The inequity and inefficiencies in our current health programs and the resulting need for change, have been obvious for decades. Finding the necessary political boldness to change this situation has eluded us to date. I acknowledge that there have been a number of governments and ministers who wanted to improve the healthcare of Australians and the cost efficiency of the same.

However, both major parties’ efforts in this regard have always focused on manipulating a system that is not, and never could be, “fit for purpose”, rather than acknowledging the need for evidence-based bold restructuring. This restructuring must have at its core switching to a single funder model for healthcare. It is impossible to integrate efficiently an individual’s healthcare while the federal government is responsible for Medicare and the states for hospital care.

I have written extensively about this issue in a number of my P&I contributions. If you have available a copy of John Menadue’s remarkable book “Summing up” you will find 55 pages detailing our attempts and failures to reform our health system. John’s knowledge of healthcare issues is remarkable and recognised. He was asked by the SA Government to review healthcare in that state, such was his reputation. The chapter in question is a miserable but indispensable read for those interested in this issue. John was heavily involved in the Whitlam Government’s creation of what was to become Medicare, the last really revolutionary change that so improved equity in the availability of affordable care.

So with a general election approaching what is on offer for healthcare from the government and opposition?

The government has funded more than 50 community-based acute care centres that bulk bill all in an attempt to take pressure off hospital based EDs. Their location, however, is opportunistic rather than strategic. They should have only been established in specific areas of need. Geographical pinpointing of locations where such facilities are needed has been successful in a number of countries. I see that Queensland is seeking applications for such services in areas they specify but have found this very difficult to achieve. Certainly such facilities spare patients long waits in a major ED which is welcome, but they will have little effect on hospital pressures. Cost/benefit analysis to date throws doubt on the cost effectiveness of the initiative, but the government has now promised to establish 29 more such facilities at a cost of $227 million. 

Before commenting further, I need to point out that our serious lack of public hospital accomodation and service, generating unacceptably long waiting lists for surgery and other care, is not caused by patients with minor emergencies flooding into hospital EDs. Hospitals can’t provide the beds needed by patients waiting for admission because the can’t discharge so many older frail patients as there is no post-hospital care facility available for them. Exit block is increasingly problematic. Interestingly, the “Commonwealth Fund” which ranks the healthcare systems of different countries praised Australia “where every citizen is entitled to free public hospital care”. What they did not say was that there was “no room in the inn”!

Labor has promised a one off payment of $1.7 billon to public hospitals which will be welcomed, but for the reasons discussed above, won’t change their exit block problem.The money would be better spent on government-funded post-hospital care facilities and re-establishing  free specialist outpatient clinics in our hospitals.

Finally, there is the $8.5 billion to be pumped into bulk billing incentives promised by both Labor and the Coalition. Health Minister Mark Butler is convinced that 90% of all GP practices in Australia will bulk-bill because of the additional income to be phased in over five years. This I doubt, given the steady increase in practice costs. This approach is not welcomed by those of us who feel we should move away from “fee for service” payments and, as structured, will see doctors make more money with a lot of short consultations when the needs profile of modern Australia calls out for longer consultations for the many patients with complex care needs. The emphasis remains doctor/illness centric rather than emphasising and funding prevention initiatives and the need for multidisciplinary care.

The incentives to have more young doctors choose a career in primary care however are certainly welcome. Young doctors who leave hospital employment have faced large income cuts as they train to be a “primary care physician” (time for GPs to drop that designation!!). A sign-on fee of $30,000 will be available with paid annual leave and pregnancy coverage included in their package. Interestingly, 50% of young trainees express the desire to be paid a salary rather the “fee for service” model.

In thinking about the lack of political boldness required to restructure our health system, I am reminded of an initiative when 23 years ago, thanks to a grant obtained by the wonderful Clare Jackson, professor of General Practice at the University of Queensland, I had the chance to join a small team holding meetings referred to as “Citizens Juries” in each capital city. 

We presented for consideration a model of integrated care where a single level of government-provided community and hospital care with Australians having the choice to enrol in a multidisciplinary “Medical Home” where health advise and care for families was available in the one geographic entity. Everywhere the concepts were greeted with consumer enthusiasm. 

It’s not impossible to have a health system restructured to emphasise and facilitate prevention and provide timely care for all based on need not personal financial well-being, but we need the courage and, yes, flamboyance of a Whitlam to take us on that journey. Now in my 85th year and having “banged on” about the need for major health system changes to meet the needs of Australians for the last 40 years, I can report that only Bill Shorten went to an election promising to establish an “Australian Healthcare Reform commission” that would explore the single funder model. At that time both the premiers of NSW and Victoria, Liberal and Labor politicians, called for exploration of that model. One can but hope!