Some important questions about health policy and the federal election (aka your #qanda cheat sheet)

Health policy is up for debate this week thanks to ABC TV’s Q and A program, featuring Federal Health Minister Tanya Plibersek and the Opposition’s health spokesman Peter Dutton.

You can pose a question online and see some of the other questions that have already been lodged, including:

• Large corporate organisations have become major players in the provision of general practice services in Australia. They typically also own radiology and pathology services. Combined with the fee for service payment structures we have in Australia do you see there is likely to be over servicing and the contrivance of patients care so as to maximise Medicare billing? Do you see this growth of corporate owned primary care and referral services as a concern? What will you do about it? – Dan Ewald
  
• Given the clear evidence of the merits of a national health system that explicitly targets health inequalities, precisely which of each party’s policies demonstrate a clear commitment to doing this? It’s not a universal system if it doesn’t serve the homeless, refugees, people with mental health issues, prisoners or those with poor literacy for example. Where are the models of care for these people? – Lyn Morgain
  
• Peter Dutton: You have said you would abolish the 61 Medicare Locals established around the country in the last 3 years as they are “a useless additional layer of bureaucracy”. You are almost alone in taking this position. The state government here in NSW seems pretty happy finally to have organisations coordinating primary health care and it is working actively to build relationships with them. How can you justify your position or will you (please) change it? – Lewis Kaplan
  
• Would Australia’s public health system be more cost efficient and have better quality control if we prevented the duplications, fragmentation and inconsistencies caused by each state and territory government running their own completely separate health departments? Why doesn’t Australia have a national public health and hospital service? Paul McNamara

Dr Tim Senior, a Croakey contributor and a GP working in an Aboriginal health service in Sydney, has a long list of questions, including:

• What do you see as the future for Medicare Locals?
• There is clear evidence that inequalities are a cause of ill health for everyone. How will your government tackle this?
• Wherever we look, we see that those who need health care the most get the least. This is true in rural and remote Australia, and true in pockets of our cities. How will you address this?
• How do you plan to increase the capacity of the workforce to manage increasing numbers of people with complex and chronic care needs?
• How do you plan to incorporate training of health professionals in health services that are already stretched?
• How do you see the use of e-health and telehealth initiatives in the future? What impact will your National Broadband Network policies have on this?
• Given that the evidence shows improved health comes from primary care, rather than hospital care, what are your plans to fund high quality primary care?
• How will you improve the integration of primary and secondary care? What are your plans for improving access to dental care?
• Do you have any changes planned for the way Medicare funds health services?

Meanwhile, if journalists and others are looking for some hard-edged health policy stories in the run-up to the federal election (as distinct from the easier option of calling the polls), Croakey contributors have some suggestions, including:

• So much of the public focus is on the performance of public hospitals when most health care is provided in the private sector. How about shining the light on the private sector, its performance and access? Specific examples, suggested by Professor Andrew Wilson, director of the Menzies Centre for Health Policy at the University of Sydney, are access to dermatology services and to bariatric surgery, and the impact of private health insurance.

• Given the cutbacks to public health and health promotion work by many of the state governments, what are the parties promising when it comes to public health and prevention nationally?

These suggestions follow a recent Croakey article canvassing ideas for media coverage of health matters in the run-up to the federal election, in which a few themes emerged.  These included the importance of focusing on issues that matter to the community, rather than being driven by professional, corporate and bureaucratic imperatives (or as one contributor suggested, the “rent-seekers”).

Contributors also suggested that the parties’ policies should be judged according to principles around equity and sustainability (ie beyond the usual refrain of more hospital beds, more doctors etc).

In this second instalment of the series, more ideas are put forward in response to a few prompts from Croakey, as per below.

1. Many sectors have a responsibility when it comes to the quality of our public debate about health. How would you advise the media to approach its election coverage of health? What can journalists and media organisations do to move beyond calling the “horse race”? What are some specific investigations that you’d like to see done?

Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
About 50 per cent of hospital care and 70 per cent of other healthcare is provided in the private sector, yet the overwhelming discussion is around performance of public sector hospitals. Almost all private healthcare is publicly subsidised through either the private health insurance rebate or the MBS and PBS. There seems to be continuing support in the Australian community for a mixed public, private model. However, there is little discussion about what this means, about the expectations of the private sector and on its performance.

