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What did Minister Roxon achieve? Some wins. But the ambulance is still parked below the cliff

When asked to assess Nicola Roxon’s tenure as Health Minister, Croakey contributors gave varying responses (see here and here) late last year.

However, there was fairly wide agreement that she will be best remembered for her achievements in public health, especially tobacco control, where she helped to make Australia a world-leader in passing legislation mandating plain packaging of tobacco.

In the latest edition of the Journal of the American Medical Association, Andrew Mitchell and David Studdert from the Melbourne Law School at the University of Melbourne, review some of the potential legal challenges facing the legislaton.

Overall, their assessment is moderately upbeat. They conclude:

“…the Australian government has good prospects of winning this legal battle. It will be worth watching developments from abroad, not least because most of thelegal questions resemble those likelyto confront plain packaging initiatives elsewhere.”

(The full paper is not freely available. If you would like a copy, please leave your details below or email direct.)

Meanwhile, Paul Smith, political editor of Australian Doctor, has published a lengthy review of Roxon’s time as Minister, in the January 20 edition of the magazinem, republished below with thanks. He also reminds us of the chequered history of health reform efforts, and that major systemic problems remain.

***

Roxon’s report card: the wins and the disappointments

Paul Smith writes:

It is a few moments after what turned out to be Nicola Roxon’s final speech to the AGPN conference, in November 2011. The auditorium in Melbourne is emptying as the delegates exit for lunch.

Sitting at one of the tables is a GP I’ve known for a long time — not a dyed-in-the-wool AMA hardliner, not someone ideologically opposed to everything that falls from a Labor minister’s lips. But Roxon has just been defending the declining value of patient Medicare rebates by claiming GPs’ incomes are “more than generous”, and he has a glum look on his face.

“She doesn’t seem to get it,” the doctor says. “Never has really.”

It’s true to say that at the end of her four-year tenure as health minister, the extent to which Ms Roxon lost the medical profession — the grassroots — had become stark. Perhaps this disconnect resulted from the axe taken to GP mental heathcare funding by the government, which RACGP president Claire Jackson described as a “slap in the face”. But the disenchantment began much earlier, and cut much deeper.

Understanding its source is important because it helps explain the complexity of Ms Roxon’s legacy. She was the politician who for a brief period claimed she was embarking on reforms “bigger than Medicare”. Such statements need quote marks now. They are only used ironically.

Yet there remain many health experts who describe her as exceptional. This is the voice of the public health lobby, who see her as someone who took up their cause, whether it was the introduction of tax on alcopops or her crusade to bring in plain packaging for cigarette packs.

***

During Ms Roxon’s first year as health minister, she gave a speech in Bathurst. It was shortly after the government had launched the National Health and Hospitals Reform Commission to draw up a blueprint for sorting out the health system’s woes. In the speech she described the importance of preventive health — “a key weapon in the arsenal of health”.

She added: “Investing just in hospitals can play only a very limited role in addressing disadvantage. It can do a great deal of good, but the chance at early intervention, and a better life, has been lost. It is the notorious ambulance at the bottom of the cliff — not the fence at the top that stops the fall in the first place.

“[Prevention] must also be at the forefront of reform for social democratic governments across the world, as we strive to redress inequity. It is not only a tool of health policy; it is a crucial aspect of our wider fight against disadvantage.”

These were emotional words, exposing the moral values that drove her into politics. But this was also the notorious “Light on the Hill” speech, a tribute to the Labor Party icon Ben Chifley, during which Ms Roxon attacked the medical profession for its battles against her party’s crusades for social justice.

She condemned the profession’s historic opposition to the introduction of universal health insurance under Gough Whitlam, along with the AMA’s campaign against the evils of “socialised medicine”.

“And so what we have seen, over time, is a clear cycle — Labor introduces a signature health reform; it is opposed by the conservatives, and by the medical profession; as it gathers public support, the fight is won; and the Liberals are forced to accept that the reform has won community support and a firm place in Australian society.”

