Integrating our health system — a map for the reform journey

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The fact that Australian and state governments are responsible for different segments of our health care system has produced jurisdictional inefficiencies for which solutions have been sought for at least the last 20 years. The current arrangements are now recognised by all as a serious impediment to the delivery of quality, equitable and cost effective health care.

The Australian Government is a “purchaser” of health care for Australians and is caught up in a number of open-ended programs which provide little capacity to tie health expenditure to health outcomes. State governments are ‘providers’ of services that are partially supported by grants from the Australian Government. It is becoming ever clearer that the lack of integration of the programs organised by State and Federal governments is resulting in an unfortunate and costly amount of duplication and inflation within the health care sector and a lack of capacity to focus on patients’ needs.

Over the last two decades, promises from politicians to fix the problem have not been delivered, as the challenge always seems to fall into the “too hard basket”. It is now obvious however, that the solutions required present a leadership, rather than mechanistic, challenge. The Premiers, Chief Ministers and Prime Minister have established a COAG working party to advise on ways of resolving this dilemma. This initiative, backed by the commitment of Australia’s health ministers to promote health care reform, perhaps provides our “last best hope” of finding a way forward.

The journey to health care reform

The longest journey, of course, starts with the first step and that first step must involve action, not rhetoric. History tells us that it is highly likely that even if the COAG working groups were to produce an excellent and politically acceptable raft of suggestions, supported by Australian health ministers, those suggestions may remain just that.

For this reason a crucial step involves the establishment of a task force to actually implement health care reform suggestions. This task force should be constituted as a National Health Reform Council (NHRC), reporting directly to COAG. Keeping the nation’s leaders involved in the journey is crucial as many of the reforms needed involve issues not handled exclusively by the health ministers and their bureaucracy. There are, for example, socio-economic factors driving health outcomes that require a whole of government and community approach. While NHRC strategies would require endorsement by COAG, implementation would so often require the cooperative efforts of health ministers that we envisage NHRC activities involving a partnership with the Australian Health Minister’s Council. Therefore a first challenge for contemporary political leaders is to see our state and federal leaders, including health ministers, support, indeed champion, the creation of this National Health Reform Council.

The National Health Reform Council (NHRC)

A National Health Reform Council would have an extended place in the Australian health care landscape, remaining active for at least the next few years. The sustainability of the health care programs that we desire in Australia will require a continuing and major oversight effort to ensure that cost effectiveness is achieved with the dollars spent actually producing desired outcomes.

For this reason, the NHRC should be a living, breathing, full time, innovative, well resourced, transparent, inclusive, semi-independent and dynamic entity. Its role would be to implement reforms approved by COAG and/or the Health Ministers’ Council. Yes, it would involve the establishment of a new agency but it would not require any increase in our bureaucratic workforce.

All jurisdictions have in their departments of health, knowledgeable and talented professionals who work on the interactions of state and federal governments pursuing health care programs while others are involved in the most important issues an NHRC would tackle on an ongoing basis, namely workforce, manipulating our health care resources to provide more of a “wellness” model and the fusion of state and federal programs. Bringing together these talented individuals, many of whom are excited by the concept, in partnership with consumers and clinicians would actually make it possible to reduce significantly the number of bureaucrats involved in delivering health care to Australians.

Thanks to Clay Bennett.

Mission of a National Health Reform Council

There is little controversy in Australia that there are three major issues that must be addressed as we promote health care reform.

1. The provision of an adequate workforce.

2. The development within Australia of a health system promoting “wellness”, the prevention of disease and earlier diagnosis to minimise the development of chronic disease.

3. The integration of current and future health care programs to increase quality and therefore better health outcomes while addressing issues of cost effectiveness.

These three issues cannot be addressed independently.

Engaging Australians in the reform journey

Very importantly, the NHRC would lead initiatives which would see us engage the Australian community in a significant dialogue about health care into the future. The NHRC would implement programs that would engage, inform, listen to and empower the Australian community to provide direction for, and embrace, necessary reforms.

Integrating state and federal programs

The NHRC would be responsible for taking us on that part of our reform journey that would see an ever-increasing integration of state and federal programs. Thus the NHRC could be involved in assisting with the development of bilateral, and even trilateral, agreements between Australian governments around specific programs.

Examples would include the integration of primary and community care services, the integration of cross border programs to solve many current inefficiencies and the fusion of numerous state and federal programs all aimed at improving the care of older Australians. The Commonwealth would always be a partner in these bilateral and trilateral arrangements and the NHRC would promote the notional, or real, pooling of funds to achieve the goals of the fused programs.

Very importantly, the NHRC would establish and evaluate the governance mechanisms set up for each of these joint ventures. In this way, we would learn as we proceed along our journey, what safeguards produce appropriate comfort zones for state and federal governments, making them more confident into the future that they can, through collegiality and partnership and a determination to focus on the needs of the community, end many of the jurisdictional inefficiencies that currently exist.

The partnership that we need between federal and state governments must be supported by efforts to promote and evaluate partnerships between the public and private sector deliverers of health care in Australia. The NHRC would be charged with driving these initiatives as well.

What awaits us at our destination?

It is conceivable that over the years of a journey that would produce continuous improvement to health care in Australia, political leaders and the community alike may decide on a central government assuming responsibilities for all aspects of health care. We believe it is more likely that the journey would see the exploration of the formation of an Australian Health Care Corporation, a third party that would run the Australian health care system on behalf of both state and federal governments, reporting through COAG to parliaments and therefore the Australian people.

What is clear is that a National Health Reform Council utilising the best talents available would be best suited to developing models that would provide Australians with the superb health care system we deserve and can afford.

We would wish that the COAG working groups, in reporting to the Premiers, Chief Ministers and Prime Minister would support the concept of National Health Reform Council. We encourage health ministers to discuss this concept and at least support it in principle. COAG could request that they orchestrate, over the next six months, the establishment of a working party to consult widely and determine the exact terms of reference for National Health Reform Council. The appropriate legislation if required, could be passed and a site, funding and personnel could be agreed upon. The NHRC should be operational by July 2006.

It can certainly be anticipated that in the short term, the commitment to reform and the establishment of an NHRC to provide leadership for that reform would generate public enthusiasm for the approach. Australians are tired of the constant blame shifting that is a feature of every story about problems in our health system and would welcome signs that political leadership is at last moving us forward.


These initiatives would see an end to cost shifting, an end to perverse and inappropriate outcome measures while increasing the amount of “health” being extracted from the available dollars. These reforms would therefore do much to resolve problems related to the inequity of access to and outcomes from health care that is so troublesome in contemporary Australia.

Professionalism rather than politics would dominate the health agenda while the restructuring of a health care system that has been failing to keep up with the contemporary needs would again provide us with a program that is second to none.

Recommendations on integrating health care programs:

1. Establish the National Health Reform Council (NHRC) to implement health care reforms approved by COAG and/or the Health Ministers’ Council 1.2 NHRC to coordinate programs in partnership with clinicians and consumers to reduce the number of bureaucrats delivering health care to Australians. 1.3 COAG should establish a working party to determine the terms of reference for the National Health Reform Council. 1.4 The NHRC Mission should be endorsed.

The mission of the council should reflect reform priorities:

· The provision of an adequate workforce

· The development of a health system promoting “wellness”, the prevention of disease and minimization of chronic disease

· The integration of current and future programs to increase quality and therefore better health outcomes while addressing cost effectiveness.

This article is based on the Action Plan for Health Care Reform in Australia – Paper V: Integration of health care programs’, one of five papers forming a submission by the Australian Health Care Reform Alliance to the Council of Australian Governments in 2005

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