JON BLACKWELL and KERRY GOULSTON. Aspects of Australian healthcare reform (part 1 of 3) – Some history

This is the first of three papers. It deals with the history of some healthcare reforms in NSW in 2001, their scope and outcomes. The second will comment on similar but in many ways different and more successful healthcare reforms in Denmark, which has a similar population to the Greater Metropolitan Sydney Area. The third will discuss the present difficulties in implementing meaningful healthcare reforms in Australia.

In 1999, the incoming NSW Health Minister, Craig Knowles, faced with growing disquiet by Clinicians, asked John Menadue to chair a review of the NSW Health system. It emerged that there was no over-arching plan for NSW Health. Knowles therefore set up a number of working groups, one of which was the Greater Metropolitan Services Implementation Group (GMSIG). In 1999 there were almost 5 million people living in the metropolitan areas of Sydney, Newcastle, Central Coast and Illawarra. Of course, the population of the greater Sydney metropolitan region has increased significantly since then.

The authors of this article, an Area CEO and a clinical academic, led the Greater Metropolitan Clinical Taskforce, which produced a Final Report in late 2004, which was the subject of an article in the Medical Journal of Australia in 2006. We were appointed by the Minister to Co-chair an inclusive group of 42 (doctors, nurses, allied health practitioners, consumers and administrators) to prepare a plan for greater Sydney.

It became obvious that the uneven distribution of hospital care had to be addressed. Patients should have the right to be treated according to clinical need, regardless of where they lived. The centre of Greater Sydney’s population had moved west and population growth to the North and South was accelerating. This was unanimously accepted by the GMSIG, recognising that higher level services should be provided in a relatively few locations, whilst there should be a fairer distribution of services such as cardiac catheterisation away from the centre of Sydney.

Few doctors had ever met to plan a Metropolitan-wide health services and none had done this with allied health or nursing colleagues. Many of the clinicians that we met with struggled with the concept of Sydney wide planning anyway, as historically they had (rightly) concentrated on clinical excellence and resource acquisition for their own specialist units within their teaching hospital environment. This environment, where scarce resources were often the subject of annual budget contests, hardly encouraged specialists to pursue co-operative clinical planning at the hospital level, let alone across and between individual Area Health Services.

Knowles wanted us to develop a Greater metropolitan Health Plan which was “open, consumer-focussed, accountable and financially responsible,” utilising a population-based approach.

The uneven distribution of health services across Metropolitan Sydney had to be addressed. Also, patients had a right to be treated according to clinical need, regardless of where they lived.

Knowles ensured that there were 14 members of GMSIG from outer metropolitan areas, including ex-politician Peter Anderson, who kept asking why his neighbour from South West Sydney had to drive 3 times a week to have kidney dialysis in central Sydney.

Tertiary services (including cardiac and cancer treatment services) were concentrated in the major Sydney Hospitals, and access therefore limited for outer metropolitan patients. Quaternary services (eg. Renal transplants) were delivered at a number of Sydney Hospitals, but the efficient use of resources and the need to ensure clinical excellence demanded consolidation of these services.

Also, in NSW our initiatives, which at the time seemed revolutionary, did not put General Practice or Primary Care and Prevention at the heart of the Healthcare system. Any first-year health economics student could tell you that the greatest “bang for buck”, or return on investment in health services, comes from health promotion and prevention, and effective primary healthcare.

We succeeded in establishing new cardiac centres in Wollongong, Nepean and Gosford, stopping the transfer of patients to central Sydney. Stroke Units were set up in all area health services, as were improved cancer services. Cross area clinical networks were also established in various disciplines to encourage sharing of clinical expertise and training, and the establishment of patient pathways between the outer metro areas and major referral hospitals.

Due to clinician, consumer and political forces, the number of renal and trauma centres and other quaternary services were unable to be reduced and consolidated. As one clinician said at the time, “I agree with everything you are trying to achieve, but if you take renal transplants from my hospital it will be over my dead body.”

These attitudes still persist, witness the current stoush over paediatric cardiac surgery between the two Sydney children’s hospitals.

Moreover, full implementation of the recommendations required the transfer of funds from Area Health Services in the centre of Sydney to those on the metropolitan fringes. This led to inevitable resistance as cash strapped central Area Health Services were unable to identify savings to fund such transferals. It should be said, however, that at the clinical level significant support was provided by city-based specialists to assist in the establishment of the new outer metro units.

The whole model and process were outlined in a commentary published in the Lancet in 2004.

Later, in 2008, the Special Commission of Inquiry into Acute Care in NSW Public Hospitals, led by Peter Garling, published its Final Report. Yet again, Garling noted the breakdown of good working relations between clinicians and management. He colourfully likened this to the Great Schism of the Church in 1054. His model of Reform had four pillars:

· The Clinical Innovation and Enhancement Agency (now called the Agency for Clinical Innovation)

· The Bureau of Health Information

· The Institute of Clinical Education and Training (now called the Health Education and Training Institute)

· The Clinical Excellence Commission

These pillars were subsequently established, and have made contributions to enhanced clinical standards, better treatments and patient outcomes. However, whilst they themselves consume a fair amount of the NSW health dollar, none address the issues of allocative efficiency (the fair and effective allocation of the health dollar either between populations or clinical programmes) Thus, primary health care and promotion, and mental and dental health services, continue to be under resourced, whilst the most expensive services, (and, some would argue, least cost-effective in terms of outcomes) hospital services, continue to thrive and grow.

In retrospect, our proposed reforms in NSW were unsuccessful in a number of aspects:

· Prevention and Promotion of Health were not considered

· Community Medicine, Family Medicine and General Practice were also not considered

· The social determinants of Health were ignored

· Vested interests of speciality clinicians, Area Health Service Boards and senior managers, and local politicians proved overpowering

· Discord between clinicians and managers remained, except in a few places

· There was no concerted move to bring the consumer – both the patient and the public at large – into the whole process

· Private hospitals and the growing proportion of corporatized General Practice, Pathology and Radiology clinics were not included at all

Craig Knowles gave hospital specialists the opportunity to lead significant reforms and made them feel an involvement and responsibility for these. These reforms were confined to hospitals however. It had been hoped that a further achievement would be that the new structure would report directly to the minister and parliament. However, despite Garling’s recommendation (that oversight of the reform process should be independent of the NSW Dept of Health) the “4 pillars“ now report directly to the Head of the NSW Health Department.

The opportunity for significant healthcare reform remains. But will it be achieved with leadership and involvement of all healthcare professionals, with significant involvement of patients and the general population? This remains a significant issue.

Jon Blackwell has managed hospital and health services in the Pilbara and South Australia and was the CEO of the Central Coast Area Health Service from 1997-2003. He was subsequently CEO of Workcover NSW from 2003-2009.

Kerry Goulston was convenor of the Health Reform Group from 2002-2018. He worked for many years as a Gastroenterologist in hospital salaried positions and in private practice.

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