How would it be to have a health system which delivered timely high quality care to everyone, with such a system emphasising that prevention of illness and promotion of health at every level to improve health, as well as potentially increasing productivity? How would it be to have a society which recognised that poor health is frequently a result of structural inequalities in that society?
Even better, how would it be to have leaders who shared such a vision? I dream on.
The vision of the Coalition for our society is based on the individual. For so many of them there is no such thing as society or for the less extreme, individuals matter more than society. So the above vision will never be a part of their thinking. As John Menadue’s recent article pointed out, they have been working to kill Medicare since its inception, at least as a means to achieve the above vision. The current Health Minister, Anne Ruxton clearly stated 7 years ago that Medicare is not sustainable without co-payment, which in effect indicates her belief that Medicare should be a safety net, not a system to sustain universal access to timely high quality care, let alone address the structural inequalities in our society which perpetuate poor health.
But what of Labor? Does it have a vision, and if it does, is it similar to mine? Whitlam introduced Medibank, public hospital care for all at no cost to the individual and universal access to a rebate for any medical consultation. Hayden, introducing Medicare under Hawke stated ‘in a society as wealthy as ours there should not be people putting off treatment because they cannot afford the bills. Basic (my emphasis) health care should be the right of every Australian’. The vision underlying these plans was at least strongly in the direction of my vision and Labor under both Whitlam and Hawke also pursued policies to address the structural inequities of our society. There was little interest in seeing private health insurance or private hospital care as a concern for government. There was no financial support for either, except for payment of Medicare rebates to specialists and funding pharmaceuticals and prostheses. Indeed in 1986 the Commonwealth bed day subsidy for private hospitals was abolished. Private meant private. It was more supplementary to Medicare rather complimentary.
Whilst Labor did strongly but ineffectually resist the introduction of the Private Health Insurance (PHI) rebate in 1996 and has made minor adjustments to it under the Rudd/Gillard period in office, it clearly does not have plans to make major changes. Indeed under the Rudd Health and Hospitals Reform Commission, a supposedly ‘root and branch’ review of the health system, the private system was not considered and a PHI executive was chosen to chair the Commission. The vision then was clearly not to aim for a health system that I dream of. Labor has not improved its vision since despite its rhetoric.
Encouragingly, Labor’s policy platform at the last election regarding various legal tax dodges by the wealthy and/or aspirational did go some way to addressing some of the major structural inequalities in our society and the vision behind those policies is consistent with addressing the social determinants of health to which I have alluded. Their commitment to raising the unemployment benefit to a poverty level income has however, been absent. This election we know nothing of such plans. Nor sadly, have there been any substantial plans to address the problems of timely access to high quality care. The proposal for a pilot of 60 GP run emergency centres flies in the face of the reality that less doctors are choosing GP work every year and instead are going into specialist practice. So how will such centres be staffed? Even if it works it is minor.
What should we expect from a Labor party which introduced Medicare? Primary Health Care needs restructuring. The emphasis on chronic disease management requires a move away from fee for service funding to a blended mixture of capitation payments and/or programme payments alongside fee for service payments. The basic change required is patient enrolment. This means that patients commit to a specific GP or perhaps a specific practice. Incentive payments to GPs on the basis that enrolled patients are their priority means that patients are rewarded for enrolling by being prioritised for access. GPs benefit through incentives, as well as the satisfaction of dealing better with chronic diseases management. These suggestions are in the Coalition’s unfunded 10 year Primary Health Care Plan. Enrolment is supported by the conservative doctor centred Australian Medical Association. New Zealand GPs get 50% of their income from a capitation payment instead of fee for service payments. Such payments, with enrolment as the basis, make continuity, comprehensiveness, and integration of care so much more feasible. Additionally, such capitation payments should be adjusted for socioeconomic status.
Public hospital funding needs a shake-up. Currently the Commonwealth funds only 45% of new funding spent in public hospitals. Labor has previously committed to 50% and needs to do so again. In addition, at least a temporary raising of the 6.5% cap on growth per year to recover from Covid-19 related workloads is required.
Labor’s vision on recognition of the mouth as an integral and important part of the human body, i.e. its position on dental care, has been ahead of the Coalition with its introduction of the Commonwealth Dental Scheme which funds limited fee for service access to children and disadvantaged adults. It planned to improve on the Coalition scheme but was forced to do more than it planned because it had to negotiate with the more ambitious Greens to get legislation for its plan. Clearly then and now, it did not and does not have a vision for equitable access to quality dental care. Its plan is just to improve things somewhat. The mouth remains separate from the body.
Labor’s position on Aged Care is lukewarm. The Coalition’s position is tepid. A much stronger commitment to most of the Royal Commission recommendations is required. The interim report was called ‘neglect’. Neglect will continue unless much more is done.
But a truly visionary Labor Party would recognise that what is needed is a more fundamental reform of how and by whom health care is funded. The State/Federal divide of health care funding and the self interest of stakeholders including politicians, doctors’ groups such as the AMA and the various Colleges, pharmaceutical groups such as the Pharmacy Guild and the Pharmaceutical Industry, private hospitals and PHI companies need to be addressed because patients are being neglected. Their health and welfare remain secondary to the self interest of such stakeholders. We desperately need a single independent funding body about which I have previously written on this blog, a body independent of stakeholders, delegated to identify need and fund accordingly. This would almost immediately see a large increase in funding for dental and mental health. Politicians need to respond with appropriate funding but should be prevented from decisions about what to fund because they will make such decisions for political or ideological reasons, with patient need as a reason relegated to last place. The Coalition isn’t interested because the whole concept of needs based health care is anathema to them. Labor has shown no interest, perhaps because they don’t have the vision anyway, but also because they don’t believe they are capable of leading such a significant change.
I dream. The reality is neglect.
Tim Woodruff is a specialist physician working in private practice. He is President of the Doctors Reform Society and Chair of the Australian Health Care Reform Alliance.
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