The Drum Wrap: Rudd vs Abbott

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What did healthcare experts and observers think of Kevin Rudd and Tony Abbott’s performances in the debate over the future of Australian healthcare? Jennifer Doggett tells ABC’s The Drum what she thought.

Published in ABC’s The Drum on 23 March 2010.

Jennifer Doggett, Fellow for the Centre for Policy Development:

The question by SBS’s Karen Middleton on out-of-pocket costs for health services revealed the black hole at the centre of both the government’s and the opposition’s plans for health system reform.

While both leaders acknowledged that direct consumer payments for health care were here to stay, neither could articulate how their government would address the problems with our current approach to this issue.

Despite being a major source of health funding, contributing more than twice as much as private health insurance, direct consumer payments have been largely ignored in the health reform debate.

However, for consumers out-of-pocket costs are much more important than debates over which level of government is responsible for hospitals or quibbles over what level of funding should be contributed by the Commonwealth.

Co-payments are crucial in determining how consumers access health care and which services they access. Our current system is illogical, inequitable, prevents many consumers from accessing the care they need and steers others toward more expensive and less effective forms of care.

The problem is not always the quantum of the co-payment. For many people, health care expenses occur unexpectedly and coincide with reduced earning capacity. This makes them difficult to afford in the short-term although they may be manageable over a longer period.

One solution would be to approach health care expenses the same way we approach many other personal and household expenses. We generally pay for our cars, houses, tertiary education and credit card expenses through regular and planned payments. This allows us to access goods and services when we need them and make repayments that fit within our budget.

A similar approach to health care costs could be achieved if the Commonwealth took responsibility for paying all health care bills, deducting the relevant subsidies (such as Medicare rebates), and billing consumers directly for the net out-of-pocket costs, allowing them to make regular repayments if they could not afford to pay back the full amount straightaway.

This would ensure that everyone could access the care they needed and that no-one would be denied necessary health care due to high out-of-pocket costs.

Karen Middleton was right to steer the debate away from hospital funding mechanisms and focus on out-of-pocket costs for health care. If the Prime Minister and Opposition Leader want to win support from the community for their respective health reform policies, they should also focus on this central issue to the consumer experience of health care.

Professor Kathy Eagar, Director, Centre for Health Service Development, University of Wollongong:

As we expected, today’s debate was more about politics than health policy and it certainly reinforced how difficult it will be for the Prime Minister to get bipartisan support for his plans to attempt to improve the health system.

But the public wants improvements and is sick of the political bickering and we won’t get improvements unless people work together. There’s a lot of wisdom, skill and knowledge in the health system that can be harnassed in the reform process and that includes quite a lot of expertise in the various health departments as well as clinicians.

It’s easy for both sides to score easy points by bagging ‘bureaucrats’ but the fact remains that the health system really needs the best managers it can get. After listening to the debate today, what competent manager would want to continue working in health system?

It’s time for both sides to stop casting clinicians as the goodies and managers as the baddies. Just as there are great clinicians, there are great managers. And they will be needed to implement any reform plans, regardless of who is in government.

Today was not a debate about health care, the whole focus was on hospitals. Both leaders were largely silent on other essential health services – dental care, aged care, mental health and primary care to name just a few.

Building the whole system around hospitals is doing it the wrong way round. Hospitals should be there to back up the rest of the health system, not the other way around.

I was pleased to hear the Prime Minister say that he is prepared if necessary to look at different funding approaches for small and remote hospitals. His comments will go a long way to alleviating the anxiety of small rural communities.

Most of the Prime Ministers other comments have already been outlined in his reform plan. There is a lot more detail we are all waiting for but I suspect we may be waiting for some time until we know the full picture.

The Opposition Leader did not present any alternative policies of substance but attempted somewhat unsuccessfully to defend the track record of the previous Liberal Government on health spending.

The fact is that the Liberal Government did increase hospital funding in the 2003-2008 Australian Health Care Agreement. But they did not provide adequate indexation to the states and territories over the 5 years to cover increased costs due to (1) population growth, (2) population ageing and (3) inflation.

The states and territories protested loudly at the time (in 2003) but to no avail. The outcome is that, over those five years, the states and territories were left to pick up a greater share of hospital costs each year.

