Research Paper 24 2008–09
The interim report of the National Health and Hospitals
Reform Commission—a summary and analysis
Rebecca de Boer, Anne-marie Boxall, Amanda Biggs, Luke
Buckmaster, John Gardiner-Garden and Rhonda Jolly
Social Policy Section
19 March 2009
Contents
In February 2008, the Rudd Government established the National
Health and Hospitals Reform Commission (the Commission) to provide
a ‘blueprint’ for reforms to the Australian health
system. On 16 February 2009, the Commission released its interim
report, A healthier future for all Australians. The interim report proposes 116 ‘reform
directions’, covering a wide range of issues including
governance of the health system, primary health care, prevention,
Indigenous health, hospitals, aged care, workforce, mental health
and rural health.This research paper outlines the
Commission’s major proposals, identifies substantial shifts
in policy direction and provides commentary and analysis on key
issues.The main conclusions of this research paper are:
- the interim report contains an extensive and thought-provoking
set of proposals, some of which, if adopted by the Commonwealth
government, would lead to significant changes in the health
system
- examples of significant proposals include a Commonwealth
takeover of all primary health care funding, policy, and service
delivery; a universal, publicly funded dental scheme called
Denticare Australia; and proposals for new governance arrangements
for the health system
- amidst the large number of proposals, the interim report lacks
a single, focused and overarching blueprint for reform and
- the lack of detail in some areas raises several unanswered
questions, some of which may be addressed in the final report.
|
Introduction
Health system reform is rare. Only two major, long-lasting
changes to the Australian health system have been implemented since
World War II—the introduction of a voluntary, private
insurance system in the 1950s; and the introduction of Medicare, a
compulsory, tax-funded insurance, in 1984.[1] The release of the National Health and
Hospitals Reform Commission’s (the Commission) interim
report, A Healthier Future for all Australians (the
interim report) potentially marks the beginning of a new episode of
major health system reform in Australia.[2] The interim report outlines a range of
policy proposals that, if implemented, would substantially change
the nature and operation of the Australian health system in the
future.
The interim report considers four strategic reform
themes—taking responsibility, connecting care, facing
inequities and driving quality improvement. It lays out key
messages and policy proposals for each of these themes. The
Commission will consider feedback on the report and deliver its
final report by June 2009.
This research paper outlines the major proposals made by the
Commission, identifies proposed substantial shifts in policy
direction and provides commentary and analysis on key issues.
Stakeholder and commentators’ views are discussed in some of
the more contentious areas. Considerable attention is paid to key
policy proposals, such as the options for new heath system
governance arrangements and Denticare. The governance models are
particularly important because the model chosen will have a
powerful influence on other reform proposals made in the interim
report. The report does not examine how specific reform proposals
would operate under the various governance models proposed and,
thus, this has not been explored in this research paper.
The Commission was established by the Rudd Government in
February 2008 for the purpose of providing a ‘blueprint for
design and a plan of action to tackle current and future challenges
in the Australian health system’.[3] The Commission’s review of the
health system should be considered in the context of other reform
initiatives in the health portfolio as these may influence the
proposals adopted by the Government. Amongst the most significant
changes are the new National Healthcare Agreements and National
Partnership Agreement on Preventive Health negotiated at the
Council of Australian Governments (COAG) meeting in November 2008.
These agreements outline outcomes, progress measures and benchmarks
across a range of areas, but only the National Partnership
Agreement on Preventive Health includes reward payments for
achieving defined targets.[4] In November 2008, COAG also announced a
significant funding boost for Indigenous health aimed at closing
the gap between Indigenous and non-Indigenous life expectancy in
Australia. Funding will be used to improve chronic disease
management, help reduce risk factors for ill health and ensure that
Indigenous people have better access to health professionals and
health services.[5]
Several other major inquiries are also currently underway in the
health portfolio. In April 2008, the Minister for Health and
Ageing, Nicola Roxon, announced the establishment of a National
Preventative Health Taskforce to take responsibility for developing
a Preventative Health Strategy by June 2009.[6] The Government also committed to a
Maternity Services Review and the development of a National
Maternity Services Plan. In February 2009, the Maternity Services
Review released its report, which outlined a range of reform
options.[7] The
Government has yet to respond.