The Preventive Health Taskforce which paralleled the National Health and Hospitals Reform Commission recommended the establishment of a national preventive agency to coordinate and lead prevention in Australia.   ANPHA was established as a response to this. The Coalition has it on its hit list to get rid of. Other public health experts are arguing we should be moving to a national CDC type organisation, given the threats from emerging infectious diseases and the speed at which these can spread globally. The current state of public health reflects the broader health system and is fragmented and loosely coordinated. What vision/plans do the parties have for prevention?

Both Labor and the Coalition publicly praise the quality of the Australian health system. Indeed, on many outcome measures like life expectancy, Australia does very well. But there are countries with similar economies spending similar amounts on healthcare that do better on measures such as waiting lists and coordination of care outside hospitals. Germany, for example, has no waiting times for elective surgery.

Carol Bennett, CEO, Consumers Health Forum
We need to pull focus of the health debate squarely on to the interests of the patient.  That means more attention to issues of access to appropriate care, cost and effective health systems.

What have the Rudd/Gillard health “reforms” really delivered for patients?  What does the Coalition offer that would improve health care?

Why are costs continuing to climb while access, even for those with insurance, seems to be shrinking?  More media examination of out of pocket costs, which have risen steadily in recent years.

And more scrutiny of the now-emerging data from the various performance and hospital costs authorities which are beginning to deliver data on how the health system is performing.

Selwyn Button, CEO, Queensland Aboriginal and Islander Health Council
Focus on comprehensive primary health care – all research and data indicate that the most effective mean of improving outcomes for Indigenous people is through comprehensive primary health care models of delivery, yet we are still struggling with governments to understand how to support this delivery through more effective and transparent resourcing and contract management.

Craig Thomler, Delib Australia and Gov2 advocate
I think the media has to stop beyond ‘gotcha’ stories and provide a lot more background on the overall health landscape for Australia.

It seems most media is now small target focused and isn’t providing a big picture view on how the health industry operates or all the interconnected pieces (and funding) that is required to address population health topics. In particular there’s a lack of focus on the underlying cause of many health issues, probably because these topics are not considered ‘health’ – such as personal hygiene education, work-life balance, food choices & respectful relationships.

I’d like to see a change in the entire approach to health reporting with a commitment to communication the big picture and then fitting every smaller story into context.

Mental health also needs to stop being treated as a ‘dirty’ and discrete topic and looked at in relation to physical health, considering the interactions between mind and body and their impact on overall wellbeing.

Special investigations: provide a breakdown of how health dollars are spent by type of health issue, alongside a matrix of how health issues influence the prevalence of other health issues, to see if proposed spending is direction towards ‘root’ or ‘branch’ concerns.

A dollar spent on obesity prevention provides benefits towards cardio-vascular disease prevention and treatment and therefore has a magnified impact – we get more than a dollar of value for the spend. Contrarywise there are undoubtably diseases where a dollar spent results is far less than a dollar’s value.

Only by mapping the expenditure and magnification factors do we get a clear picture on how our dollars can be best spent, and therefore be able to critically judge a party’s proposed health expenditure approach.

Anonymous Aboriginal health practitioner
Policy development and implementation is a complex process in which rational and ordered debate often play little part. Social systems, such as the political, draw boundaries between themselves and their chaotic (and potentially hostile) environments precisely so that the chaos and hostility can’t enter them or influence them. It’s therefore reasonable to conclude that policy is an instrument by which social systems seek to impose order on the ‘chaotic and hostile’ environments which surround them. Policy’s first task is to bring ‘order’ to the environment and, in so doing, ‘evidence’ becomes a technology of a lower order in policy development. It’s small wonder then that an informed – even (god forbid) scholarly – discourse developed over the course of any particular issue (though it might be rigorous, considered and thoughtful) is likely to play little part in the public discourse that surrounds any controversial subject in the charged electoral environment.

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2. The health sector also has a responsibility and often health organisations’ election statements are driven by narrow interests/perspectives rather than a wider focus on community interests. What practical things can health organisations and leaders do to contribute to a more informed and useful election debate around health?

Professor Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
In publishing statements, some commentary of the potential conflicts of interests of the parties would be useful and in particular to contrast statements on different issues. When juxtaposed, contrasting responses to different issues can highlight the conflicts.

