Australians will soon know what conclusions Prime Minister Kevin Rudd and Health Minister Nicola Roxon have drawn from their various commissions of inquiry.
Professor Stephen Leeder believes the problems we face wont be solved by tinkering and trying to do better with more of the same.
This article is taken from the latest issue of Radius (PDF), in which several members of faculty provide their perspectives.
Money's run out: time to start thinking
by Stephen R Leeder
Health reform takes off in Australia
Google finds two million sources with the exact phrase
“health reform”. Australia has made substantial deposits to
this cache in the past two years. The current Federal Labor
government came to power frothing with dire threats about
taking over the public hospitals unless the states lifted
their game. Then after the federal election in November
2007 came the Australia 2020 Summit in April 2008. One of
six streams in it dealt with health. Commissions of inquiry
into hospitals, health care more generally, prevention, and
primary care followed over the next year.
Nor has New South Wales been napping on the health
reform stage: the Garling Report, a rolling, ponderous
Tolstoyesque three-volume (12.6 Mb PDF file) work made
134 recommendations based on hundreds of pages of oral
evidence from doctors, nurses and others about what needs
to be done to improve acute care in our rather unhappy state.
This trumps the report, A Healthier Future For All
Australians, of the National Health and Hospitals Reform
Commission (NHHRC) published on June 30th this year: it
has a mere 123 recommendations in a meagre 7 Mb PDF file.
But if you add in the recommendations of the Preventative
Services Taskforce report Australia: The Healthiest Country
by 2020, a 1 Mb file with numerous targets and strategies
to reduce obesity, smoking and harmful drinking also
published recently, then the feds are back in front again.
A federal takeover ?
Following the publication of these documents the Prime
Minister, Kevin Rudd, and other parliamentarians including
the Federal Minister for Health and Ageing, Nicola Roxon,
visited hospitals throughout Australia to discuss with
clinicians and managers the major problems in health
care provision. The discussion has concerned both the
recommendations of the NHHRC and also whether public
hospitals would fare better if financed directly from
Canberra. The NHHRC has recommended a revised approach
to hospital funding based more on performance - activity and
efficiency – consistent with direct federal funding. A federal
takeover was Mr Rudd’s pledge prior to the federal election
unless the states and territories did better.
But there is more to health care than hospitals, as the
NHHRC report recognises and as expressed in a further
report, this time from the External Reference Group of
the Primary Health Care Strategy. Both make a plea for
better connections among general practitioners and other
community workers, and suggest that those publicly-paid
community workers not remunerated through Medicare
should also receive their funding from Canberra directly
rather than from the states.
Were this move to pay for all primary care from
Canberra to happen, and were hospitals simultaneously
to be federally funded, we would have for the first time a
unified financing system. A single payer would reduce the
state-commonwealth blame-game tensions: its superiority
as a mode of financing is supported by evidence from many
While there is an ever present risk that hospitals would
suck dollars from primary care into their coffers – Boyle’s
Law of joined-up small and large institutions – it is possible
that the load on public hospitals might decrease. This
would require enlightened, tough regional or area resource
allocation to succeed.
Denticare – a proposal with teeth
A further likely outcome is public funding for dentistry.
While details of Denticare are sparse, the principle is sound.
At present millions of public dollars support dentistry, but
only for those with private insurance: in 2004-05, 82% of
Commonwealth expenditure on dental services was spent
on the Private Health Insurance rebate; this accounts for
14 % of total spending on dental health, the majority
of which is borne by the patient or their family. Under
Denticare dental services would be supported irrespective
of whether the patient had private insurance.
Incremental change or reform?
These changes may be all that is possible at the moment.
They are more managerial than structural. Is this what we
want? As my Canadian colleague Steven Lewis and I wrote
in a recent article in the Medical Journal of Australia:
There is a case against reform. In advanced countries,
health status has been steadily improving. Life expectancy is
up. Erstwhile rapid killers such as AIDS and several cancers
are now chronic conditions. Heart disease rates have declined.
Avoidable mortality has plummeted . Health technology is
ever more dazzling, from high-resolution medical imaging
to robotic surgery. There are more effective drugs than ever
before. From diagnosis to surgery, health care is steadily less
invasive. Health care practitioners are rigorously trained and
entry-to-practice credentials are on the rise. Citius, altius,
fortius: faster (technology, recovery, publication); higher
(credentials, spending, intervention rates); and stronger
(institutions, drugs, methods). Everything’s coming up roses,
so better to fine tune here, innovate there, and stick with a
model of proven success.
Well, quite frankly, wrong: we face problems that won’t
likely be solved by tinkering and simply trying to better
with more of the same.
On the money side, we see demand outstripping supply,
we have yet to take the social determinants of health
seriously and spend money effectively on them, we do
not have a preventive agenda, and perhaps strangest of
all, Australians take to their hospital beds in numbers that
find no comparison in the rest of the world. It is as though,
beside an entitlement to a few weeks at the beach every
year, we consider it OK to pop into hospital for a few days.
What on earth is that about? (In passing, let me tell you:
it is about failure of our investment in primary care and
community support, that’s what.) And of course serious
questions about safety, quality, efficiency, equity of access,
and much else niggle away at our peace of mind.
Why you should bother about reform
I hold the view that it is important for medical practitioners
including medical academics to take a lively interest in the
reform process, in part to inform it and in part to ensure
that their interests and those of their patients are being
served. Indifference of the sort that claims that all reports
achieve nothing and simply gather dust is feeble and
unhelpful. It fails to understand the policy process.
My professional judgement as one interested primarily
in health, secondarily in the way we maintain it and manage
illness, and then, thirdly, in the policies that determine
the allocation of resources and shape the management of
the system, is that we do need transformational change in
the health system – not more fiddling at the edges on this
occasion, useful though that generally is.
If I am correct, then this is no time for us to be sitting
back and waiting for things to happen entirely according
to others’ agendas. It is one thing to advocate for ‘clinicians
being more involved in clinical governance’ and altogether
another to argue for those same clinicians to bend their
admirably capable minds to larger questions of system
change. It is the latter that is so hard and it is, at present,
the latter that is most important.
How reforms affect us and our patients
In this issue of Radius several members of your Sydney
Medical School whose careers are in areas of special need
in health discuss what they see to be the reform agenda.
First, each of them comments on the need as they see it
in their area of work. Second, they critique the current
reform agenda and documents, providing us with insights
into what they regard as good proposals. Third, they tell us
where the lines of reform need to be stronger as they see it.
It is true that Australia does not have a fiscal crisis in
regard to health care – yet. Several exuberant, detached
and fantastical suggestions for changes in the way we
finance health care may change that. But in any case
with unbridged inequities in access to care, dangerous
unresolved quality and safety issues, a preventive agenda
that we have to grasp and finance, substantial changes in
the demographic structure of our nation, mental health,
dental health and Indigenous health all requiring more of
us, we need to do more cerebrating about how we spend the
health dollar in the future.
Time to start thinking
As Steven Lewis reminded our readers at the conclusion
of our MJA paper on health reform, Nobel Laureate Lord
Rutherford of Nelson (NZ), author of the planetary model
of the atom that he then went on to split in 1917, said to
his charges experiencing the constraint of scarce resources,
“Gentlemen, we have run out of money. It is time to start
thinking.” So, too, it is time for us think very seriously
indeed about health reform – new models for a new age,
please – in Australia.
Stephen Leeder is Professor of Public Health and Community Medicine at the University of Sydney and Director of the Menzies Centre for Health Policy.
Angela Beaton of the Menzies Centre helped prepare this article.