"Health is now such a dog's breakfast of divided responsibilities that sooner or later it will have to be sorted out," said Tony Abbott, Australian Health Minister, in The Sydney Morning Herald.
What is Mr Abbott on about? Well he may be the first Australian Health Minister to have stumbled upon a remarkable fact – that we have an unnecessarily complicated and inefficient health system. The division of health-care funding responsibilities between the federal, state and territory governments is unhealthy.
What do we Australians want from our health system? I venture to say that first, we want a system, not a hodge-podge of separate unintegrated programs and second, we want a system that promotes and maintains health, treats illness where possible and alleviates pain and suffering when not. We also want a system that is based on sound principles accepted by the broad community. I would also suggest that the principles that underpinned Medicare still find broad support. These include universality (all people have the same rights and entitlements to good quality health care), access (based on health needs rather than individual ability to pay), equity, efficiency and simplicity. To this I would add safety. Increasingly we are aware that too many people are unnecessarily damaged rather than helped when they engage with the health system.
What do we get? Well, by world standards health outcomes in Australia are good. But can we do better? Health care is expensive, costing in the order of $66.6 billion (about 9.3 per cent of GDP) in 2001-02. We spend a lot less per head than the USA but more than Japan, New Zealand and the UK. A third of this is spent on hospital care, 6.6 per cent on residential aged care, 17.8 per cent on medical services, 14.3 per cent on pharmaceuticals and 5.9 per cent on dental services.
Do we get value for money and if not how can we get better value? Social factors are potent contributors to ill health. Although our Indigenous-health statistics remain a national shame, non-Indigenous sickness is also related to a socio-economic gradient and social policies that alleviate inequality are life (and money) saving. More than 50 per cent of our health spending goes on chronic diseases (cardiovascular, digestive, mental, musculoskeletal, injury and poisoning and respiratory diseases), much of which is preventable. By the age of 36 more than 50 per cent of Australians are overweight and have high blood-cholesterol levels. As in most “Western” countries, diabetes is an epidemic. Prevention requires, however, an integrated response that includes our schools, public health measures and a well-staffed and funded primary health care system.
What is happening to our public hospitals? Zajac argues that hospitals are inefficient places driven by budgetary demands and handicapped by old-fashioned work practices. Although throughput is increasing, with length of stay falling from 4.6 to 3.6 days in the past eight years and bed numbers are falling those admitted have multiple diseases and are sicker. Most large (state-funded) public hospitals have the equivalent of a ward full of patients waiting for a (Commonwealth funded) nursing-home place. Patients commonly wait in emergency departments for unacceptable periods. Hugely expensive infrastructure is left relatively idle at night and weekends and prolonged “shutdowns” of up to three weeks over the Christmas New Year period delay care. Clinical information systems are virtually nonexistent leading to costly and dangerous inefficiencies.
The management of public hospitals is a state and territory responsibility. About 50 per cent of public hospital funding is from Commonwealth funds raised through taxation. There are at least two major problems with this.
First, until quite recently health outcomes were not major considerations in the five-yearly federal, state and territory funding negotiations. In April 2002 the Australian Health Ministers Council, in an encouraging break with tradition, agreed to set up National Reference Groups. Health bureaucrats and senior clinicians were asked to report on nine important areas. These included the continuum between preventive, primary, chronic and acute models of care; the interface between aged and acute care; collaboration on workforce, training and education; hospital funding and private health insurance; improving Indigenous health; improving mental health; improving rural health; quality and safety; and information technology, research and "e-health". Unfortunately, although the Reference Groups met the process stalled.
Second, divided responsibilities inevitably lead to cost-shifting and buck-passing. States and territories claim that the Commonwealth underfunds them and the Commonwealth claims that the states and territories are using health funds for other purposes. An egregious example of cost-shifting is the transfer of costs of public hospital outpatient care from the states and territories to the Commonwealth by “privatisation”. Patients are either referred to private rooms of hospital-based specialists or patients in previously “free” outpatient clinics are billed under the commonwealth-funded Medicare System.
While privatisation has helped public-hospital budgets (to the extent that many hospitals are now dependent on it) it has had adverse effects. A significant proportion of patients finds difficulty in paying any “gaps” between the hospital bill and the Medicare rebate. Bureaucrats, politicians and the press are preoccupied by surgical waiting times. The lengthy waits for public outpatient appointments that can be sometimes measured in years receive much less attention. Large numbers of patients are denied expert advice about management of chronic disease with inevitable adverse outcomes. The movement of large numbers of patients to private rooms has also made teaching of undergraduate and postgraduate students increasingly difficult, especially in disciplines that clinically function in the ambulatory setting.
Does the present Australian system of separately funded public hospitals, high-level residential aged care, pharmaceutical benefits, medical services and public health make any sense? Would an integrated system based on principles of universality, access, equity, efficiency, simplicity and safety be better? Of course it would but changing the present system is far from a simple issue. This is, however, a problem that the commonwealth and state and territory governments all have to take responsibility for. The time for blaming and buck-passing is long gone and the Australian people deserve leadership, statesmanship and a practical demonstration that health is not just one of the pawns that is moved about the political chess board but a fundamental concern of the Australian people. It does need to be sorted out Mr Abbott, and sooner rather than later.