A report card for the health reform commission: 'D' for disappointing

The final report released by the National Health and Hospitals Reform Commission is a serious disappointment. After years of debate about the need for fundamental reform of the health care system and masses of evidence to demonstrate the inability of the current system to meet the needs of the community, the commission has put forward a weak and flawed approach for the future health system that will see the blame game further entrenched and cost and blame shifting continue.

Cost and blame shifting as a result of the current system of governance and funding are the central problems with the health care system - the commission failed to seriously address them in their interim report, which should have alerted us all to the possibility that they would somehow (despite all the reports, senate inquiries, and independent reviews) overlook the most glaring problems, brought about by the separation of responsibilities for our health system across different levels of government.

The proposal to hand primary health care to the federal government and for the states to continue to be responsible for hospitals will further entrench the blame game, do nothing to address the issue of inequitable access, and fail to achieve the integrated system we need.

One of the biggest gaps in our system falls precisely between these two levels of care - two different levels of government responsible for these two areas of health care will mean our fragmented system will continue, patient journeys will continue to be interrupted and confusing, and each level of government will claim the other is failing to shoulder their responsibilities. State governments will claim the federal government is failing to keep people well and out of hospital, and the federal government will say the states are failing to provide adequate hospital services.

It will also be politically fraught as it will be resisted by some states, won’t improve overall systemic efficiency, and will not provide for the development of locally responsive services that use all the members of the health care team.

The health reform commission has let down the health sector and the Australian community with this report. Health care stakeholders have been advocating for reform for decades and there is a considerable level of consensus in the sector (and in the community) about the need for major reform. The commission was provided with hundreds of submissions, many of them with extensively researched and with innovative ideas to solve the problems in our health care system.

The problems have been laid bare: safety and quality of care is declining, access to health care is dependent on socioeconomic circumstances, the system is inefficient and inequitable, preventable and chronic illnesses are increasing, and we are wasting much of the health care budget by failing to ensure that health care resources are distributed on the basis of need.

Despite the promises of boldness, the report is superficial and ineffectual. Efforts to address the four key themes: taking responsibility, connecting care, facing inequities and driving quality performance are largely rhetorical, with “responsibility” more about shifting it to individuals (in spite of the failure of governments to accept any); and “connecting care” a pipe dream in the absence of any system to facilitate it. Equity is limited to the provision of safety nets for the most severely disadvantaged. The Denticare proposal is welcome (given the overwhelming evidence of our failure to provide oral health services to the poor and underprivileged in Australia and those living in the bush), but as it relies on private health insurance, will deliver very little in the way of significantly improved oral health outcomes for the most needy.

Given the role of the Chair of the Commission, it should not have been unexpected, but is still somewhat surprising, that one of the key recommendations is to enhance the role of the private health insurance industry. Especially given the overwhelming evidence of the inequities perpetuated by the taxpayer funded subsidies currently being provided to the private health insurance industry.

The proposal to give consumers a choice of using a government-funded health care plan or one provided by a private or not-for-profit healthcare provider flies in the face of all the evidence about equity and efficiency. We already have a situation where the “inverse care law” rules (in which those who need health care the most receive the least), and this proposal seeks not only to further entrench a two-tier system in hospital care, but to extend it to other health care services.

Access to health care should be a basic human right, but is not assured at present in Australia, and nor is it under the reforms proposed in this report. The most efficient way to fund health services is through universal public health insurance. To deliver equity, we also need to make sure those funds are distributed on the basis of need, not the ability to pay. This is not achieved by the targeting of disadvantaged groups but through the establishment of a system of health care that protects against the health impacts of disadvantage, whether that is to do with socio-economic status, race, cultural background, intellectual or other disability, mental illness, age, gender or geographic location.

This was a significant opportunity to describe a future health care system that would make Australia the envy of the world. Instead the commission is suggesting we move in a direction from which the Obama government is trying desperately to escape.

Better proposals exist. One such idea involves the establishment of a national authority to administer all health care funding and distribute it to regions on the basis of need. This was explored as Option B in the commission’s interim report but is mysteriously absent in the final, despite significant public and health sector support for the model. But the potential for significant improvement under this option demands its revival along with a clear explication of, “how to get there”.

A new paper published this month by the Centre for Policy Development offers some direction in this regard. Impatient with the lack of clear reform directions in the Commission’s earlier report, its four authors turned their minds to the task of how a new system of funding and governance could be introduced without dramatic interruptions to the current system.

In this paper, a staged process is outlined that would see the establishment of locally governed Regional Health Organisations which (armed with substantial data about the health needs of their community) would advocate for, and ultimately distribute funding for, services to meet the priority health care needs of their particular population.

This would enable resources to be equitably distributed among the national population for the provision of high quality, clinically effective services.

It would improve integration of care, and put an end to the confusing and bewildering pathways that patients are so often forced to navigate alone. Accountability would be enhanced, there would be greater citizen and community engagement in health care planning and delivery, and social and geographical inequities could be overcome.

In terms of addressing the essential reform directions outlined by the Commission (healthy communities, strong primary health care, timely access, integrating aged care, closing the gap, addressing rural and remote inequity, a sustainable workforce and improving funding and governance) this proposal ticks all the boxes.

It is time to act, but the government should act on the spirit of reform with which they established the commission in 2008, and for the sake of the health of the people of Australia, implement substantial, systemic, reform. The establishment of RHOs is a good place to start.