By 2008, when the Rudd Government took office, most states and territories were really struggling to cover the extra costs and waiting times in public hospitals were, in many cases, far too long. The states and territories received a significant injection of funds in Rudd’s first health care agreement with them, with a better rate of indexation built in over the five years than existed in the previous Liberal Government agreement.

The question now is whether the Prime Minister can convince the states and territories that his hospital reform plan is better than what they’d already been offered in the 2008-2013 agreements that they have already signed.

Cydde Miller, Policy and Networks Manager, Australian Healthcare & Hospitals Association:

We all recognised late last year that any discussions and announcements in health during 2010 would be framed around the pending election. This debate played out very clearly in these terms.

Some of the questions cut to the heart of the matter, both for health industry stakeholders like ourselves, the Australian Healthcare and Hospitals Association (AHHA), and for the Australian public. Some of the answers were less than enlightening though.

We found out a bit more about Rudd’s National Health and Hospitals Network, perhaps even that the Local Networks would be the coordinating bodies for service integration across hospitals, GPs, allied health, aged care and specialist services.

Aside from this statement, however, we had very little comment on the rest of the system outside hospital walls, namely primary healthcare and aged care.

We found out nothing more about Tony Abbott’s proposals.

Some argue that he’s within his rights to not have a policy to announce right now, and that the debate was sprung on him.

Regardless, in an election year it is the job of an Opposition to have critical issues like health worked out in considerably more detail than what the Coalition has showed to date.

What we got was a “credible alternative in good time” – we need more than credible, and we need it as soon as possible.

One of the trickier questions came around the private health insurance rebate. Would a returned Rudd Government commit to NOT changing the rebate? The Prime Minister said yes, but… still seemed committed to putting through changes that made the rebate ‘fairer’ via means testing (such that lower income earners are not subsidising people earning mega bucks).

The AHHA supports the strongest public hospital system possible, and the several billions of dollars spent every year on the private health insurance rebate is no doubt responsible, in part, for less money to go into hospitals directly.

Of course, the Coalition commits to keeping the rebate just as it is, and was from the day they introduced it.

Tony Abbott raised a very good question about impacts of the Government’s proposal on small rural hospitals, which needs considerably more clarity and illumination from Kevin Rudd, but he failed to answer it for himself.

The sum total of what we know about the Coalition’s health policy for Australia is that big (metropolitan) hospitals in NSW and Queensland will get boards of governance. What about the small hospitals? How will they be governed? Why would you establish so many different forms of governance in a system that we’re attempting to unify and bring greater consistency to?

Finally, one of the larger concerns of the AHHA’s members has been the complete lack of action and commitment on oral healthcare. The best question fell to both leaders: will Australia have Denticare, Medicare covering oral healthcare, or neither?

The answers characterised how politicians can react when faced with a problem that seems insoluble. Yes, universal dental care will be expensive. Targeted dental care less expensive, which is what the states and territories already do and need immediate support from the Commonwealth to expand.

The AHHA developed a lower cost solution and step into a brave new world that has sat for well over a year before both major parties which would have seen both sides win – to implement the Government’s promised Commonwealth Dental Health Program for Healthcare Card Holders and pensioners, and keep the Coalition’s Medicare Chronic Disease Dental Program with more checks on the items of service provided.

But somehow politics have overwhelmed what is best for the public and neither side is willing to come clean.

Let us hope that this does not characterise future debates nor the decisions the leaders and their parties make.

Professor Stephen Leeder, Director, Menzies Centre for Health Policy, University of Sydney:

First it is rare but very encouraging that both the Prime Minister and the Leader of the Opposition debated health care today. This is healthy democracy.

Second, the debate confirmed that both sides of parliament are committed to securing funding public hospitals directly from Canberra. The need for greater local management of hospitals was also agreed between the two leaders.

Third, neither had a satisfactory answer to the need for improved dental care. Currently Australians spend more on dental care than on cancer and yet it defies us when it comes to public funding.

Fourth, the system has been starved for capital. The Rudd government has allocated billions of stimulus dollars for this purpose and more is needed.

Fifth, actual increases in funding remain unclear as does the management of the reformed system under either party.

