now one-third of all health expenditure.)
Three ‘waves’ of reform
In his presentation to the Health Budget lockup (9 May), Minister Hunt described three “waves of reform”.
- Five major compacts (with AMA, RACGP, Pharmacy Guild, Medicines Australia and Generic and Biosimilar Medicines Australia.)
- Guaranteeing Medicare through: Investing in our health professionals through Medicare and the re-indexation. “The Government will establish a Medicare Guarantee Fund from 1 July 2017 to secure the ongoing funding of the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme – – . Proceeds from the Medicare Levy (less the contribution for the NDIS) will be paid into the fund and topped up with a portion of personal income tax receipts to ensure it covers the combined costs of the MBS and PBS.” And throughl owering the cost of medicines and reinvesting in new medicines.
- Agreement by COAG on opt-out model for My Health Record
- Agreement with the Tasmanian government on the transfer of the Mersey hospital
- Mental health psychosocial support (“$80 million for community psychosocial services for people who do not qualify for the NDIS. Contingent on matched commitments from the states and territories.”)
- Ensuring the sustainability and affordability of private health insurance
- Strengthening mental health – particularly in rural areas
- Workforce strategy (“which would look at issues of distribution”)
- Aged care reform
- National Sports Plan
- Reform of public hospitals and post-2020 agreement with states
- Strengthening Primary Care (“through building on the transformative nature of Primary Health Networks”)
- Strengthening Preventive Care (“with particular focus on Indigenous health”)
Not actually reform
There is very little ‘reformist’ about these three lists.
Most of the elements are, as I described in an earlier piece in Croakey (6 March 2017), Grand Principles: general statements of principle or intent with which no-one could disagree: ‘guaranteeing Medicare’, ‘ensuring the sustainability of private health insurance’, ‘strengthening primary care’ etc.
Others are means to an end, such as ‘five major compacts’, ‘workforce strategy’ and a National Sports Plan.
Real reform in the nation’s health sector would mean action to improve existing arrangements by alteration, correction of error or the removal of defects.
Elements of current health policy that do have a sense of genuine reform are the shift to opt-out for My Health Record and the trial of Health Care Homes (a large part of which has been postponed until 1 December).
Work on some of the Grand Principles may include reformist action, such as a new approach to mental health care – assuming it to be substantially different from the status quo. And genuine reform could be involved in “workforce strategy”, “aged care reform” and “a national sports plan”.
But to this point in time these are merely generic labels on areas of intended activity.
Presumably the Minister’s reference to ‘waves of reform’ is intended to demonstrate organisation and a sense of priority. But one of the clear implications of the ‘waves’ terminology relates to timing: one thing happens before another.
This is a problem in the lists provided: there can be no justification for putting off work on “Strengthening preventive care with particular focus on Indigenous health” until after “Ensuring the sustainability and affordability of private health insurance” or “Aged care reform”.
A 16-point plan for real reform
It’s not as if there is any shortage of true reform ideas for the health sector and its leaders. Real and desirable reform would include the following.
- Building a whole-of-government approach to health in certain policy and program areas. Ministers can provide leadership on this through demonstrating their personal cross-portfolio commitment. This would legitimise and strengthen inter-departmental action on such things as targeted improvements in access to high speed broadband and telecommunications; action on food security; the taxation of alcohol and selected foodstuffs; work to support vocational education and continuing professional development; and the development of recreational infrastructure.
- Reform of the structure and work practices of the health workforce, doing away with restrictive practices that are protected by special (mainly professional) interests. This would entail more job sharing, flexible allocation of tasks and functions, and lighter demarcation of clinical roles.
- Work to develop and act on a national Healthy Start in Life Manifesto, including a commitment to resourcing high impact cross-portfolio actions relating to pre-conception, infant, child and adolescent health. The required initiatives include a focus on child and adolescent mental health within the National Mental Health Plan, and a platform to bring together data collected by different agencies on child and youth health and wellbeing, including issues relating to family violence, self-harm and suicide.
- Cross-portfolio and inter-governmental action on a National Strategy on Climate, Health and Wellbeing for Australia to prepare the health sector and protect all Australians from the health impacts of global warming.
- Using the principles of ‘Consumer Directed Care’ to bring about greater collaboration (especially in rural and remote areas) between the health, aged and disability care sectors. There are opportunities in the workforce, information and infrastructure areas to see these three functions more closely integrated.
- Further action to bring together and make full use of research, (big) data and information systems, including for capability development and research translation in health and health-related services.
- A government-wide and industry-wide review of telehealth services, opportunities and barriers.
- Inter-departmental action to maximise the commercial and employment opportunities (especially in rural, regional and remote areas) provided by the production and utilisation of newer energy sources.
- Ministerial leadership to ensure that all health practitioners achieve and maintain competency to deliver and manage culturally safe services.
- Further action on an Arts in Health Strategy to harness and grow the wisdom, resources and impact of the sector.
- Coordinated inter-governmental action to improve food security. This could include the development of a National Food Security Strategy to consider food production, distribution, pricing, storage and preparation.
- Extension of the Health Department’s monitoring and management of health workforce policies to incorporate closer attention to matters concerning allied health, nursing, dental and health service manager staff. This work should include implementation of National Standards for Remote Health Worker Safety and Security.
- Alternative consideration of the primary care needs of people who, either because of geography or financial means, cannot access a doctor.
- Reform measures that result in a significant increase in the proportion of total health expenditure going to illness prevention and health promotion. This should be achieved through an expansion of programs relating to obesity, alcohol and tobacco.
- Commitment to a new National Rural Health Strategy and long term funding for an associated National Implementation Plan.
- An expanded health care role for pharmacists, as is currently being explored through the Pharmacy Trial Program.
Australian Government leadership on all or any of these would constitute some real health reform.
• Coming up next in this series by Gordon Gregory: Why we need a Rural Health Commission (rather than a Rural Health Comissioner)
• Follow on Twitter: @gnfg