Splintered healthcare, divided responsibilities

Treatment plans for our ailing health system proposed by Labor are welcomed while the Government continues to propose division rather than integration of health services.

The imperatives

Before the last Federal election Australians consistently told pollsters that the state of our health care systems was their major domestic concern. None of the major structural reforms required to improve services and so ease those concerns have been forthcoming. The wretched jurisdictional inefficiencies associated with the current division of state and federal responsibilities, hinder reform and deny Australians the seamless focused care they need.

Without spending any additional dollars reforms could provide us with a system that far better responds to contemporary needs. Surely, with a new Federal election looming, both Labor and the Coalition should be vigorously and loudly promoting policies they believe would convince us they can improve the health of the nation?

The increasingly urgent need for health system reform is driven by four realities. First, given the ageing of the population and technological advances we would all like to enjoy, even a wealthy country like Australia must have a health system that is cost effective. The jurisdictional inefficiencies associated with the splintering of responsibilities for health programs between our governments waste between $2 billion and $10 billion a year and markedly reduce the quality of care available.

Second, and surely for most of us unacceptably, our “system” is increasingly unfair with personal financial resources rather than need determining the availability of high quality services in a timely manner.

Third, unlike so many other western countries, we have failed to respond to a mass of evidence which proves that the “win win” for health systems and their consumers is an adequately resourced new model for delivering primary care, traditionally the domain of general practitioners. In this new model a major emphasis is placed on prevention strategies and the early diagnosis and treatment of potentially chronic diseases.

The service, know widely as “Integrated Primary Care”, is delivered by primary care teams consisting of a full range of health professionals and frees up doctors to do what only doctors can do. This includes caring for sicker patients in a community setting who are currently sent to hospital. Such an approach can ease suffering, save us money and reduce the demand for hospital services.

In insisting that all is well with our primary care system as bulk billing rates are currently high, the Prime Minister fails to recognise that the quality (outcomes) associated with a visit to a doctor is what really counts. Socio-economically deprived Australians who must be bulk billed often experience inefficient very short consultations and unsatisfactory outcomes.

Finally we have a severe work force shortage that has been neglected for far too long. Health professionals and informed consumers have recognised for some time that in many hospitals there is too often a mismatch between the skills available and patient’s needs: a recipe for “misadventure”.

The Government’s approach

We know we can expect little in the way of structural reform from the Howard Government. Mr Tony Abbott has said on many occasions that he does not see the need to consider “reform” in his area of responsibility. High “bulk billing” rates are his measure for successful primary care from our GPs rather than the quality of the encounters with our doctors. Mr Abbott is however a consistent critic of the way states manage their hospitals, which are burdened with ever increasing demands that all too often is a product of unsatisfactory community care, largely the responsibility of his portfolio!

How ironic that just as Tasmania decides on a long overdue and sensible master plan for its hospitals, developed after extensive community and professional consultation, the Government stepped in and diminished the plan by taking over the Mersey hospital because its role was to change? Those changes were essential. Acute services could no longer be offered safely as the necessary workforce was not available.

The community must understand that all hospitals cannot provide a full range of services. Their ability to offer services of quality and safety must be the major factors determining role delineation. The distressing level of misadventure in our hospitals is most often related to a mismatch between patient needs and the available skills. It is essential, therefore, that hospital services be networked.

We now learn that the Mersey hospital will in future act as a private hospital. The Tasmanian Minister for Health has asked her department to reconfigure her networked services to accommodate the loss of the Mersey to the public system. Individual hospitals must no longer act as islands in an ocean of health care but rather be part of a network of hospital services where the role of each hospital is carefully delineated, safety and quality being major determinants.

These imperatives should have stopped the Howard Government interfering with the master plan for Tasmania’s hospitals, which was derived by experts using the above principles. Mr Abbott’s suggestion, on Channel 9’s Sunday program, that he favours community control of “local” hospitals such as the Mersey is disturbing.

Such interference by the federal government is reprehensible. It may be politically “savvy” but it represents poor policy. The current splintering of responsibilities is a major focus for reform strategies, which concentrate on integration not division. Dividing the responsibility for hospitals between the Australian and state governments is a reformist nightmare. Thus it is all the more distressing to hear rumours that before the election the Howard Government plans to “take over” many country hospitals!

Provide additional dollars to the states to help them run their hospitals by all means Mr Abbott, take over the entire hospital system if you wish, but do not further fracture the health system.

Labor’s approach

What about Labor’s plans for reform? It is not at all surprising that health professionals and consumer organisations, long engaged in promoting significant reforms for our health system, are enthusiastically endorsing Kevin Rudd’s approach to health. The fact is that his plans are “our” plans. There has been a remarkable degree of consensus around the major elements of a reform package for Australia’s health system and Labor has listened, understood and acted.

So what is Mr Rudd proposing to the states and more importantly the electorate in his policy paper? Media reports of the policy have concentrated almost entirely on the “takeover” of public hospitals if the states don’t improve hospital services and thus neglected the commitment of the federal government to improve its performance as well.

I believe his suggestions can be paraphrased as follows:

Let’s be clear, I am not just saying that if in 18 months you are not achieving much better results I will take over the running of your hospitals. I know how hard it is for you to respond to demand with quality service in the present system. The federal government needs to introduce changes to the programs for which it is responsible that will help you achieve what I am asking. Therefore we will resource, nation wide, and a new model of “Integrated Primary Care” that has a good chance of reducing the demand for your services. We will also supply you with many more transition beds to help you discharge, from acute care beds, older patients who no longer need you. We will build these initiatives together with two billion new dollars into the next Australian Health Care Agreement, which traditionally has only dealt with your inpatient services.

To guide us along the journey to health reform, we will establish a commission, strengthened by input from clinicians and consumers that will report to COAG and thus all levels of government. If all co-operate, integrating related programs and pooling our dollar and human resources there is a very good chance we can transform our health system to the one we want.

Now, despite all of these efforts, the cumbersomeness of the basic arrangements now in place may defeat us. If this occurs we will suggest to Australians that we take over the entire health system, administered from Canberra but implemented, of course, by regional authorities. We all agree that if we were starting from scratch we would have only one level of government providing our health system. We must have this ultimate solution available if we are to credibly promise Australians that we can give them the health system they need and can afford.

There have been some disappointments however. Mr Rudd’s decision to “honour” the Australian government’s promise to take over funding of the Mersey hospital in Hobart is particularly regrettable. As Labor seems to understand the importance of networking hospital services this decision smacks of an approach that would be defended by the old “well if we don’t get elected we can’t do anything” logic.

Not good enough Mr Rudd.

The decision to reverse Labor’s opposition to the Medicare “safety net” might be similarly explained. The policy however is indefensible as it is unfair (most of the “safety” dollars go to wealthier Australians), inflationary (no matter how large the doctors fee the government will pay 80 per cent of it) and requires disadvantaged patients to bear the costs of care for many months till they reach an out of pocket threshold. Far better to concentrate on removing the sharp rocks below the safety net so that a net is no longer needed.

Finally the dental scheme Labor proposes is grossly inadequate and suggests that Labor does not appreciate the reality that most people on the waiting list for public dental services need major procedures that will need hospital care.

Despite the above caveats Labor’s master plan represents a major advance towards health system reform. For 20 years the missing but essential ingredient for health system reform has been political leadership. It’s exciting to see signs that it has arrived at last.