Finally, while Rudd was the more formidable debater and Abbott the more witty, there was little to actually to differentiate between the two policy proposals. The record of the previous government was introduced rather late in the debate. More could have been made of it. It was an era of increasing privatisation. This should be clearly recognised when consudering how to improve the public system.

Whatever else more money will be needed.

Dr Dennis Grube, Lecturer in Politics and Public Policy at Griffith University:

The Prime Minister attempted to return today to the script that brought him to the Lodge.

His rhetoric once more echoed heavily with that ubiquitous term ‘working families’ and his childhood and family memories in his opening statement signalled an attempt to once again demonstrate his connection with Australians from all walks of life.

He personalised his health care reforms as something more than just a shifting of funding models by referring frequently to the needs of patients as being paramount, and promising that his reforms would deliver more doctors and nurses on the ground.

He appeared on top of his detail, and attempted to strike a statesmanlike pose by being seen to reach out to work with the Opposition, an attempt which juxtaposed uncomfortably with his criticism of Tony Abbott’s record as Health Minister.

Tony Abbott struck a more combative note from the outset, seeking to draw the debate into a broader assessment of the Government’s record of policy delivery, contrasting it against his own record as Health Minister. He continually raised issues such as the insulation scheme and the building of school halls, and attempted to use cut-through terms to capture what he characterised as government failures.

His previous catch-cry of ‘a great big new tax’ was revised into a ‘great big new bureaucracy’ in health, and he promised that an Abbott Liberal Government would deliver ‘real action’ and ‘real difference’ – perhaps roadtesting some potential slogans for the electoral battle ahead.

Professor Ian Hickie, Executive Director, Brain and Mind Research Centre, University of Sydney:

What we have heard today is a debate between a half-baked plan (the Rudd Plan) and no plan (the Abbott Plan). We are no more informed on the key issues.

Repeatedly, the Prime Minister represented health as “hospitals”. His focus was clearly on “waiting times, elective surgery and hospital beds”. He spoke of consultations with the community as “101 consultations with hospitals”.

To date, the Rudd Plan is simply a modification of the existing public hospital financing plan. Again, he did not detail how this system will work with the private sector to deliver more services to those in real need.

As the Commonwealth already funds general practice, its
commitment to funding 100 per cent of these services is simply a re-statement of the existing system.

The additional commitment to funding more training programs is welcome but does not address the real issues related to the current systems of restrictive work practices.

There is no suggestion of real sector-wide economic, insurance, professional or services reform.

It is not anywhere near the size of the reforms that gave birth to Medicare.

As stated by the PM, the AMA is very happy with this outcome. Activity-based financing is good for surgeons and procedural medicine.

Doctor-dominated local hospital networks will now do hand-to-hand combat with state and commonwealth bureaucrats.

In this context, other community priorities will once again be left far behind.

Those other key community issues that are mental health, alcohol and drug services, maternal and child services and dental care. Under the Labour Plan these essential services remain unfunded and are effectively left in limbo.

After today’s debate we are no clearer as to whether there will be any significant improvements in these key services. They were highlighted by the Bennett Commission as key areas of dysfunction in the Australian Health Care System.

Disappointingly, there were very few straight answers to the well-informed questions. The lack of attention to infrastructure funding during the GFC does reflect poorly on the National Government and those responsible for administering health.

Hopefully, the media can maintain a six month campaign to get straight answers before the election.

Mr Rudd has often described this process as a “once in a generation” opportunity.

If the outcome of the current process is that the National Government moves its share of the spend from its traditional 50/50 split to 60/40 of Government spending
(remembering that Governments only pay 70 per cent of the total costs of health care, while we pay the other 30 per cent from our own pockets and insurance) then we will have
squandered that real opportunity.

In my view, while voters (and the WORM!) will give the Rudd Government a large opportunity to get this right, they will eventually punish national or state governments who fail to deliver real new services.

Professor Helen Christensen, Centre for Mental Health Research, The Australian National University:

Everybody knows that hospital reform is important, but is it the priority?

As usual the focus of any debate about health and hospitals focuses on doctors, nurses, bureaucracy, costs, waiting lists for surgery, bricks, mortar, and hospital beds!!!