For many doctors who dealt with Ms Roxon, this mindset — even if it was never again made so explicit — remained a constant through her time in the health portfolio.

***

Less than a year later, Ms Roxon was handed the National Health and Hospitals Reform Commission’s report, a blueprint that was meant to become Labor’s next “signature health reform”.

It was about equity and access, redesigning Medicare, improving patient care and ending the blame game.

It was also about one of her favourite themes of the early days — the importance of mechanisms to strengthen primary care, particularly to shift GPs away from so-called ‘six-minute medicine’ to reduce Australia’s sky-high hospitalisation rates.

She had already promised her own policy revamp — a pledge made in the first months of the Rudd Government — to overhaul GP-attendance Medicare items. This was to boost prevention by offering better rewards for consultative medicine.

There was consultation with doctor groups, but the policy suddenly disappeared in the bowels of the health department. The delays sparked warnings by the AMA that promises were unlikely to be welcomed by doctors. When it finally emerged — at the beginning of 2010 — it amounted to little more than a $1.25 increase in a level C consultation and the streamlining of Medicare items for health assessments. The disappointment grew deeper when it was revealed in budget papers that the changes had actually saved the government $12.5 million.

Not much more was heard about tackling the “culture of six-minute medicine” until then-Prime Minister Kevin Rudd’s doomed attempt to get the states signed up to his $50 billion health reform — a complex, spaghetti-wired system of channelling federal cash into public hospitals, requiring state governments to sacrifice 30% of their GST.

To halt the merry-go-round of hospital admissions, Roxon and Rudd fronted the media to announce they were adopting one of the key ideas from the National Health and Hospitals Reform Commission. It was a $450 million voluntary enrolment scheme for 260,000 diabetes patients. Annual cash sums would be paid to both GP clinics and Medicare Locals to fund each patient’s care. Access to Medicare fee-for-service items would be scrapped for all those who signed up.

In reality, this was a proposal the reform commission or the experts who drew up the government’s primary care strategy never suggested. Fee-for-service was, in their view, the “cornerstone” of GP funding.

The key aspect of their plans was not just an attempt to improve funding for chronic disease care, it was that they were saleable to the wider medical profession – despite the opposition from many of the AMA faithful.

Its supporters could see the benefits of lump sum payments for complex patients (enrolled with a GP practice) so that specific packages of care could be developed for their complex needs. It would help break the worst anomalies of fee-for-service. The emphasis on coordination remained something that could stop patients bouncing around the insides of the health system.

The commission, in the words of its own reform jargon, said its scheme would give “greater freedom for primary health services to take a long-term, whole person and population health perspective”.

In the end Ms Roxon and Mr Rudd unveiled their own version without consulting with the main doctor groups. All the medical leaders received – including the president of the RACGP – was a cursory phone call the night before the ministers made their big announcement live on TV. It fuelled distrust.

The health minister and her boss claimed – somewhat optimistically – that 4000 general practices would sign up. And they held out the possibility of extending it to other chronic conditions if it proved a success.

“This will begin with improving health outcomes for … Australians living with diabetes — too many of whom end up being treated in hospitals,” they declared.

There was no explanation of what would happen if the cash ran out — whether government would pull the funding plug, whether patients who couldn’t pay would be turned away. Just vague talk of “contingency funds” to deal with the outliers.

Ms Roxon herself described it as a “fundamental” change. Again she loyally pushed the reforms but critically made little attempt to sell them direct to grassroots doctors on whom such fundamental changes would rely.

The reaction was predictable. Doctor groups, considering the scheme made doctors responsible for rationing patient care, said no. When an expert panel was set up by the government to offer advice, Roxon excluded the AMA, with one spokesman saying the AMA would only be invited if they agreed to “work constructively” with the government to implement the policy.

