In the run-up to the last federal election, The Centre for Policy Development published three papers on health policy matters:
Primary care by Stephen Duckett,
Lack of integration of commonwealth and state health functions by John Menadue
Health election policies of the major political parties by John Menadue.
This was followed by discussion on these issues by many people involved in the health sector.
Following that discussion, the Centre for Policy Development thought it would be useful to summarise what we consider to be the key building blocks around which a national health policy should be build.
Australians have good health by world standards. The major exception is the health of indigenous people. But our health system is under great pressure. The excellent and dedicated staff who work within it are expected to do more than is reasonable. As a community we keep demanding more than the system can deliver.
So much of our ‘public debate’ is about how we finance our present delivery system which has been basically unchanged for decades. We need also to focus on how that system should be modernised.
As the health debate proceeds, the Centre for Policy Development will update these building blocks with a view to finalising a health policy for Australia which has broad support from our subscribers. Your comments would be very much appreciated.
The building blocks
1. A universal and compulsory health system in preference to a two-tiered health system, such as in the USA.
Medicare efficiently and equitably raises revenue through taxation. It provides or should provide access for all, particularly in primary care through bulk billing. As the monopoly purchaser of health services, Medicare has considerable purchasing clout. A universal system is also important in promoting a cohesive society and giving everyone a stake in a high quality public service. The commonwealth government’s $3 billion rebate on private health insurance should be abolished or diverted to other health programs, eg indigenous health. The rebate is inequitable and has been largely ineffective and inefficient as a means of taking pressure off the public health system. In most cases, the rebate subsidises households that would have purchased private health insurance in any case.
We need to be quite clear about the values and principles we want reflected in our health system, or we will get blown off course by short term political pressures, crises, opportunism and self interest.
2. The integration of commonwealth and state health functions to provide a seamless health service.
The present divided responsibility results in costs and blame shifting, confusion and inefficiency. The community is less concerned about who delivers the service. It is more concerned about the quality and efficiency of the service provided.
The integration of commonwealth and state health functions would be as significant as the establishment of Medicare thirty years ago. A pooled funding arrangement with appropriate governance, coverage and management could significantly provide greater efficiency and change professional behaviour. There would be improved value for money. The community and health professionals would welcome this reform. What is lacking is prime ministerial and premier leadership.
It is unlikely that the commonwealth government would be prepared to hand over its health functions to the states and be content to provide only general-purpose grants to the states.
The best solution would be for the states to cede their health functions to the commonwealth. But for opportunistic and political reasons, all the states are unlikely to agree to this on a national basis. One option would be for the commonwealth to negotiate the establishment of a commonwealth/state joint health commission in any state that would agree (see ‘Breaking the Commonwealth/State Impasse in Health, a Coalition of the Willing’ in The Centre for Policy Development). Hopefully success in one state would lead to other states following. This joint commission would hold all commonwealth and state funds, plan and integrate funds on a statewide basis (or on a regional basis if preferred) and purchase services from existing providers including commonwealth and state, NGOs and the private sector.
The purchasing of these services should drive the integration of care and in full cooperation with the providers who have considerable knowledge and skill in this matter. In addition to cooperation on a geographic basis described, it would also be possible for commonwealth and state governments to cooperate on a program basis (eg pharmaceuticals) or in respect of a particular age cohort (eg the commonwealth taking hospital responsibility for all persons over 75 years as in Medicare Gold).
Any increases in commonwealth and state funding should be conditional on reform of the antiquated delivery system in ways described below. The system is reaching the end of its architectural life. It is no longer sustainable in its present form.
Too often, money is ‘thrown’ at problems identified by the media. The ‘political’ intention is to get the issue out of the news, rather than addressing the real problem. Surgery rather than band-aids is required.
3. Primary care must be the key building block in a reformed health system.
We have a hospital-centric system where hospitals pre-empt the debate and the resources. We need strong core services in the community that are linked to hospitals but not driven by them. The health debate is so often about what is urgent (hospitals) rather than what is important (primary care delivered principally by GPs).
The autonomy and dignity of the patient is much better enhanced if patients can be treated in their home or as close to their home as possible. The greatest cause of poor health in Australia is poverty – poor diet, poor lifestyle, and stress – which is best addressed in the community and not through hospitals. Pharmaceuticals and advanced methods of coronary care have produced significant health benefits in recent years, but historically the great advances in health have come from public health and prevention – clean water, sewerage, vaccination and more recently, anti-smoking campaigns. It is cheaper to treat patients in primary care rather than in an expensive tertiary hospital. Failure of the primary health care system causes untold and expensive repercussions in the rest of the health care system.
Primary health care must be multifunctional in nature and provide a range of clinical skills — doctors, nurses and allied health, such as physiotherapists and dieticians. The nature of primary health care clinics will vary greatly from community to community.
Employment status in primary health care clinics will also vary. Some will be private, some public and some will be a combination of both.
