Take health governance out of politician’s hands

The government’s announcements on hospital reform are bold and deserve widespread support. They are a step in the right direction. I am agreeably surprised, given the history of previous health reform attempts.  I hope the states and the coalition are not churlish and miss a great opportunity for themselves
and the Australian people.

In the months ahead there will be hard negotiations and further policy announcements to flesh out yesterday’s announcement.

I will be looking for future policy statements about how hospital care is integrated with primary care. The announcement has a clear hospital focus, a continuation of an obsession we all have with iconic hospitals. The best health systems in the world are grounded in primary care. In Australia we are over hospitalised.
A policy objective should be to keep people out of hospital with alternative arrangements in the community. Hospitals are like the family refrigerator; regardless of size it will always be full.

The government is challenging, quite correctly, the special interests of state governments and their health bureaucracies. What is needed next is for the government to find the political will to challenge other stronger special interest groups, particularly among the providers – the AMA, the Australian Pharmacy Guild, pharmacy companies and the private health insurance funds. They have legions of lobbyists who dominate the public debate at the expense of a community that is effectively excluded and disenfranchised.

The current debate is between the government and well-funded and well-organised special interest groups – the community is pushed aside. We need to take it out of that closed room and put it in the hands of an independent umpire – a body solely looking out for the health needs of Australians.

A key part of integration of all health care will be governance at both national and local level. The solution to Australia’s ailing health system would be for both the States and the Federal Government to relinquish power to an independent health commission. If our health system had its own independent body – a Reserve Bank for health – Australians would have more confidence that decisions were being made based on need rather than political point scoring.

An independent commission has already proven its worth in the Canadian province of Ontario. In 1996, the provincial government there set up an independent Health Services Restructuring Commission, not only to advise on restructure but also to implement the restructuring. The ministers there recognised that they were too subject to pressure by special interests and that a more arms-length and independent commission could achieve outcomes that they couldn’t. The independent Commission made significant progress, and after a period of time handed back its powers to the ministers.

The Commonwealth Government should establish a permanent, independent, professional and community-based statutory authority, an Australian health commission, similar to the Reserve Bank in the monetary field. The Reserve Bank’s governance structure has made it almost impervious to lobbying and generally, it has been independent.

Such an independent health commission with strong economic capabilities is necessary to facilitate informed public discussion, counter the power of special interests and determine programs and distribute Commonwealth health funds across the country. Last year, the Business Council of Australia called for a single ‘independent body that can lead and be accountable by the Australian community’ for health services. The traditional ministerial/departmental model is proving just too susceptible to special interests in health.

The Commonwealth Government should not opt out of policy responsibility, but issue principles, as it does to the Reserve Bank, to provide policy and implementation guidelines for the health commission. The principles could include:

  • universality,
  • equity,
  • efficiency (both technical and allocative),
  • single-payer (to best manage costs),
  • choice of provider (with government funding for private hospitals),
  • subsidiarity (delivering healthcare at the most feasible local level),
  • accountability (With all providers obliged to meet key benchmarks. What about a ‘my hospital’ website? With fee for service, providers are compensated for the number and length of transactions rather than health outcomes.),
  • social solidarity and risk-sharing, and
  • personal responsibility (For personal health outcomes and use of health services).

Not only would the introduction of an independent commission here mean the health of Australians could finally be made a priority, but it would also distance our ministers from day to day partisan health issues. It would be a major step towards evidence based policy and practice. It would allow them to get out of the daily firing line, freeing them up to concentrate on strategic policy issues.

In addition to the need for integration of all health care and independent and professional governance, a range of other health reforms are essential.

First, the Health Insurance Commission (Medicare) should be what its name implies, a proactive public insurer anticipating risks and controlling costs. With a default option policy for everyone, it should also provide a range of policies for members, eg higher excess for GP visits in return for increased hospital benefits.

Secondly, we need a major reform of the restrictive work practices and demarcations that bedevil our health workforce structure. In the name of safety, these archaic work practices are designed principally to protect the turf of doctors. This is at the expense of hundreds of thousands of other health professionals and the community.

Thirdly, quality and safety must be urgently addressed. There was a media frenzy over four Australians who died installing insulation batts. There was a Royal Commission in Victoria over 172 bushfire deaths. Yet 200 Australians die each week in our health sector as a result of avoidable mistakes. The silence is deafening.

Fourthly, we need to include dental care within Medicare. The $4b p.a. subsidy to the wealthy with private health insurance should be transferred to a universal dental scheme. (I assume that the government has buried the outlandish proposals by NHHRC on Denticare and Medicare Select.)