What was arguably the Rudd Government’s most radical health policy pledge — introduction of GP fundholding in place of fee for service — ended after his political decapitation. Five months into the new Gillard administration, a cryptically worded press release signalled that the new PM was shelving the scheme and instead handing over cash to a management consultancy to run a three-year pilot.

It was just one of many health pledges Ms Gillard killed off. Mr Rudd’s demand for a chunk of the states’ GST was ditched. The Commonwealth’s pledge to become the single funder of primary care went too, effectively kyboshed by the Victorian Government that wanted to retain financial and management control of its community services.

For many observers, these were the biggest losses — the chance to end the never-ending blame game between the government and states on health funding; the commitment to a system that would think with one brain.

It meant that Ms Roxon’s flagship primary care reforms extended little further than the creation of the Medicare Local network and the establishment of GP super clinics, a policy that still retains the stench of political opportunism.

Critics accuse the government of spending $650 million on building concrete monuments to its own electoral interests. The locations for the clinics were chosen by Labor Party hacks, never assessed by the Federal Department of Health and Ageing to ensure they would be serving real needs. Of the 24 seats Labor won from the Coalition during the 2007 federal election, 16 had been slated to get a super clinic.

Roxon claimed they would reduce pressure on the public hospital system – the driver of all primary care reform. Maybe, but then there has also been that equity question – these taxpayers’ millions are being lavished on around 60 practices.

“She has never blinked,” according to a high-level source in one of the GP groups. “When you talk to her, she believes super clinics will deliver improvements in care, she believes in time they will show that she was right … Whatever you say about her, she was always passionate about health reform.”

The problem, he says, was that she often responded to criticisms, even well-intended criticism, as personal affronts.

***

Judging Nicola Roxon’s time as health minister solely on the disparity between her words and the government’s deeds is unfair.

What remains impressive is that politically she has remained unscathed. She stood side-by-side with Kevin Rudd over health reform. She was never damaged by the fallout when he was deposed and his ideas dismantled.

In debates she frequently monstered the opposition, particularly Opposition health spokesman Peter Dutton. Last November, during her speech to the National Press Club of Australia, she said: “I’ve now gone 800 days in the Parliament without a question from the shadow health minister. Surely that’s got to be some sort of a record?”

Even when you strip away the promises of “bigger than Medicare” health reform, it would be foolish to suggest little remains in terms of action during Ms Roxon’s tenure. She did front up to the tobacco lobby and she managed to stick tax on alcopops. Australia has a national preventive health agency. She’s also put significant investment into the GP workforce. This year, 1000 new doctors will begin vocational training in general practice.

The tough political context also has to be acknowledged.

She worked under Kevin Rudd, a politician whose obsessions lay with opinion polls and media spin, his weaknesses in making reform happen. She was also attempting to rectify long-standing dysfunction between states, territories and Federal Government at a time when the collapsing global economy meant the government’s bank balance could not survive the kind of open-ended funding commitments typically demanded by the health system.

For her final year as health minister, she was also dealing with the savage political sensitivities involved in sustaining a minority government.

There are plenty of health ministers who achieved far less. Yet it seems doubtful she will be missed by general practice. GPs know that at the patient end, very little has changed. The health system functions in the same way as it did back in 2007. The incentives for six-minute medicine remain.

Mental health services — an area which under Mr Rudd, Ms Roxon rarely championed — still await their promised millions in early intervention centres, Headspace clinics and care packages for the long-term ill. Aged care — that other afterthought — remains virtually untouched.

And the National Health and Hospitals Reform Commission’s report sits on a shelf somewhere gathering dust. It cost about $16,500 a page to produce. Yet too much of its content remains relevant.

The political failures — however understandable — will mean those deep-seated systemic problems that continue to blight the health system are likely to remain for another decade. It is here we can identify the legacy of Ms Roxon’s tenure.

In her own words, the ambulance is still parked at the bottom of the cliff.