We need a more informed discussion about new ways to improve health that do NOT involve a focus on the pointy end of the medical system – the hospitals. We need a focus on new ways of delivering health care in the community, through innovative types of health care services and through reformed general practice environments.

Mental health was not discussed, despite the efforts of one journalist to raise it. Yet, we know that depression is second only to ischaemic heart disease as the major cause of disease burden in Australia.

In 2007, the 12 month prevalence of anxiety disorder in Australia was 14.4 per cent, the prevalence of depressive disorder was 6.2 per cent and a further 5.1 per cent experienced a substance disorder.

The highest combined 12 month rate of mental disorder was experienced by 16-24 year olds, with rates exceeding 25 per cent. More than 65 per cent do not get access to health services.

There are approx 671,000 young people with depression in Australia today. And, despite 10 years of health services reform – better outcomes in mental health care, awareness programs etc – and a rapid rise in the rate of anti-depressant prescription, there has been no discernable reduction in the prevalence of depression or other high prevalence mental disorders in Australia in the last 10 years.

Improvements in hospital beds and better operating theatres will not solve the difficulties for these 700,000 young people.

If we are talking about health reform, let’s get serious and talk about REFORM. We need high level discussions about new forms of early intervention and prevention for our young people – we need more youth specific centres, we need better early intervention using new (cheaper methods) of providing services such as through virtual clinics and internet technologies.

We need full commitment to prevention and prevention services.

Jon Wardle, National Health and Medical Research Council Scholar at the School of Population Health, University of Queensland:

There is a lot of talk about health action, but the chance for health reform has unfortunately escaped us again.

A bigger health system awaits, though evidently not a better one. We now know who will apparently pay for it, and who apparently didn’t pay for it, but unfortunately the debate on what we’ll actually pay for – or whether we actually get bang for our buck – still seems a long way off.

Both debaters were equally myopic, focusing on reactive rather than proactive approaches to healthcare. The health and hospital system seems to have become very little about health and all about hospitals.

While preventive health was given its usual cursory nod it was again misrepresented by both parties – focusing on early treatment rather than real prevention. Where were the education, workplace, non-health policy or non-hospital interventions already known to be very effective – and very cost-effective – internationally?

The PM’s definition of primary care as “GP and GP-related care” only should send shivers down the spines of unattended patients and overworked GPs everywhere. Let’s get the debate away from superficial doctor, nurse and waiting list numbers and start talking about whole-of-government approaches that can actually make a difference.

Just as building new roads does little to relieve traffic problems as they become clogged by the very traffic they create, any new hospital beds, doctors and nurses will simply be immediately soaked up until we begin addressing upstream factors.

Why was actually keeping people out of hospitals and doctor surgeries in the first place entirely missing from the debate?

Whilst the debate focuses on simply rolling out more of the same failing system, the chance of Australia getting a health system that can really face future challenges head-on diminishes considerably.

Until then we’re just mopping the floor with the tap still turned on.

James Gillespie, Deputy Director, Menzies Centre for Health Policy, University of Sydney:

The debate offered little new, but did clarify the governance questions that lie at the heart of the current health reform debate.

Abbott offered so few details of Coalition policy that it is difficult to comment on his contribution.

Rudd offered little new, but did clarify the emphases of his reforms.

Much of the momentum Rudd’s reforms have gained with significant interest groups and public opinion responds to widespread disquiet about excessive centralisation and the feelings of disenfranchisement of health care professionals within the system.

The main pillars of Rudd’s proposals bear directly on these questions: ‘efficient pricing’ only works if institutions are given increased autonomy to allocate budgets and manage services. The ‘Health and Hospital Networks’ offer a promise of increased autonomy and responsibility for those who provide the direct services.

Much of the canvas remains blank but some details are slowly emerging – it is clear planning of services across the system will remain for the moment in state hands, and it is difficult to see what alternative is available.

However, it is not clear how the new Commonwealth weight will be asserted. It will be a lot easier to judge the reforms when we see how primary care and population health will be handled.

These require much larger units than the proposed networks, more like the much larger primary care organisations proposed by the National Health and Hospitals Reform Commission.