There are also over a hundred committees, councils, authorities,
statutory agencies, advisory groups and working parties currently
operating in the health portfolio, ten of which have been
established by the Rudd Government.[8] Their influence on policy, however, is difficult
to anticipate.
The Commission makes it clear that it continues to support the
principle of universal access to care, a commitment to ensuring
equity and a mixed public and private health system. Within these
parameters, however, the Commission makes numerous major reform
proposals. The most significant are: a Commonwealth takeover of all
primary health care funding, policy and service delivery; a
universal, publicly-funded dental scheme called Denticare Australia
(Denticare); and proposals for new governance arrangements for the
health system. These proposals and several others contained in the
interim report are examined in detail in this research paper.
The interim report also makes many recommendations that, if
adopted, would signify major shifts in health policy direction.
They include: expanding the role for the Commonwealth Government in
health; a renewed focus on prevention, health promotion and the
social determinants of health; introducing performance payments and
incentives; a greater amount of transparency and public reporting;
and redefinition of the roles and responsibilities of some health
professionals.
The following section briefly discusses these shifts in policy
direction.
Two of the most important proposals that recommend expanding the
Commonwealth Government’s role in health are Denticare and a
Commonwealth takeover of all primary health care. Many other
proposals, however, also require a shift in responsibility from the
states and territories to the Commonwealth. Some examples of these
proposals include: establishing national systems for professional
registration, performance reporting, private hospital regulation
and workforce education and planning; national leadership on safety
and quality in health care; evaluating new technologies, medical
devices and prostheses; and creating several new Commonwealth
health agencies.
The proposal to expand the Commonwealth’s role and
responsibilities is significant, primarily because its current role
is relatively limited. Under current arrangements, the Commonwealth
has responsibility for the Medical Benefits Scheme (MBS), the
Pharmaceutical Benefits Scheme (PBS), subsidising private health
insurance and funding and regulating a range of other health
services. It also shares responsibility for public hospital funding
with state and territory governments.
Expenditure on hospitals in Australia far outweighs that
allocated to public health activities, such as health promotion,
cancer screening, immunisation and environmental health. In
2005–06, total recurrent health expenditure on hospital care
was $31 billion, which was 39 per cent of total health expenditure.
In contrast, expenditure on public health activities in the same
financial year was $1.5 billion, or around 1.8 per cent of total
health expenditure.[9]
While few would argue for a radical reversal in funding
priorities, many health stakeholders have argued for greater
investment in preventive health activities.[10] The Public Health Association of
Australia, for example, has called for ‘a considerable
increase in the percentage of health budgets that go to
prevention’. The Association explains that, at present,
preventive health activities only receive about two per cent of the
health budget, which it considers ‘simply
inadequate’.[11]
Many of the proposals outlined in the interim report, if
implemented, would strengthen the role of preventive health in
Australia. Some of these proposals would require significant
funding increases. Others would require greater coordination and
leadership at the federal level. Some of the more important
proposals include: establishing wellness and health promotion
programs to be delivered by employers and private health insurers;
developing ‘Healthy Australia Goals’ for health
promotion and prevention; and establishing a national
community-based program offering screening for mental health
disorders and sexual health for youth.
Responsibility for health is seen as both an individual and
collective responsibility. The interim report acknowledges the
impact of individual lifestyle risk factors (such as smoking,
obesity, and physical inactivity) on the burden of disease, but it
also points to a range of powerful ‘social determinants of
health’, such as socioeconomic and environmental factors,
education, housing and access to clean water and safe food.
