Lesley Russell: Health reform hurdles

HEALTH policy experts are optimistic about the possibilities to reform the way health care and related services are delivered to improve health outcomes for all Australians.

However, what has been implemented so far falls well short of community needs and the current health care system is not affordable into the future.

The Sydney Health Policy Network (SPHN) recently sponsored a conference that looked at the federal government’s major health reforms — the National Health and Hospitals Reform Commission, the Preventative Health Taskforce and the National Primary Health Care Strategy — 3 years on.

The conference addressed funding models and barriers to access, the future of primary care, and taking prevention beyond rhetoric and beyond the health care system.

The reality is that while the commissioned reports provide the guiding principles for reform and decent sums of money have been committed to implementation, there is little evidence that better health outcomes are being achieved, disparities are being addressed, and efficiencies and cost containment are being delivered.

To some extent this is due to a lack of data, but it is mostly due to a failure of political and professional will to fully implement what was recommended. Governments have fought over control and funding. Politicians have focused on the short-term, “big bang for the buck” investments. Health professionals have stood guard over the status quo and have been slow to adopt new ideas.

The public feels the reforms are not about them and remain unengaged.

So far, the major focus has been on acute care when the solutions to Australia’s health problems lie outside of hospitals.

The federal Minister for Health Tanya Plibersek has indicated her view that an Australian health care system for the 21st century must be centred on primary care and prevention. And this is certainly where the conference participants saw the real gains will be made.

While the ideal situation of having the federal government take full responsibility for primary care is off the agenda for the foreseeable future, there was hope that other reforms — especially developing the potential of Medicare Locals — will offer ways to work around this funding fissure. Medicare Locals have the potential to deliver primary care that is comprehensive, including mental health, substance misuse and dental health services, and is better integrated with specialist, acute, rehabilitative and residential care.

There is concern that, despite the government’s recent announcement on reforms in dental health services, publicly funded dental care remains inadequate.

Tackling the current obesity crisis, reducing tobacco use and excessive alcohol consumption, and closing the gap on Indigenous disadvantage  will require efforts beyond those delivered through health care services. The establishment of the Australian National Preventive Health Agency marks real progress here, but conference participants bemoaned the continuing lack of sustained funding support for public health and prevention, which comes nowhere near matching the resources of tobacco companies, the food marketing industry and the licensed liquor lobby.

It is clear that more advocacy is required if Australia is to reap the rewards that an increased focus on prevention can deliver.

None of this can happen without an appropriate infrastructure. Health IT and personally controlled electronic health records are essential, workforce reforms must reflect demographic and geographic needs and maximise the skills of all health care and public health professionals, and the continuing collection, analysis, evaluation and feedback of data is the only way to effectively assess progress.

Conference participants agreed that, to meet community needs, health services must be more embedded in regional development (with links to services such as education, housing and transport), more integrated into workplaces and schools where people spend most of their time, culturally sensitive, and more bottom up rather than top down.

Current financing arrangements — split responsibilities for some services, a large reliance on fee-for-service, a failure to integrate public and private sectors, and growing out-of-pocket costs for patients — provide a raft of disincentives and barriers to the sort of health services needed to deliver improved health outcomes.

The conference found clear evidence that much is happening in health reform, although not all of it is advancing improved outcomes. Concerted national efforts will be needed to keep the reform agenda moving despite fiscal constraints.

An informed public debate and getting the community engaged should be the priority.

Dr Lesley Russell is a senior research fellow at the Australian Primary Health Care Research Institute at the Australian National University. She attended the SPHN conference. This article is her opinion based on the speeches and discussions.

Posted 3 December 2012