Will the ‘health and hospital networks’ nest within these larger bodies, confining themselves to immediate problems of clinical governance? Most important, each statement on the future of the system starts with warnings about chronic illness in an ageing society – problems that demand better coordination across the system, from prevention and primary care, through hospital and aged care.

So far we have had a series of policy proposals that tiptoe around these issues without confronting the problem of how patient care can be improves across the system.

Professor Glenn Salkeld, Head, Associate Dean, Sydney School of Public Health, University of Sydney:

It’s hard to have a debate on health when we don’t know where one side of the debate, the Coalition, stand.

That said, both leaders appealed to the public – the families, pensioners, rural communities and what is in it for them.

We should have had a debate about public health – everything that helps us lead healthy lives, whether it’s in the hospital, the home, the community or where we work. Instead we got a debate on institutional health – the health of our hospitals. Most people get their health care outside of hospitals.

It is very important to have hospitals with the capacity and management to work efficiently and meet population needs for acute care. More beds won’t solve our problems.

Rudd did recognise the importance of prevention, the need for education and the importance of primary care, aged care and other care outside the hospital. But it clearly is not seen by our leaders as the main game.

Real reform comes from making it the main game.

By all means let’s ensure that the health of our institutions is assured but please let’s have more attention to the health of the public. Real reform comes from helping people manage their health where they live and work, knowing that hospitals are there for those times when everything else fails.

Jane Hall, Professor of Health Economics and Director of the Centre for Health Economics Research and Evaluation, University of Technology, Sydney:

We didn’t really learn very much about the two leaders’ policies, and we were not expecting to. A lot of it was predictable.

However there were two very interesting possibilities opened up by the prime minister, one potential funds pooling and the other less reliance on case-mix or activity based funding.

The first was part of the discussion about local networks with the Prime Minister suggesting they would take on preventative medicine, aged care, community services and primary care. If funding for these servies also flowed directly to the Local Network, it raises the possibility of being able to move funds from one type of service to another.

This is interesting because one of the criticisms that has been made about the current plan is how it leaves hospitals isolated from the rest of the system.

This has created a blame game that’s not about federal versus state, but different funding streams that are very rigid and inflexible.

There was also a real hint in the debate there the government may resort to a very different funding model from total reliance on case-mix or activity based, with the suggestion that at least in some cases, such as rural hospitals, other mechanisms would be required to sustain the service.

On the opposite side it was very interesting that Tony Abbott was most proud of his introduction of the Medicare safety net and its impact on out of pocket expenses during his term as Health Minister. My group did some research on that and discovered it was marginal in terms of impact on out of pocket expenses but had a big impact in terms of its influence on increasing doctors’ fees

Dr Peter Parry, child & adolescent psychiatrist and senior lecturer, Flinders University:

Accepting that the agenda focussed on the pubic hospital system, preventative medicine and child mental health were not going to be prominent in the Rudd v Abbott debate.

However Mr Rudd did talk about long term illness burden and need for a sustainable health system. These things are dependent on preventative medicine and healthy secure childhoods.

Research in developmental neurobiology highlights the importance of secure parent-child attachment and reducing parental stress during pregnancy, infancy and early childhood.

This leads to more resilient healthy (both mentally and physically) individuals, who are productive in society.

Journalist Sandra O’Malley did raise the issue of lifestyle factors and Mr Rudd whilst affirming the “fair go”, implying people should not be discriminated against for illness due to lifestyle factors, referred to “preventative health care” and “integrated care” across the lifecycle.

Mr Abbott referred to his personal healthy lifestyle but then spoke about keeping a strong economy, implying lower taxes, and without making the link with early childhood factors and preventative medicine – despite evidence of their role in long term economic stability.

I thought Mr Abbott was given another opportunity to elaborate on his very important and promising parental leave policy with a later question, but he didn’t and instead spoke again of keeping taxes low for a strong economy.

Ian Olver, CEO, Cancer Council Australia and medical oncologist:

Today’s debate provided little insight into how a comprehensive approach to cancer control fits into the health reform agenda.

The question about disease prevention was welcome and, while Mr Rudd’s response reflected a rhetorical commitment to improved prevention, we wait with great interest for a plan.