Adopting an approach to health that more strongly emphasises the
social determinants of health would be a significant policy shift
in Australia. Under the Howard Government, the focus of health
policy was on individual responsibility and reducing individual
risk factors for ill health. It maintained this approach even when
attempting to address persistent health inequities between
Indigenous and non-Indigenous Australians. For example, the Howard
Government’s National Strategic Framework for Aboriginal and
Torres Strait Islander Health identified eight priority areas. All
but one focused on individual aspects of disease prevention and
treatment.[12]
While the interim report has a discernable shift in rhetoric on
responsibility for health, it does not specify which proposals, if
any, reflect this new approach. The final report may provide more
information and clearer direction on how this change in policy
direction would be put into practice.
The use of benchmarks, targets and goal setting in Australia is
not new, but linking them to funding is only a recent initiative.
The idea was foreshadowed in the Commission’s earlier report,
Beyond the Blame Game, which outlined a framework for the
most recent round of health care agreements.[13] Until 2007, pay-for-performance
measures had not been used in publicly funded health care in
Australia. Since then, Queensland has piloted their use in public
hospitals.[14] Some
of the proposals in the interim report suggest expanding
pay-for-performance into other areas such as primary care and aged
care.
The interim report makes a number of recommendations for
improving transparency and public reporting in the health system.
Most aim to standardise data collection, including, making it
possible to compare health care and aged care facilities and track
progress towards quality improvement. Some recommendations also aim
specifically to mark progress on efforts to address health
inequity.
According to an independent survey conducted in 2007, there is
strong public support for measures that could increase transparency
of hospital performance.[15] The majority of respondents wanted hospital infection
and patient readmission rates to be published. They also wanted
doctors to make available information on the number of times they
had performed an operation and their success rate.[16]
The former Health Minister, Tony Abbott, proposed introducing
some form of health performance scorecard.[17] There is some international evidence
that publishing performance information in the form of scorecards
can lead to improvements in the quality of care, especially where
these focus on the ‘processes of care’ rather than just
the outcomes.[18]
The Commonwealth Government abandoned plans to introduce scorecards
or league tables for hospitals in January 2008. It did so after
encountering strong resistance from the then NSW Health Minister,
Reba Meagher, during negotiations on the new health care
agreements.[19]
While the interim report stops short of recommending the use of
league tables or scorecards, it would be possible to construct
these if publicly available information was comprehensive and
accurate.
The interim report makes three recommendations on roles and
responsibilities for health professionals that, if implemented,
would lead to significant changes. It proposes to:
- expand the role of nurse practitioners and other registered
health professionals in remote and some rural areas and thereby
give them access to the MBS and the PBS
- allow medical practitioners to bill for specified procedural
items on the MBS where work has been done by another accredited
health professional and
- encourage health professionals working in the proposed
Comprehensive Primary Health Care Centres to shift away from
fee-for-service practice over time, although this is not specified
in the interim report.
The research paper now turns to a more detailed discussion of
the interim report’s four strategic reform themes.
The ‘Taking responsibility’ section of the interim
report emphasises measures aimed at promoting health and preventing
illness. According to the interim report, the promotion and
prevention focus is driven by factors such as the increasing burden
of chronic disease and the unequal health status among particular
groups, particularly Indigenous people. This contrasts with other
sections, where the emphasis is more on rationalising and/or
reforming models of health care funding and delivery.
The interim report focuses on promotion and prevention at two
levels:
- the community level (taking a population health perspective)
and
- the individual level (from the perspective of how individuals
can take greater responsibility for their health).
Preventive health was a major focus of the Australian Labor
Party leading up to the 2007 federal election. Since then, the
Minister for Health has spoken about shifting prevention from the
margins to the centre of health care because of the growing burden
of preventable conditions such as diabetes, obesity, cardiovascular
disorders and lung and bowel cancers.[20]
On 9 April 2008, the Government established the National
Preventative Health Taskforce (NPHT). The NPHT is responsible for
advising the Government on the framework for the Preventive Health
Partnerships between the Commonwealth and the state and territory
governments, and developing a National Preventative Health
Strategy. The work of the NPHT overlaps with that of other Rudd
Government health advisory bodies, the National Primary Health Care
Strategy External Reference Group and the NHHRC. Local and overseas
health policy experts have been arguing for a greater focus on
preventive health in their respective countries for many years.
