The difficulties of health reform

Feb 23, 2023
GP talking to senior woman in surgery sitting down looking at each other.

When he was Treasurer Paul Keating complained that the resident galah in every pet shop across Australia was talking about microeconomic reform. Over the last few months the galahs have learned a new script: health reform.

After years of largely benign neglect, it is now apparent that Medicare is failing to provide affordable access to primary care for a large and growing number of people. The media is full of commentary on how to deal with the problem.

As well as health system academics, the chatter has involved medical colleges, health trade unions and commercial associations of various kinds, state health ministers, and mainstream economic commentators. Even the private health insurers – motto “never let a good crisis go to waste” – have got involved.

Health Minister Mark Butler must be drowning under the wave of free advice on how to solve the problem of poor access to primary care.

The trouble is that much of the advice is self-serving. Each interest group reframes a particular aspect of the problem in such a way that the obvious solution is the one that suits its interests.

So according to the AMA, there is nothing wrong with the fee for service payment system for general practice other than the fact that the fee is too low.

The private health insurers want to be allowed “to directly support patients in primary care with programs approved by medical experts”.

The Pharmacy Guild wrote to National Cabinet calling for “pharmacists [to be] able to prescribe medicine to treat uncomplicated conditions, freeing up GPs to treat more serious conditions and avoiding unnecessary patient presentations to already overcrowded emergency departments”.

(Four days later, the AMA urged the government “to increase the maximum dispensed quantities on selected PBS items from one month’s supply to two months’ supply”, reducing dispensing fees and co-payments.)

The Australian Primary Health Care Nurses Association welcomedthe recognition that nurses working to their full skill set [code for doing some things GPs currently do] can help drive significant improvement in the health of Australia”.

The RACGP agreed that GPs need to work “hand in glove” with allied health professionals, pharmacists, and practice nurses “within general practice”, as long as GPs retained their role “as the stewards of patient care”.

In other word, every interest group is wholeheartedly in favour of reform to the extent that it suits the interests of group members. Who would have thought it?

I think there is a real risk that nothing much will happen after the government announces in the Budget its response to the smorgasbord of reform options thrown up by the Strengthening Medicare Taskforce Report.

First, as other commentators such as Professor Stephen Duckett have pointed out, real reform will cost a lot more than the $250 million a year which is on the table.

Assuming part of the problem of poor access to primary care is inadequate GP remuneration, part of the solution will involve paying them more. Increasing their pay by, for example, five per cent will cost about $600 million a year.

And if part of the solution is paying other people to do some of the work that GPs do, that cannot be funded from the existing bucket of GP remuneration without lowering GPs’ pay, meaning it will be an additional cost to the budget.

The second issue is that the problem – poor access to primary care – is complex, poorly defined, and multidimensional, with many necessary but not sufficient partial solutions.

Human institutions, including governments, struggle to deal with such problems.

The major health policy reform of the last 50 years – the introduction of Medibank/Medicare – was fundamentally very simple. It replaced a regressively funded system of private insurance with a progressively funded system of social insurance. Instead of taking their doctor’s receipts to a private insurer’s shopfront, patients took them to a government shopfront. There was no change to how health services were organised or delivered.

By contrast most other health reforms dealing with smaller but more complex problems – access to better mental health services, access to dental health, fairer private health insurance – have foundered due to an inability to prioritise policy objectives and devise workable trade-offs between competing goals.

Finally, successfully addressing the problem of poor access to primary care will require the government to focus on primary care, not only general practice. This will almost inevitably mean some diminution in the role and standing of GPs, who will resist any such changes.

It is over 500 years since retired Florentine diplomat Niccolo Machiavelli wrote his textbook on government, The Prince. He cautioned that “there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things”.

This is because people who will benefit from the reforms will not really believe in them until they are implemented, and will be lukewarm in their support, while those who stand to lose will “attack… like partisans”. This is still true today.

If the government is to be successful in improving access to primary care it needs deep pockets, a clear plan with obvious benefits that can be explained simply, and the courage to overcome resistance from the losers. While the Budget announcement will demonstrate if the first two criteria have been met, the weeks and months following the Budget, as the government deals with its critics, will be crucial to success.

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