Principles and people should guide our health system

The views expressed in the Medical Journal of Australia recently by a former health bureaucrat and a health economist are striking not only for their commonsense but also their emphasis on the importance of values in public policy development.

John Menadue (article here) and Gavin Mooney (article here) have the support of key stakeholders in their calls for a coherent set of principles to guide our health system based on the values of its citizens (MJA, August 4, 2008).

The key health care stakeholder alliance, the Australian Health Care Reform Alliance (AHCRA) has been advocating just such a position since its inception in 2003. More than 40 organisations constitute this broad alliance, with representatives from academia, professional, consumer, and health providers, making the alliance itself a microcosm of the health sector and therefore reflective of broader views within the sector.

One of AHCRA’s most fervently held principles is that of community engagement, with members committed to advocating for process of policy development that ensures health care systems are built on a partnership between the community and consumers, and health care policy grounded in and measured against community values. AHCRA believes the community, especially consumers and carers, must play an integral part in the development, planning and implementation of our health services.

As Menadue and Mooney (MJA, August 4, 2008) both attest, giving citizens a voice to outline a collective vision for health care not only ensures decisions are based on their values, but will help achieve consensus and is vital to ensuring public confidence in the system.

The legitimacy (and success) of any major policy decision depends on the extent to which it reflects the values of the community.

With a plethora of health reform initiatives underway, the timing could not be more urgent for a considered and effective process to ensure the health care system we design for our future is reflective of community values and priorities. As Menadue also advises, such a process could be based on the dialogue Canada undertook with its citizens in reforming its own health system. As the Chair of that Commission, Roy Romanow, found, Canadians view their health system as a moral enterprise, not a business venture and embraced the opportunity to develop a collective vision, based on community values, to guide their future health system.

Australians deserve and should demand this same privilege, although it shouldn’t be a privilege at all. As AHCRA found when it conducted its own national consultations in 2007 (using tools based on the Canadian experience) it was clear that participants considered the health system to be their health system, not the government’s, the Minister’s or the providers’.

These consultations not only demonstrated the effectiveness with which ordinary Australians can articulate what they value in health care, but confirmed the importance of articulating a set of moral or ethical values against which to measure the performance of any aspect of the health system, policy or service. In this way, the development and implementation of health policy can be tested against the underlying principles or values of the system, regardless of the context.

AHCRA regards the development of principles to underpin the future health system as a key opportunity to begin to articulate what we want from our health system in Australia, and to lay the foundations for a future national health policy.

The findings confirmed the importance of access to care and equity as crucial principles to Australians, and the need for a stronger focus on prevention.

These consultations provided AHCRA with an opportunity to develop a set of draft principles based on an understanding of the values health professionals, consumers and other key players in the health sector regard as important. While these 15 principles have been documented in detail in the recent AHCRA submission to the National Health and Hospitals Reform Commission, AHCRA maintains a comprehensive national consultation, using appropriate deliberative techniques (such as those outlined in this journal by Gavin Mooney), must still be undertaken with ordinary Australians to test their support for a set of values to underpin the future health system.

Further to a value-based system there is also an urgent need to establish a permanent National Health Reform Commission or Council to implement reforms.

The current National Health and Hospitals Reform Commission is only temporary. It is vital that once this Commission has disbanded - having made what we hope to be strong recommendations for fundamental reforms - we will need a permanent institution established to ensure reforms are implemented in coherent way.

Medicare didn’t roll out without the oversight of a health commission in the 1970s, and the comprehensive reform needed to the health system will also require the same level of considered oversight.

The permanent Commission should pull together the various reform measures being considered currently, including those focusing on improving preventive health (the National Preventative Health Taskforce); strengthening primary health care (National Primary Health Care Strategy); addressing the inadequacies of national workforce planning (National Health Workforce Taskforce); the collection the development of consistent national standards for e-health (National E-Health Transition Authority); addressing Indigenous health inequalities (Health Equality Commission); safety and quality (Australian Commission on Safety and Quality in Health Care); and national health reform (National Health and Hospitals Reform Commission).

It is hard to imagine how, without a body to oversee implementation, all of these disparate policy measures will fit together and form a comprehensive and consistent national plan for health.

AHCRA urges the Australian Government to establish a permanent Health Commission to co-ordinate the development, implementation and evaluation of national health policy, informed by an ongoing conversation with Australians to ensure all policies reflect the underlying values and views of the community.