Elements line up in the big picture

The sails of the Sydney Opera House are lit up each evening in colourful and dramatic images as part of a festival. The map of Australian health, too, will soon bear impressions of a very different sort beamed from two projectors.

One will cast the light and colours on the communities embraced within new local hospital networks. The other will reveal outlines of geographic areas containing community based health services provided through primary healthcare organisations. The two sets of images must be aligned for a good picture of national health.

The driving force behind healthcare reform isn't political whim but the rising prevalence of chronic illness, such as heart disease, lung problems, diabetes, arthritis, controlled cancer or HIV, mental illness and stroke: illnesses that account for 80 percent of our health suffering as a nation. Care for people with such disorders consumes 70 percent of our health budget, a cost rising faster than productivity growth.

Good quality care for people with chronic problems requires co-ordination of hospital and community services. Traditionally, these services haven't worked together perfectly. Unfocused care is due to entrenched suspicions among health professionals working in hospitals or the community, worsened by different arms of government paying for hospital and community care.

There are other reasons for primary healthcare organisations and local hospital networks to cover the same areas. To respond rapidly to outbreaks of infectious disease or environmental threats, it's important to provide integrated services.

But to go back to the most important reason for health reform, the first step to improved care of people with chronic illness was taken recently when the commonwealth proposed that it pay most of the cost of running public hospitals and all community-based care. It's a good start. Yet the gains could be lost if hospitals and community services manage different populations.

How well will the new hospital networks and primary care organisations suit us? Size matters. While the areas served by hospital networks will vary from rural to urban settings - and there's good sense in moving elements of health care away from state bureaucracies to smaller administrative units, the local hospital networks - we must not create areas that are too small.

Kevin Rudd's new mosaic of hospital areas, the National Health and Hospitals Network, concentrates governance at the local level. The definition of these hospital networks is critical to ensuring safe, top quality care.

The hospital network areas must be big enough to attract outstanding practitioners, research workers and academic educators. But they must also be small enough to avoid remote and demoralising management and risk losing local ownership, autonomy and flexibility.

The Prime Minister's first proposals suggested hospital networks might be so small as to be medically dysfunctional. Populations less than about 300,000 will not support the maintenance through practice, for example, of competent obstetric services and surgical procedures. Expensive equipment must serve populations of about this size or more to justify the cost of installation and avoid expensive periods of idle standby.

Then there's the balance between hospital and community services. Too much of one colour will wreck the picture. The May budget gave hope that a better balance is coming.

Primary healthcare organisations contain general practitioners and other health professionals. They'll assume responsibility for local communities. It's important these organisations have enough clout to fill the gaps that will emerge or are already visible - such as preventive health - and are large enough and have the funds to mix it with the big players in hospitals. They should serve the same constituencies as the hospital networks.

At the recent Council of Australian Governments meeting to consider Rudd's proposed health reforms, states and territories were assigned responsibility for determining how many and what size the hospital network areas will be in their jurisdictions. The commonwealth retains responsibility for setting the boundaries for primary care organisations.

A task group with representation from senior clinical groups, health service management and health economists could make recommendations. The group could report to the government before the next federal election.

This month the Rural Health Alliance met Indigenous, Rural and Regional Health Minister Warren Snowdon. The alliance emphasised the importance of local management and control, along with the critical community service functions undertaken by smaller hospitals. A unit has been set up within the Department of Health and Ageing to oversee implementation of the reforms in rural and regional areas. Ensuring the proportions of hospital and community care are correct and in focus, and that the overlay of services is precise is critical to the success of health reform.

We're going through the disruption of reform principally to give patients with chronic illness the co-ordinated care they need. This is likelier to occur if we enable inspired artistry to create co-ordinated hospital and community-based services - a light show of health - across the entire map of Australia.

Professor Stephen Leeder is director of the University of Sydney's Menzies Centre for Health Policy, and director of the Sydney West Area Health Service's research network.

Media enquiries: Sarah Stock, 9114 0748, 0419 278 715, sarah.stock@sydney.edu.au