Governments in countries such as Sweden and the United Kingdom (UK)
have placed an increased emphasis on public health and prevention
in recent years as part of their efforts to reform their health
systems. Experience from such efforts has highlighted the need for
long-term, sustained commitment and engagement at all levels of
government if preventive measures are to succeed.[21]
The main reform directions proposed by the Commission at the
community level of prevention include:
- proposals for improving the information available to evaluate
the health status of the community and to track progress towards
the achievement of health objectives and
- establishing an independent national health promotion and
prevention agency, which will have responsibility for
‘national leadership’ on ten-year health goals known as
‘Healthy Australia’.[22] It will also ensure prevention becomes the
platform of healthy communities and is integrated into all aspects
of the health care system.
The most notable proposal at the individual level in the
‘Taking responsibility’ reform direction is the
inclusion of health literacy as a core element of the National
Curriculum (across primary and secondary schools). For a full list
of reform directions under the theme of ‘Taking
responsibility’, see the appendix to this research paper.
The interim report argues against the idea that Australia has a
‘level playing field’ in health and highlights the
association between socioeconomic disadvantage and poor health
outcomes. It argues that ‘the appalling health status of our
Aboriginal and Torres Strait Islander peoples provides the most
clear-cut repudiation’ of the position that there are few
barriers to accessing health care in Australia and that health is
evenly distributed across the population.[23]
In a later section entitled ‘Facing
inequities’, the interim report proposes measures
aimed at addressing inequality among specific populations or people
suffering from particular conditions. The main mechanisms for
addressing inequality and building healthy communities in the
‘Taking responsibility’ section revolve around
collecting and reporting data on health status and setting
specific, long-term goals for improving health outcomes. These
include proposals for a regular report tracking our progress as a
nation on health inequity and a rolling series of ten-year goals
for health promotion and prevention, to be known as Healthy
Australia Goals and commencing with Healthy Australia 2020
Goals.
These proposals are tentative first steps towards addressing
inequalities in health status across the community. It is likely
that better information about the nature of the problem and
specific agreed targets for health improvement (against which
Government performance will be measured) will also help focus
health policy and programs around the problem of health
inequality.
However, it is likely that much more than information and
goal-setting will be required. The interim report is relatively
quiet on the policies that might transform information about the
nature of the problem into improved outcomes. It makes some
interesting (albeit tentative) comments about the need to target
disadvantaged groups (for example, ‘targeting within
universalism’), without saying very much about specific ways
in which this might be done. The interim report refers to several
examples (more inclusive health screening programs and needs-based
funding) from submissions to the Commission and states that it
welcomes feedback on the issue. Given the centrality that the
interim report gives to addressing health inequality as part of
building healthier communities, it will be interesting to see
whether the Commission provides more direction on this matter in
its final report.
One of the main reform directions proposed by the Commission is
the establishment of an independent national agency with
responsibility for leadership and coordination of preventive health
activities, the National Health Promotion and Prevention Agency
(NHPPA). As the interim report notes, the idea of an agency like
the NHPPA is not new. There have been calls for such an agency
since the 1970s, including, most recently, from the NPHT.
According to the NHPT, recent experience of public health in
Australia shows that ‘preventative efforts have been most
effective when effective supports have been put in
place’.[24]
Establishing an agency with responsibility for health promotion may
also help ensure that such efforts are sustained and engage all
levels of government.
The interim report advances some preliminary ideas as to how
such an agency might be established, funded and operated, including
that it be independent (preferably established by statute), have
reasonable funding certainty, be cross-portfolio in scope and
report directly to the Prime Minister and the Parliament. It is
also suggests that the functions of the NHPPA should include:
… building the evidence base for the value of health
promotion and prevention; leadership, development and management of
the proposed ten-year goals; undertaking social marketing and
educational campaigns; and leading cross-sectoral action on health
promotion and prevention.[25]
The agency would also be responsible for the collation and
dissemination of ‘information about the efficacy and cost
effectiveness of health promotion and prevention
interventions’.[26] This is an impressive list of responsibilities. One can
reasonably assume that, in order to do its job properly,
substantial funding will be required. This may pose a challenge to
policy makers in the current financial climate.