The LHHN/Local Health Districts are supposed to bring greater local ownership, community accountability and responsiveness. This was stated in the response to the NHHRC and has also been part of the rhetoric of Coalition-led state governments in establishing them. It is debateable whether the current board arrangements actually achieve this in many cases.

Carol Bennett, CEO, Consumers Health Forum
We need to put out really clear messages on three big issues areas to put much more focus on:
·        Outcomes and performance of Medicare and PBS
·        On stopping the rise in out of pocket costs in health care
·        On improving quality and safety

Selwyn Button, CEO, Queensland Aboriginal and Islander Health Council
Self-determination and self-responsibility – in recent weeks much has been spoken about the notion of practical reconciliation from the opposition, whilst there is still some talk of self-determination being critically important to improve outcomes for Indigenous Australians.

Conceptually both these discussions a sound in there logic and proposed approach, although still do not go to the heart of real self-determination of ensuring that not only are Indigenous people provided with access to required services, resources and involvement in decision-making about how this happens, but going a step further to give overall autonomy and responsibility for policy, planning, program development, delivery and outcomes to Indigenous people.  This can and should happen particularly in places where there is demonstrated capacity and willingness to take on this challenge and risk associated, although governments are risk averse in nature and generally shy away from this next step.

If Indigenous communities and organisations can demonstrate willingness, understanding, organisational maturity and capacity, perhaps we should take the risk together in order to support improved outcomes.  This work is not ground breaking as it has already happened in Canada and NZ with significant results and could provide a template for greater autonomy in delivering services to Indigenous people by Indigenous organisations in or own country.  Working alongside this notion is also the importance of Indigenous communities and organisations willing to accept the challenge and demonstrate capacity and leadership in this space for governments to want to take risks.  This also would mean that not only are Indigenous communities and organisations willing to accept the challenge, we must also be willing to accept and embrace our failures if it doesn’t work.

Craig Thomler, Delib Australia and Gov2 advocate
A fact checking site would be brilliant. We have too many myths passing themselves off as facts these days & it is eroding public confidence in institutions. They could also be much clearer about their own interests and finances. It sometimes seems like a bit of a free-for-all with each group lobbying for their own interests without disclosing them, destroying trust across the board.

Anonymous Aboriginal health practitioner
It’d be worth looking at the Social Determinants of Health Alliance as an example of what you’re outlining. It is a group of widely disparate (and high profile) organisations drawn together in a ‘community interest’ (particularly disadvantaged communities) agenda. It has a website, has identified  September14th as its short term horizon and is unashamedly canvassing and lobbying politicians in order to get the government to sign on to the WHO-sponsored Commission on the SDoH.

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3. What about the role of the public service? The public service has largely disengaged from contributing to public debate (for eg James Button describes in his excellent book, Speechless, how senior public servants are now far less likely to provide background briefings to help a more informed media coverage, and Andrew Podger has also written about this). How might the public service and related agencies help contribute to a more informed debate?

Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
There is certainly a debate to be had to what extent this is the role of the public servant. While I think it is the role of the public serviced to provide honest unfiltered answers and data to requests from parties (and I use that term broadly) relating to issues in their portfolio, I have reservations about the extent to which they can enter into public debate (other than as citizens) on the issues. Similarly. it would be entirely appropriate for a public service to provide a listing of issues (and explanation and even the options identified for addressing the issue) in their portfolio. It is difficult to see how they would enter into a public discourse about the relative merits of different approaches where there are different political positions on those options.

Carol Bennett, CEO, Consumers Health Forum
The public service should be more accountable, such as in areas like negotiations for the Community Pharmacy Agreement, which should be much more transparent given the significant contribution taxpayers make to them

Craig Thomler, Delib Australia and Gov2 advocate
Firstly, we need the media to stop ‘gotcha’ reporting which has led to agencies withdrawing from public health debates on the basis that there’s no point in speaking about a topic if the media is reporting only to their own agendas. Secondly there’s a political issue where parties restrict external spokespeople to Ministers (or sometime their direct advisors) – this needs to be challenged and exposed by the media.

The public service and related agencies should first be encouraged to release as much raw data as possible, so it is available to inform media and public opinion. Then they can build on this data by providing professional perspectives and the various choices and consequences of specific decisions.

