JOHN DWYER. Health care reform – Part 1.

Jun 19, 2018

Without acceptance of a ten year plan and the creation of an instrument to implement that plan, we will not be able to engineer the evidence-based structural reforms to our health care system that will improve quality, equity and cost effectiveness. 

In Australia health care policy initiatives, such as they are, constantly fail to successfully address the integration of health care, the lack of the infrastructure needed to help us avoid chronic illnesses, the related inadequacy of Australian’s health literacy and so much about our delivery of health care that is not cost-effective. Inequity is palpable with health outcomes increasingly related to personal financial well-being rather than need. We extol to the world our tax-payer funded “universal” health care policy yet, in reality, Australians are  burdened with “out-of-pocket” health care costs exceeding $30 billion a year.

In an excellent article by Ruth Armstrong (P & I, 1 June) “Four Corners – Mind The Gap episode: a one dimensional look at a multifaceted problem”, she started with the following observation:

“A single tweet put Monday night’s Four Corners episode into perspective for me. I’d been trying to put my finger on what seemed out of kilter with the whole segment and there it was: the program had virtually ignored the bedrock of Australian health care, the public hospital system.”

The program in question focussed on the costs of care in the private health system and particularly the excessive fees charged by too many surgeons. Working in the public hospital system for many decades, I have seen the ever increasing deterioration in the ability of such hospitals to offer timely access to surgical services so I left the following comment:

“While it may not be obvious to many, the problems Ruth explores have their genesis in the failure to provide the infrastructure needed in our primary and community health services to keep patients with chronic diseases out of hospital. More than 650,000 admissions to public hospitals each year are deemed “avoidable”. Over the last 30 years the percentage of public hospital beds occupied by medical patients has steadily risen (on average 75%). The legitimate demand for surgical help cannot be met in a public system so burdened. As access to surgical beds became so unreliable, surgeons who once enjoyed and were champions of public hospital surgery left the system and settled in private hospital land. The reforms to our system so often canvassed in P & I focus on restoring a healthy balance through better resourced primary and community care freeing up beds for surgical procedures. Then (once again) public hospitals can compete for surgical patients and surgeons and the resulting reliable service could see many relieved of the financial burden of PHI as their confidence in our public system is justifiably restored.”

None of the above ambitions can come to fruition without major restructuring of our health system, so frustratingly difficult to initiate in Australia. One major impediment was highlighted in another excelled article (P & I  12 June) by Kim Wingerei entitled “The longevity vacuum”. He started with the following comment:

Short term thinking has taken hold of our society at all levels – our political leaders rarely see beyond the next poll or the next election, and in many ways they are responding to a populace that is equally sucked into the demands of the moment – resulting in ‘the longevity vacuum’ – putting us all at the mercy of an unplanned future.”

In more than 30 years of unsuccessful agitating for numerous structural reforms to health care, I am certain that “the longevity vacuum” is, so far, an insurmountable impediment to reform. Short election cycles with politicians only interested in a “pat on the back” today undermine dedication to the decade-long process that would deliver the essential outcomes. What is equally obvious is that even if we were to settle on a plan that would take ten years or so to complete, success would be unlikely if we did not have an adequately resourced instrument to deliver that plan. Are there lessons from the past that would helps understand what that instrument would look like? Yes, so let’s go back to 1973 and see what can learn.

In 1973 Gough Whitlam established a Hospitals and Health Services Commission. Simultaneously the Health Insurance Commission was established which created Medibank, which was to become Medicare. At the time problems with access to health care and the rising costs of same were political “hot potatoes” so in 1972 the Coalition government had launched a Royal Commission into the state of affairs headed by Mr Justice Nimmo. As the 1972 federal election was approaching, the Labor Party promised that it would establish a commission to promote the modernisation and regionalisation of hospitals. On winning Whitlam announced that the commission would also have  additional responsibilities for community-based health services and preventative health programs in close cooperation with the States. Dr Sidney Sax was appointed Chairman of the commission and three full-time and six part time members were appointed as well. Whitlam explained his philosophy thus:

“Health is a community affair. Communities must look beyond the person who is sick in bed or who needs medical attention. The Commission will be concerned with more than hospital services. Its concern and financial support will extend to the development of community-based health services and the sponsoring of preventative health programs.”

I recently had the opportunity to discuss this initiative with its CEO, Professor Richard Southby who is now the “Distinguished Professor Of Global Health” at the George Washington University in the US. Of major interest to me was the reality that his commission was not set up to be a “think tank” advising government but rather was an instrument for real change with the authority to implement policies. Compare that approach to the Rudd government’s establishment 30 years later of a National Health and Hospitals Reform Commission to advise the government which it did, only to be ignored by the incoming Coalition government. I well remember, at a meeting of the Australian Healthcare Reform Alliance, Tony Abbott telling us that he hated to hear discussion of reform as the system was near perfect and only needed “a little tinkering at the edges”.

Thinking of our current situation and need for a  reform vommission, I asked Southby to provide me with key messages for success in such an endeavour. He told me that the commission envisaged, from the outset, that practical difficulties could be overcome by goodwill, mutual respect and experience. The commission went on to receive a gratifying amount of cooperation from the Department of Health and other Australian Government departments and statutory authorities as well as State health authorities.

Writing in the Medical Journal of Australia in 2008, Southby discussed the achievements of the short lived commission. (The Fraser government disbanded the enterprise in 1975.) The commission provided the first comprehensive approach to national health policy development based on analysis of data and consultations with all levels of government, professional organisations, universities, non-government agencies and individuals. It brought about major changes in the delivery of health services, education of health workers and research and highlighted long neglected areas including aboriginal health, occupational health, public health and health transport.

Why the current interest in this bit of health history? Well – Labor is promising that if elected it will establish a Health Care Reform Commission. This is an important initiative. To be successful however, lessons from the 1970’s will need to be appreciated, the commission must have the authority to implement change and have a vision for ten years of continuous improvement to help it reach its goals. In part two of this submission I will explore this further, focussing on the terms of reference needed by a contemporary commission.

John Dwyer, Emeritus Professor of Medicine at UNSW, founded the Australian Health Care Reform Alliance and has long been involved in the promotion of structural reform of Australia’s health system.

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