The health debate in Australia is awful. Medical associations sometimes behave like militant trade unions – Painters and Dockers in white coats – while bureaucrats are often obsessed with process and not with outcomes. If the public health system is to survive, we need a rational approach to rationining, perhaps informed by citizens’ juries. The so-called health reforms now underway will not end cost-shifting or blame-shifting, and what we really need is one level of government to take over funding responsibility.
Those are the key points from a recent lecture at St George Hospital in Sydney by Emeritus Professor Peter Baume AC, a Former Minister for Health, Aboriginal Affairs, Education, and a man of many other achievements. You can read an edited version of the speech at Online Opinion.
Meanwhile, Andrew Podger, Professor of Public Policy at ANU and a former Secretary of the Federal Health Department and Public Service Commissioner, argues that while the current reforms are disappointing, they could be improved with the help of minor modifications and sensible implementation.
The article below was first published in the Australian Financial Review last week, before the Medicare Locals guidelines were released, and is republished here with the author’s permission (I thought that perhaps some Croakey readers had missed the AFR piece).
Gillard’s health reforms: is the glass half-full or half-empty?
Andrew Podger writes:
For those of us wanting substantial reform, a turning of the corner to see genuine patient-oriented care and much more value-for-money, the Gillard health reforms are a disappointment. For those with more modest expectations, looking for some improvement in hospital services and a little more efficiency, the Gillard reforms are welcome: at least they seem likely to be implemented.
Somewhere in the middle, the reforms may be viewed as a glass half full or a glass half empty. A dispassionate assessment suggests a glass half empty. Yet with a little modification around the edges and some sensible implementation, they could represent a glass half full: a genuine step towards the reforms we need.
Key elements of the earlier Rudd package are now agreed by all government across Australia:
- Activity based funding of public hospitals from pooled Commonwealth and State moneys;
- Local governance of hospital networks;
- Primary health care organisations to assist with primary health care integration and broader health services planning;
- The Commonwealth to have full responsibility for aged care (Victoria and WA to settle their concerns by the middle of the year).
Of course, activity based funding and funds pooling have been on the COAG table since 1995; enhancement of the role of GP Divisions has been pursued since the late 1990s; and the very same aged care measures as now proposed were agreed in principle by COAG (with the exception of Victoria) in 2005.
One of the troubles of the Gillard Government, as with the Rudd Government, is its failure to distinguish between radical and incremental reforms and to use this distinction to manage the politics involved.
When I advised Howard on health and aged care service delivery in 2005 I presented two basic options. A radical option to move to a single government funder that would facilitate a more efficient, patient-oriented system rather than one based on separate programs and providers (increasingly important given the growth in chronic illness and frail aged). The alternative was a package of substantial but incremental measures to place more emphasis on primary health care and community aged care with increased Commonwealth involvement and the beginnings of a regional structure, making it easier sometime in the future to consider seriously the radical option.
I was a little disappointed that he and his Government elected to pursue (most of) the second option, but I appreciated the first option would involve much greater risks and more up-front investment to get it through, and would require long-term political commitment and energy to sell it and implement it. Moreover, the incremental package his Government agreed to was certainly a significant step in the right direction.
A big problem now is that Rudd and Gillard have spent the sort of moneys necessary for radical reform, but have been left with something much more modest.
Moreover, notwithstanding the tangible benefits from what is now proposed, it may make a later move to a single funder harder. It cements the separation of hospitals from primary health care and aged care, and it reinforces the States’ role as hospital system managers (both purchasers and providers) and as managers of most non-GP community health services.
With goodwill and good sense, however, the Gillard plan could yet deliver something more than this assessment suggests.
The key is the regional framework and the role of Medicare Locals (please could we get a name change?).
Gillard should resist pressures to increase the number of regions agreed last year. Just as there would be benefit in having more than one LHN in many regions, MLs’ governance options include allowing GP groups to continue to operate more locally if they wish while being members of a regional ML.
MLs should be seen as system-wide regional planners with some purchasing responsibilities, not as providers. They must be able to influence the non-hospital services now to be left with the States if they are to address gaps and promote integration. They must also be able to influence hospital services. For example, they should review whether sub-acute services such as mental health and palliative care now managed from hospitals would be better provided in the community. It is this sort of whole-of-health system approach that the reforms should be promoting.
Medicare Locals should also progressively take on the regional planning function for aged care now conducted by Commonwealth and State officials.
All of this requires considerable support for MLs: the resources needed are clearly available in State and Commonwealth departments.
The one central area which needs extra resources is the capacity for whole-of-system analysis of health and financial risks, a priority not mentioned by Rudd or Gillard.