Frankly I don’t see agencies being that interested in getting into the public rough and tumble. There’s little upside and much downside for them & the current crop of senior leaders are focused on propping up a faltering system with falling budgets and needlessly quarrelling political figures.

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4. What are the broad criteria by which the political parties’ policies should be judged for their impact upon health? And for their health policies?

Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
1. To what extent do the policies reflect the real spectrum of healthcare in Australia (see the point made under question 1)?

2. To what extent do policies address the continuum of healthcare? Most of the focus is usually on emergency departments and elective surgery. What about prevention, rehabilitation, chronic mental health?

3. To what extent do the policies recognise and address inequities in access, eg there is virtually no bulk billing from dermatologists, and most charge more than twice the MBS rebate, so given the limited public sector services, access is clearly inequitable. Similarly, obesity has a very strong socioeconomic gradient yet bariatric surgery is very limited in public hospitals. The bulk of bariatric surgery is performed privately on insured patients (interestingly, data I have seen recently show even among those with private insurance higher socioeconomic groups are more likely to access bariatric surgery, probably reflecting both social values and the size of co-payments.)

4. Projections of health care costs show that the major driver of future costs is the increase in the intensity of care ie we can and are doing more to just about every health condition. To what extent do health and other policies reflect this when they talk about controlling the costs of healthcare?

5. Do the health policies specifically address the major health problems comprehensively – chronic diseases and mental health?

6. Do the broader (ie non health) policies recognise the direct and indirect impacts on population health and specifically on inequities in health? Eg employment, environment, trade, aid.

Carol Bennett, CEO, Consumers Health Forum
Both parties say they are about patient-centred health care.  But how do they propose to achieve that?  Their policies should ideally contain measurable objectives in terms of patient benefit.

Selwyn Button: Taking social determinants approach to supporting outcomes for Indigenous people – much has been researched and documented about the ongoing need to consider overall social determinants in order to improve outcomes for Indigenous people, and there have been several attempts by governments to support this approach without defining where to start.  What is needed now is a bolder approach to social determinants that clearly articulates the overall approach to improving social outcomes for Indigenous people by defining the most relevant starting point within this approach and how this integrates across the whole SD spectrum.  Current thinking by governments is to commence this work through job creation, although many would argue that employment, education and others participatory programs ill only be successful if the health of the individual and family is ready to take this challenge, which posits the health sector as the most relevant starting point.

Anonymous Aboriginal health practitioner
Equity. Human rights.

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5. I am keen to run some series at Croakey in the run up to the election, broadly grouped around particular themes. Do you have any suggestions for what these series could cover?  

Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
1. The role of private health insurance and the private sector in the Australian health care system

2. What doesn’t Medicare subsidise and is this equitable?

3. Who decides priorities in public waiting lists? Is elective orthopaedic surgery more important than bariatric surgery?

4. What can/should governments do to tackle chronic disease?

5. What do we mean by universal health cover in Australia? What does the community expect from public sector health services?

Carol Bennett, CEO, Consumers Health Forum
1.  The future of Medicare and how funding can deliver a better bang for the buck.

2. The development on different models of funding health such as patient-centred budgets, more focus on treatment outcomes.

3.  How to contain growing out of pocket costs.

4. The Commonwealth-state funding divide.  Will it ever deliver an effective health system?

5.  The public-private funding mix

Craig Thomler, Delib Australia and Gov2 advocate

Aged care is a priority.

How do we manage all aspects of the aged care system? Facilities, personnel, costs? Our voters are ageing, so these concerns are increasingly relevant to people.

Look at the productivity impact of rising obesity and stress-related illnesses (including mental). If we wish to be an economically effective nation, what impact would health care improvements or primary prevention have on sustaining and improving productivity.

NB, for those interested in ‘how would you spend the Federal health budget’, see the Budget Simulator.

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6. Do you know of any useful examples from around the world, re innovative, community-focused election coverage of health?

Andrew Wilson, Director of the Menzies Centre for Health Policy at the University of Sydney
Plenty of examples of the opposite!

Carol Bennett, CEO, Consumers Health Forum
During the Queensland election, then Premier Anna Bligh initiated a Twitter campaign that proved one way of communicating messages to voters during a difficult election.

• For other federal election coverage at Croakey