Something more substantial than establishing a single agency
might also be required to ensure that prevention is prioritised in
Australia. As the interim report acknowledges, prevention is about
far more than what happens in what is generally thought of as the
health care system (clinics, hospitals, doctors’ surgeries).
In some countries, more fundamental changes—such as
separating out public health functions from the administration of
the rest of the health system—have been needed to prioritise
the prevention agenda.[27] Sweden, for example, has a Ministry for Public Health
and an independent Institute of Public Health—both
underpinned by a national public health policy and legislation
mandating that the public health aspects of all government
decisions be considered.[28] It has been argued that an approach of this nature
(based around a separate government department of public health
with substantial funding, responsibilities and powers) might be
required in Australia to achieve necessary change in the area of
prevention.[29]
The interim report includes several proposals for improving the
capacity of individuals to take greater responsibility for their
own health. The first supports strategies that aim to ‘make
healthy choices easy choices’, including ‘individual
and collective action to improve health by people, families,
communities, health professionals, employers and
governments’.[30] This idea is not developed in the interim report.
Rather, it refers to future work by the NHPT ‘on strategies
to make healthier choices in areas including obesity, tobacco and
alcohol’.[31]
A broader approach to the problem might also consider additional
impediments to healthy choices such as the cost of healthy food,
inadequate public transport and the design of urban
environments.The interim report makes much of the need to improve
health literacy as part of efforts to encourage individual
responsibility in health and presents data showing that three out
of five adults lack basic proficiency in health literacy. It
proposes that health literacy be included as a core element of the
National Curriculum for schools, and that it be incorporated into
national skills assessment. There is obvious merit in seeking to
improve people’s capacity to understand basic health issues.
However, it may be that the National Curriculum does not provide
the best avenue for advancing health literacy, given its current
focus on core subjects like maths, science and English. An
alternative approach might be to pursue something more targeted
along the lines of the Commonwealth’s Financial Literacy in
Schools program.[32]The interim report also notes the importance of good
information as the basis for making decisions about health. As
such, reform direction 1.1 encourages:
… all relevant groups (including health
services, health professionals, non-government organisations,
media, private health insurers and governments) to provide access
to evidence-based, consumer-friendly information that supports
people in making healthy choices and in better understanding and
making decisions about their use of health services.[33]
More direction could be provided to strengthen this proposal.
Arguably, the public does not lack information about lifestyle and
health (given the enormous proliferation of such material on the
Internet) but rather access to a central source of trustworthy and
credible information. Rather than leave this to ‘relevant
groups’, this could possibly be a role for the Department of
Health and Ageing and/or the proposed NHPPA (perhaps along the
lines of the Victorian Government’s Better Health
Channel website).[34]
Overall, while there may be some gains available through
enhanced health literacy and access to information, there are
likely to be limits to any such gains. There is a range of other
factors that affect a person’s ability to take control of
their health care, including the communication styles of health
professionals, the continuing imbalance of knowledge between the
health professional and patient and the sense of powerlessness of
many patients when faced with those in a professional role. This
suggests the importance of understanding the notion of choice in
health in a broader context.