In discussing infrastructure, Mr Rudd could have referred to his $560 million capital investment in a network of regional cancer centres, which could have invited the question of how the centres’ viability, including travel support for remote patients, fits into the reform agenda.

And what about the piecemeal bowel cancer screening program – the Government’s best initiative for immediately preventing cancer deaths in Australia? When will it be finalised?

Dr Harry Hemley, President of the Victorian Branch of the Australian Medical Association:

The Prime Minister won the debate but left many questions unanswered. How does he plan to improve general practice, prevention, IT, mental health and aged care? We already have casemix funding and local boards so how will Victorian patients benefit?

There was a lot of sizzle, but not much steak. For example, it’s unclear how a 60/40 funding split will end the blame game, when the existing 40/60 split results in this sort of naming, shaming and blaming.

The Prime Minister and Tony Abbott presented us with proposed administrative changes and some vague promises that things will get better. This isn’t good enough.

We need a commitment to increase public hospital funding and add beds to the system – that’s the only way to reduce patient waits for emergency care and elective surgery.

We need action, we need reform and we need to improve our health system. However, to make a real difference, we need a fulsome discussion about reform, and what it means for Victorian hospitals.

This debate — maybe predictably — was an over-rehearsed puff piece of preening politics rather than profound policy. It’s time to get into the details of the reform plan, and answer Victorian doctors’ questions.

Jane Salmon-Donovan, activist, freelance writer, cancer patient, mother to two autistic children and grateful consumer of all things Medicare:

Who should run the health system? States or Feds? I think we need a bi-partisan panel of good politicians and experts hoovered up from every state and territory health system, not just bean counters.
Health care should principally be about prevention not treatment. If a pensioner or student cannot afford fresh fruit, then there is little point in throwing hundreds of thousands at their recuperation when they inevitably fall sick.

Free exercise classes and tai chi in every municipal park and hall is probably more important than a new hospital.
I say this as an idiot with cancer.

I was too busy and too stressed by paying for therapies for the autistic kids to get a mammogram before 50. I gathered they were free after that. My cancer was found two days after my 50th birthday. It had been there growing and spreading for a year.

It would also have been better if I’d understood the benefits of exercising more and keeping slimmer. The alcohol and smoke-free lifestyle was perfect. The food was mainly vego and organic.

Do we love the safety net? Oh yes. As a family with special needs kids we don’t get too far over the Medicare safety net. But as a family with a cancer patient, we do.

Worst of all, we waste a lot of money on palliative treatments in hospitals that should be done in hospices. I don’t necessary want to be in ICU when I die. And I don’t want 50 per cent of the Medicare one consumes across a life to be squandered on my last six months of life.

I would rather see kids get treatment for dyslexia or autism or Cerebral Palsy connective therapies so that they can live life to the full. I want a bold new world where young disabled adults don’t have to live in nursing homes or at home with their frail aged parents but with other young disabled people in top quality self run homes.

Many’s the slip between cup and lip. Radiotherapy at one large Sydney hospital is not just about million dollar particle accelerators. It also seems to be all about textas, tape and rulers. There’s a new PET machine at this hospital, but because there is a delay in sorting the Medicare registrations for it, lymphoma patients like the busy bald soccer dad I met at Regimental Oval on Sunday still have to travel to Liverpool to get treatment for the next eight months.

What we don’t have in Sydney in a centre of research and treatment excellence, a place where the dream team perfect things. RPAH probably think they have one, but it doesn’t seem to stack up against the swank Peter McCallum Centre in Victoria.

Rudd and Gillard have delivered a lot of big yellow caterpillar trucks to schools for children to watch all day. I think that my kids now know more about how to build an assembly hall than they do about counting past 15 or playing handball. However that is not the same as delivering suitable education and therapies where needed to maximise the potential of the kids of tomorrow.

We need Emergency Rooms set up to receive and treat, not hold, wait and then contaminate.

If you have ever been to paediatric emergency and seen a crust of dried vomit on the cots, you know that some things have to change. And that should be as easy as skidding along to Medicare with a counsellors receipt or strolling into hospital for top quality x-rays or chemo on PBS.

In 2003 a famous anaesthetist in our family died at 83 of golden staph caught at RNS He went in with a cough. That is, he died believing in the public health system.

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