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The national reform on health: implications on service delivery and institutions

29 June 2010.

Paper delivered by Dr Harry Hemley to the Council of Economic Development of Australia.

Let me be clear: The National Health and Hospital Network Agreement is not health reform. Yet.  

AMA Victoria sees the Agreement as a health financing and governance deal. However, the Agreement presents opportunity.

We need to build on the National Health and Hospitals Network Agreement to get to real reform that will improve patient care. The esoteric arguments between governments over who should fund what and where have been had. Now it’s time to get to the real deal.

Clinicians need to be involved during all stages of the negotiations and implementation of this proposal. I think Governments around the country are realising that nurses, doctors and other health professionals can help with reform and innovation.

After all, we are caring for patients every day. However, Governments should note that clinicians come from particular points of view, and some professions will act out of self-interest.

We should always be looking at what patients need. We also need to always keep in mind what patients want — and patients want choices, they want access to care and they want quality care.[1] 

Our health system needs a vision. Innovation, alternative care options, and a long term plan for the future is how we can achieve real reform. Health care is not something that can be ‘reformed’ in the space of four months. Careful consideration and consultation with the profession must occur if we want real reform, not a re-arrangement of finances.

What are the actual implications of this reform for service delivery? It is hard to say at this point in time. The reform plan lacks detail on what form certain institutions will take.

For example, the proposal of ‘Medicare Locals’ is one that has AMA Victoria concerned. A significant amount of money will go into these bodies, yet it remains unclear what their function actually is.

We do know that Divisions of General Practice will not have their contracts renewed. Divisions will either be converted into Medicare Locals, or disbanded.[2] I am particularly concerned that Medicare Locals are being put into a position where they will control access to health care for patients with diabetes, and patients needing after hours care.

Hidden in the details of the Budget papers are the proposals that Medicare Locals become fundholding bodies. At first, Medicare Locals will hold $250 of the funds set aside for allied health care of people with diabetes, and will control access to after hours health care.  

The current proposal is that Medicare Locals will decide what services the sickest people in our community need. AMA Victoria thinks the doctor and the patient should make patient care decisions, not some faceless bureaucrat. The Commonwealth also proposes bringing in fundholding for patients with chronic disease.

For the first time since 1 February 1984 some Australians will be seeing their family doctor without the right to a Medicare rebate. After 26 years, this universal aspect of Medicare is being eroded in favour of a UK-style patient registration system that removes choice of doctor.

We are told that initially the fundholding, rationed care aspects will be voluntary, and only for people with diabetes. I worry about that word ‘initially’.

The Minister says she is not interested in a UK-style system, where patients don’t get to see the doctor of their choice. Yet, she wants to introduce UK-style patient enrolment, UK-style fund holding, UK-style government health clinics, and UK-style performance indicators. If it walks like a duck, and it quacks like a duck …

Proposals for patient registration, fundholding, changes to prescribing rights, and pay for performance, have a potential to ration care and not provide the appropriate care to those who most need it. But more importantly, patients just don’t want it. AMA research shows that choice of doctor is highly valued by Australian patients.[3]

But it’s not just general practice that could fundamentally be altered through the National Health and Hospitals Network proposal. The proposed four hour rule for emergency departments will also have serious implications on service delivery and institutions.

Given that the latest Your Hospitals report into Victorian public hospital performance revealed that only two out of three patients were admitted within the current eight hour target[4], a new target of four hours would appear somewhat ambitious.

58,000 patients missed the eight hour target for admission in just six months in Victoria alone.[5] If these figures translate nationally, then we have close to half a million people missing out on the existing eight hour target.

The four-hour rule is being phased out in the UK. The UK provided a model for what the PM plans to do with our EDs. British Health Secretary Andrew Lansley has said the targets will be scrapped so that hospitals can focus on delivering the "best possible results for patients".[6]

Arbitrary targets, particularly politically motivated ones, will not benefit patients. Unless we have the resources to reach these targets, these targets are meaningless. The problem is capacity. If there were enough hospital beds, then patients needing an emergency admission could be placed in those beds.

So if hospitals are to meet the Prime Minister’s target, then it’s simple — fund more hospital beds, nurses, doctors and other services needed. Without additional beds, then the targets will not be met, and/or hospitals will resort to clinically-inappropriate behaviour.

However, the four hour rule could well work. It could provide incentives for hospitals to improve the speed of diagnostic testing to get patients into a bed quicker.

It could provide incentives for hospitals to work towards a more efficient bed occupancy ratio. I’ve picked just two areas where we have concerns, and most of those are around the detail of implementation.

Health care is a sprawling, complex beast that successive governments have found difficult to control. There are legions of competing demands, scarce resources, and narrow self interests.

Yet we need reform. Nobody is happy with things the way they are.

Our proposal: our health system needs a vision. We need a long term plan for the future that will address inequities in the system, promote quality and flexibility and offer accountability.

We need real team based care. Health professionals should work together, not try and endlessly call for more independence and fragmentation. My message to allied health and nursing is clear. Please work with the medical profession to improve patient care, not try and set up your own sandpit to play in.

In general practice, we want more practice nurses. We want more care co-ordinators such as nurses or occupational therapists. We want more opportunity to refer patients to allied health professionals and have those consultations covered by Medicare.

We need more hospital beds to cope with a growing population. However, we also need more types of care options; not just more of the same. Aged care step-out facilities, rehabilitation, mental health facilities, hospital in the home, and other innovative care options that meet the needs of individual patients must be further explored.

The links between hospitals, aged care and community care must be strengthened. The vision should be right care, right place, right time.

We need good information technology in health. We need a patient-controlled health record. We need better communication. In hospitals, just having more access to computers would be nice.

Our population is growing. It is ageing. We need to improve our health system. For the first time in a long time, health care reform is being talked about seriously.

We aren’t yet beyond discussions on financing and governance, but I am hopeful we’ll be starting some real conversations on real health reform affecting real patients.

That’s the health reform I’d like to see.

 Dr Harry Hemley is president of the Australian Medical Association Victoria

[1]Australian Medical Association, 28 April 2010. ‘Australians want a health system that is built on the family doctor – AMA survey’ Media release, AMA, http://www.ama.com.au/node/5514, accessed 21 June 2010.
[2] Australian Government, 2010. Federal Budget 2010-2011, Budget paper two: Expense Measures, National Health and Hospitals Network — General practice and primary care — establishing Medicare Locals and improving access to after hours primary care. p. 228. 
 
[3] AMA Federal. 28 April 2010. ‘Australians want a health system that is built on the family doctor – AMA survey’ Media release, AMA, http://www.ama.com.au/node/5514, accessed 21 June 2010.
[4] Victorian Government Department of Health. April 2010. Your Hospitals: A report on Victoria’s public hospitals, July to December 2009, Victorian Government Department of Health, p. 19.
[5]Victorian Government Department of Health. April 2010. Your Hospitals: A report on Victoria’s public hospitals, July to December 2009, p. 19.

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