Professor Ian Hickie, psychiatrist and health reform advocate, has chosen an interesting metaphor for framing the health reform debate in an article just published online by the Medical Journal of Australia.
“After a prolonged gestation,” he says, “we are now witnessing the somewhat protracted birth of the Rudd Government’s health reform plan. To date, only the head of the new scheme has come into view. For those who remain anxious about the overall health of the infant, and indeed whether it has all of its necessary parts, we have been provided with an attractive slogan — “funded nationally and run locally” — rather than a clear blueprint for action.”
Hickie raises many concerns about Rudd’s plans, including the potential for local hospital networks to contribute to “further Balkanisation” of health planning and greater fragmentation between hospital and community-based services, and the promotion of intense rivalries between local services. He says the local network plan is unnecessarily hospital-centric and bound to perpetuate the blame game between these federally funded but state-governed local authorities.
He also highlights the lack of attention to equity issues. “For the Rudd plan to achieve real credibility, it needs to explain how a 60-year-old man in rural Australia without private health insurance will now get a timely hip replacement or affordable cataract surgery. Even more challenging are questions such as: how will a 50-year-old Indigenous woman with diabetes, arthritis and dental decay get access to the primary care, dental and other allied health services that she really deserves; or how will a 19-year-old man who has recently attempted suicide receive the ongoing help he desperately needs? If Mr Rudd cannot easily explain how the new system will assist these people, then the current round of national health reform may well be stillborn.”
Also at the MJA online, Dr Christine Bennett, the chief medical officer at BUPA Australia who chaired the National Health and Hospitals Reform Commission, gives a perspective that is much more cautiously welcoming (and politically sensitive). You have to read between the lines a bit to get a sense for any potential reservations. She says: “These reforms would arguably be the most significant changes to governance and public health financing in Australia over the past 30 years. While good governance and sustainable funding are critical enablers, they are not the whole reform story. The next chapters of the reform plan must demonstrate that this framework will ultimately translate into better, connected health care across all settings and for all Australians.”
Meanwhile, Professor George Rubin, professor of public health at the University of Sydney, examines below how the population health sector seems to have gone missing in the Government’s thinking. He writes:
“The much awaited Federal Government response to the National Health and Hospital Reform Commission’s final report (A National Health and Hospitals Network for Australia’s Future) and subsequent commentary proposed funding mechanisms for hospital services. It paid scant attention to mechanisms for population health action and efforts to reduce hospitalisations.
Public (or population) health is the organised response by society to protect and promote health, and to prevent illness, injury and disability; it is the starting point for identifying problems and priority health issues in communities, and for designing and implementing interventions. It focuses on populations or population subgroups rather than on individuals; on the factors and behaviours that cause illness; and on prevention, health promotion and the protection of health rather than on treatment of disease, disability or injury.
Population health services include infectious disease control, specific health promotion programs to reduce risk factors for disease and disability, organised immunisation, environmental health, food standards and hygiene, screening programs, and the prevention of hazardous and harmful drug use. These services are delivered by public health professionals at national,state and local levels.
Primary and community health services include screening, health promotion, and treatment interventions directed to individuals rather than to populations and are delivered through private providers such as GPs and allied health professionals; state funded community health centres; hospital community outreach programs and outpatient clinics and emergency departments.
The Australian Institute of Health and Welfare reports that total expenditure on population (public) health activities by health departments in Australia during 2007–08 was almost $2.15 billion or $102 per person on average with public health expenditure as a proportion of total health expenditure amounting to 2.2%.
In that year, the Australian Government provided the largest share of the funding for public health activities contributing $1.37 billion, or 64%, of the total funding. Of this, $563 million was spent on its own programs and $810 million was provided to state and territory governments through what are called “Specific Purpose Payments” to fund public health activities. In 2007-2008, the highest expenditure was for organised immunisation ($704 million or 33% of the total expenditure), selected health promotion ($367 million or 17%) and screening programs ($289 million or 13%).
The March 3 Report notes that Australia has the highest hospitalisation rate of the OECD countries with potentially preventable hospitalisations representing 9.3 per cent of all hospitalisations in 2007–08 and equating to approximately 441,000 hospitalisations in public hospitals – an average cost of about $4,230 per episode of care.
It suggests that strengthening and improving the coordination of the currently fragmented primary healthcare will reduce this high hospitalisation rate. To foster this coordination the Federal government proposes to assume full policy and funding responsibility for primary health care and to move over time to funding a greater share of those outpatient services that are better characterised as primary health care equivalent services. The federal government will thus become the single funder of primary health care and hospital outpatient services. The detail of what is “in scope” for transfer to the Commonwealth in particular states will be negotiated with the states in the near future.
While clinical preventive services such as cervical cancer testing and checking for hypertension are often delivered by primary and community health professionals, the population health activities are executed through different mechanisms. Exactly how the Government proposes to fund these activities remains unclear. Perhaps the population health funding will at least be maintained at current levels.
Whether the Federal government will propose gradually taking over this funding from the states up to 100% or propose a cost sharing arrangement – as is the current situation – remains to be seen.
Whatever the case, the need for increasing current levels of funding either through the primary health care funding mechanism or a separate population health funding mechanism will become apparent as the population ages, new genetic screening technologies become available, and new health threats emerge.”