Some public health experts argue that some of the biggest gains
in preventive health are to be made in areas where individuals do
not exercise individual choice (such as water fluoridation,
sanitation and food regulation), or where there are measures in
place to ensure the widest possible compliance (such as
vaccination).[35]
For example, UK public health expert, Nicholas Wald, arguing for a
stronger approach to intervention in nutrition and other areas of
public health, states:
Contrary to current perception, the key to effective public
health is not individual choice but collective action linked to
public trust in its value. Most of the main determinants of health
vary little among people in a community. The scope for individuals
to choose healthy and safe foods, drinks, transport, or buildings
is limited; the similarities in exposure are greater than the
potential differences.[36]
On the issue of nutrition, Wald goes on to say:
The chief merit of the increasingly popular convenience foods is
their convenience. Individuals have little influence over their
composition. Even foods that are described as being healthy can be
high in sugar and salt, counterbalancing any benefit from added
micronutrients, such as folic acid. But discouraging the use of
convenience foods is not practical; we need collective action to
reduce the amounts of salt, sugar, and saturated fat in foods, and
a sensible policy on portion sizes in restaurants.[37]
Public health arguments such as these highlight the difficult
choices governments face when seeking to make significant gains in
the area of prevention (for example, between paternalism and
individual freedom). The interim report says little on these
matters. Overall, this reflects the lack of emphasis it gives to
specific action in the area of primary prevention—that is,
public health measures seeking to control exposure to risk and
promoting protective health factors at the population
level.[38]
Arguably, it is important that this be addressed given the
substantial contribution to health made by public health measures
throughout the 20th century—far in excess of the
contribution made by medical interventions.[39]
Some public health experts argue that focusing on this area
through a revitalised public health strategy represents the most
sustainable way to address the problems of health inequality and
chronic disease.[40] It will be interesting to see if the final report
provides any more detail on how to approach prevention activities
that lie outside health clinics and doctors’ offices.
The Commission is quite clear about the importance of primary
care. It states that ‘primary care must be the foundation of
our future health system’.[41] To that end, the ‘Connecting Care’
section of the interim report puts forward 51 reform directions,
approximately half of the total number of reform directions it
makes. The major recommendations from this section are: for the
Commonwealth to take responsibility for primary care, improvements
to the administration of hospitals to facilitate greater access and
changes to the aged care sector to enhance greater competition and
choice for consumers.
The definition of, and approach to, primary care articulated by
the Commission is broad. It is described as services in the
‘community accessed directly by consumers’ ranging from
general practitioners, pharmacists, allied health, dental care,
mental health services, domiciliary nursing, alcohol and drug
treatment services and school health, amongst others.[42]
As noted by the World Health Organization in its declaration on
primary health care in 1978, primary care is more than just the
first point of contact with the health care system. It encompasses
a preventive, multi-sectoral approach with an emphasis on health
promotion and community participation.[43] In many respects what the Commission
proposes is consistent with the Declaration; the establishment of
Comprehensive Primary Health Care Centres (CPHCC), a lifecycle
approach to primary care and prevention, systemic intervention at
various stages of the lifecycle (primarily birth), specific
measures for chronic and complex illness and those with special
needs, as well as reform to hospitals and the aged care sector to
improve co-ordination of care and linkages across the health care
system.
Nevertheless, the Commission’s approach appears at times
to be fragmented, with separate initiatives to address each of
these challenges. For example, it could be argued that the
establishment of the CPHCC as well as the proposed Divisions of
Primary Health Care may lead to overlap, poor coordination of care,
and increased bureaucracy.[44] However, this apparent fragmentation does not apply to
all of the reform directions. For example, the proposal for
implementing personal electronic health records would be of great
benefit to consumers and health care professionals alike and would
be a comprehensive solution to some of the difficulties encountered
when navigating the health care system.
As noted in the interim report, access to primary care is a
significant challenge facing Australia’s health care system.
This is due in part to historical factors that have shaped the
organisation and funding of health care, but also to a growing
workforce shortage. The National Secretary of the Australian
Nursing Federation, Ged Kearney, goes further and claims:
…at the moment, all funding follows the doctor. So,
really, the only person who has access to the primary health care
system are GPs. Now that inherently has caused, in my opinion, all
the problems with the health care system.[45]
It appears that the Government is prepared to consider changes
to improve access to primary care. On more than one occasion the
Minister for Health has suggested that nurses, pharmacists and
other allied health practitioners take on a more substantial role
in the provision of primary care. Furthermore, Minister Roxon has
openly canvassed the option of granting other health
professionals’ access to the MBS, an idea that has attracted
criticism from the Australian Medical Association (AMA).[46]
As part of its election platform, the Rudd Government pledged to
establish GP Super Clinics, which are similar to the CPHCC proposed
by the Commission.[47] The objectives of the Super Clinics are
‘affordable, high quality, comprehensive primary care’
with a ‘greater focus on health promotion, illness prevention
and improved coordination’. The first of the Super Clinics is
currently being established.
