Now is the chance for change, so leap at it

The Weekend Australian - Travel - - Health - AN­THONY SCOTT

TAK­ING the Aus­tralian health-care sys­tem kick­ing and scream­ing into the 21st cen­tury will be no mean feat. The struc­ture of the sys­tem has re­mained largely un­changed since 1984, even though the things that should drive struc­tural change and re­form, such as changes in pat­terns of dis­ease, pa­tient ex­pec­ta­tions and tech­nol­ogy, are chang­ing at a fast pace.

The re­sult is a health-care sys­tem not fit for pur­pose. Stay­ing as we are is not an op­tion un­less we want to go down the slip­pery, in­ef­fi­cient and in­equitable path of the health care sys­tem in the US.

Af­ter count­less par­lia­men­tary and aca­demic re­ports over the last 20 years which recog­nised the need for change, there is some op­ti­mism that at least Kevin Rudd and Ni­cola Roxon have a plan — some­thing en­tirely ab­sent in the Howard Gov­ern­ment. But the plan’s suc­cess is not guar­an­teed, putting at risk the abil­ity to make a real dif­fer­ence to the health-care sys­tem and the health of the pop­u­la­tion.

The Rudd and Roxon plan in­volves a twostage approach. The first seeks closer statefed­eral re­la­tion­ships and co-op­er­a­tion to un­der­pin the next Aus­tralian health-care agree­ments. If this doesn’t work, then the sec­ond stage, the one that would in­volve much kick­ing and scream­ing and po­lit­i­cal risk, is to move to­wards a sin­gle fun­der of pub­lic hos­pi­tals and the health-care sys­tem at large.

Closer state-fed­eral re­la­tion­ships un­der the agree­ments are, un­for­tu­nately, un­likely to make a dif­fer­ence to pa­tients. Re­ly­ing on a po­lit­i­cal so­lu­tion to a sys­temic struc­tural prob­lem is mis­guided. This op­tion does not ad­dress the wide­spread in­ef­fi­cien­cies and du­pli­ca­tion of hav­ing joint state-fed­eral fund­ing of health care. Per­for­mance bench­marks and in­cen­tives for im­proved per­for­mance are ac­tively be­ing dis­cussed as part of the new agree­ments. How­ever, th­ese ‘‘ tooth­less tigers’’ have al­ways been a fea­ture of pre­vi­ous agree­ments and there is lit­tle ev­i­dence to show they have made any dif­fer­ence.

Fights over money, in­ef­fi­cien­cies, mis­aligned in­cen­tives and blame-shift­ing will con­tinue, per­haps less so in the pub­lic do­main with closer po­lit­i­cal co-op­er­a­tion, but they will hap­pen none­the­less. Their per­sis­tence will en­trench re­sis­tance to change that has been at the heart of the health-care sys­tem’s paral­y­sis.

There will be lit­tle op­por­tu­nity to pool funds and deal with many of the prob­lems raised by myr­iad pre­vi­ous re­ports. The Na­tional Health and Hos­pi­tals Re­form Com­mis­sion will, in all like­li­hood, rein­vent the wheel of pre­vi­ous re­ports’ rec­om­men­da­tions, but this time let’s hope the Gov­ern­ment will lis­ten and take ac­tion rather than ig­nore it.

Fail­ure of this first op­tion has not been de­fined, which is wor­ry­ing. What cri­te­ria might be used to judge suc­cess or fail­ure? Will pa­tients have a say? No one knows, and de­bate is ur­gently needed.

The sin­gle-fun­der op­tion would be dif­fi­cult to im­ple­ment, po­lit­i­cally and prac­ti­cally, but some­times the big­gest pay-offs oc­cur when risks are taken. A sin­gle fun­der of health care con­jures up images of a gov­ern­ment mono­lith and a com­mand-and-con­trol sys­tem with lit­tle flex­i­bil­ity to ac­com­mo­date lo­cal cir­cum­stances. Such fears can be dis­pelled by pay­ing at­ten­tion to the de­tailed de­sign of such a sys­tem, its struc­ture, and in­cen­tives within it.

A sin­gle fun­der does not rule out flex­i­bil­ity, com­pe­ti­tion or in­no­va­tion. For ex­am­ple, in the UK’s Na­tional Health Ser­vice, pub­lic hos­pi­tals have more au­ton­omy than those in Aus­tralia. Re­search has sug­gested that per­for­mance man­age­ment schemes, with teeth, have made a real and sus­tained dif­fer­ence to wait­ing times. There is con­sid­er­able de­vo­lu­tion of health-care fund­ing and de­ci­sion-mak­ing to lo­cal level, through re­gional agen­cies with a pop­u­la­tion health fo­cus, which are re­spon­si­ble for fund­ing all health-care ser­vices in their ge­o­graph­i­cal area.

The private sec­tor can also be in­volved in this model. The sin­gle-fun­der model pro­vides enor­mous op­por­tu­ni­ties to pro­vide more seam­less care for pa­tients and im­prove the qual­ity of their jour­ney through a com­plex sys­tem. There will still be fund­ing fights be­tween re­gions and the cen­tre, but at least th­ese would no longer be po­lit­i­cally mo­ti­vated.

Mean­while, the talk­fest con­tin­ues with the Na­tional Health and Hos­pi­tals Re­form Com­mis­sion and the Aus­tralia 2020 sum­mit. Let’s hope they stop talk­ing and start ‘‘ do­ing’’. Oth­er­wise, the risk is that the next elec­tion will be loom­ing and we will have missed a rare op­por­tu­nity to pro­vide the health-care sys­tem with the means to do what it does best: im­prove our health and well-be­ing. Pro­fes­sor An­thony Scott heads the health eco­nomics re­search pro­gram of the Melbourne In­sti­tute of Ap­plied Eco­nomic and So­cial Re­search, at the Univer­sity of Melbourne

First-hand ex­pe­ri­ence: Prime Min­is­ter Kevin Rudd meets pa­tients

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