Some will have salaried staff and some will be remunerated on a sessional or fee for service basis. The key for the future must be clinicians working in primary care as teams to provide an appropriate range of services in the most efficient way. The days of the lone general practitioners, usually a male and working 70 hours a week, are well and truly passing.
4. We can’t have all we want in health and choices have to be made.
Demand is driven by unrealistic community expectations, doctors and drug and technology companies. Politicians won’t tell us that we need to be more realistic about what the health system can provide. Health dollars and resources are limited and choices have to be made.
What is true of our private household budgets is true of the public health budget. An informed and involved community is essential in making choices and determining priorities. Otherwise, money and resources will go to the best organised and the most influential. The health debate is largely between insiders – doctors and ministers. The community is substantially excluded.
There must be genuine community involvement in numerous ways and at many levels. Well-researched surveys of community attitudes on health show very clearly that when the community is informed and involved, it comes to quite realistic views about the important priorities in health. Very often the informed community view is quite different from the fairly superficial discussion and views expressed in the media.
The views projected in the media are invariably about hospital waiting lists, emergency department pressures and the need for some new high technology equipment or some new drug.
Priorities will of course vary from one community to another, but several issues often stand out when community members are well informed. Priority is often in such areas as mental health, aboriginal health and the health consequences for women and children of violence.
5. Workforce reform is essential.
This would produce large productivity gains and increased professional satisfaction. So much of the debate on workforce is about more staff to do the same things in the same archaic and incoherent way. The workforce is trained in compartments and works in compartments.
Restrictive practices entrench professional demarcations. Nurse practitioners encounter resistance across the country. Discussion about expanding the functions of generic health workers are stalled by the professional unions. Midwives are unable to get reimbursement under the medical benefit scheme. Only 10 per cent of normal births in Australia are delivered by midwives, compared with 70 per cent in the Netherlands and over 50 per cent in the UK. Universities and professional colleges continue to entrench and protect specialists, when it is clear we need generalists who treat the whole person and not just an organ.
Relative to specialists, GPs are underpaid. The distribution of provider numbers to general practitioners bears little relationship to community need. Outer suburban and country areas are very short of GPs. Affluent areas are relatively over-supplied.
Workforce reform will require strong political and industrial will and skill. Reform of the blue-collar workforce has delivered great productivity benefits to Australia. But that reform has not touched the professions and particularly the health workforce, which is the largest in Australia. 9 per cent of Australia’s GDP is now spent on health and 70 per cent of the health dollar is spent in employment costs.
6. We need to overcome the disconnect in hospitals between ministers and health executives on the one hand and the professional responsibilities and autonomy of doctors on the other.
Doctors admit, treat and discharge patients. Their clinical decisions drive both the hospital inputs and outputs. Doctors supply the clinical services and in a sense manage the clinical demand. Ministers and senior executives are responsible for staffing and budgets, but don’t make the clinical decisions that effect outcomes. Nurses hold the system together but don’t have any real authority.
Few public hospital boards effectively govern their hospital. Clinical governance is often a separate governance stream and not subject to the over-arching governance of the main board.
The situation is often more confused as a result of attempted micro-management by ministers and senior health department executives which doesn’t address the disconnect and succeeds largely in confusing the organizations and making all staff reluctant to make decisions.
Senior clinicians have responsibility for life and death professional decisions. That responsibility is usually not reflected in delegated financial authority.
One result of this disconnect is that Australia does not have an effective system for monitoring and delivering quality and safety in healthcare.
Hospitals are dangerous places. Recent research suggests that being conservative and assuming that only 25 per cent of deaths in hospital are due to avoidable ‘adverse events’, 4,500 deaths per annum die in hospital as a result of avoidable mistakes. The national costs of these avoidable mistakes was estimated at more than $4 billion in 1995-96.
The commonwealth government recently provided $580 m to further subsidise the medical premiums of doctors. This has addressed the symptoms and not the underlying problems.
In addition to addressing the disconnect in hospitals between ministers and executives and doctors, additional steps are necessary to address these problems. These include inadequate hospital accreditation, particularly of small hospitals, unreliable and inefficient record keeping, poor hospital systems, fragmentation of specialist services, inadequate clinical accreditation and poor clinical peer review. Underlying it all is a lack of transparency for fear of professional, legal, financial or political repercussions. A few doctors are blamed when the real problem is a system failure.
7. Information technology and telecommunications are critical system enablers. A priority is the need for an Australia-wide personal electronic health record (subject to privacy concerns).
There are tens of thousands of IT users in the health system in Australia. Very few adequately connect to each other. Patients are often requested to provide their personal details many many times. There must be the provision of accessible, system-wide information, both within and across state and commonwealth boundaries and between all providers. It is critical for the development of common records, sharing of information, clinical planning and the linking of all services. Technology could help overcome many of the jurisdictional boundaries in our fragmented health service.
John Menadue is Chair of the Centre for Policy Development.