Two dominant themes emerge from the ‘Connecting
care’ section of the interim report— these are that the
Commonwealth has sole responsibility for primary care and improving
the coordination of care. The interim report suggests that a single
point of responsibility and accountability will lead to greater
equity and better funding arrangements.[48] However, the role of state and local
governments under these arrangements is not addressed and there is
no suggestion as to who might provide additional primary care
services. Furthermore, the interim report is silent on the proposed
funding mechanisms and how the current tensions between the
Commonwealth and state health budgets for the provision of primary
care where one is capped (the states) and the other is uncapped
(the Commonwealth) budget and might be resolved.
Poor coordination of care is a problem across the health system,
not just in hospitals or general practice. Therefore, it is not
clear how sole responsibility for primary care by the Commonwealth
will improve coordination of care, which is the very issue it aims
to address. Furthermore, the role of Medicare in this approach has
not been articulated.
While there are many reform directions in the ‘Connecting
Care’ section of the interim report worthy of further
consideration, the focus in this research paper is limited to aged
care and hospitals.
The aged care recommendations are consistent with the broader
reform objective of consolidating responsibility for funding and
policy under the Commonwealth. The interim report also encourages
greater competition in aged care, less regulation and greater
consumer involvement in decisions about how aged care subsidies are
spent. Of note are the reform directions that suggest allowing the
use of accommodation bonds in residential aged care and providing
funding for aged care to care recipients rather than
places.[49] This
would essentially amount to a voucher system which, if implemented,
may allow for greater consumer involvement in aged care and
competition in the sector.
The interim report notes that the demand for aged care is
increasing. It proposes to change the ratio of places per 1000
people aged 70 or over to care recipients per 1000 aged 85 or over
to reflect the changing demographic and ageing profiles of older
Australians. This would increase the number of residential and
community care places available and enable many more older
Australians to access subsidised aged care.[50]
Many of the reform directions are consistent with what has been
advocated previously in the Hogan Review of Pricing Arrangements in
Residential Aged Care[51] and the Productivity Commission’s report on
trends in aged care services.[52] However, unlike those reports that called for
more deregulation and competition, the Commission has not advocated
complete deregulation of the sector but a ‘hybrid
approach’ to regulation, whereby the number of places is no
longer limited to the number of places funded by the Commonwealth.
This would enable aged care providers to offer additional services
based on perceived need. The Commission also advocates better
integration of Commonwealth aged care programs so that older
Australians can remain in the community longer.
The Aged Care Association of Australia has welcomed these
recommendations, particularly the changes to bonds and to aged care
assessments.[53] In
addition to support for changes to the planning ratio, Catholic
Health Australia also supports the introduction of accommodation
bonds.[54]
The Commission notes the strengths of Australia’s public
hospital system, namely the provision of high quality care that is
free of charge at the point of delivery. The main changes it
proposes concern the internal workings of hospitals and their
linkages outside to other sectors such as the aged and community
care sectors. The Commission also noted the gaps in health care
service provision in the ‘sub-acute’ sector,
particularly rehabilitation services. [55] There are three main proposals for
hospital reform: the introduction of activity-based funding, reform
of emergency departments to improve access and integration with
other parts of the health care system (including within the
hospital), and contracting out of elective surgery or establishing
specific centres to perform selective elective surgery
procedures.
Consistent with the Commission’s focus on performance and
reporting, National Access Guarantees for planned procedures and
National Access Targets for emergency care would also be developed.
Achievement of these would be linked to bonus payments as part of
the funding for public hospitals. The Commission also recommends
introducing activity-based funding (commonly known as case-mix) for
all public hospitals.
These changes would be supported by the proposed improvements to
the sub-acute sector. These are considered by the Commission to be
the ‘missing link’ in the health care system and
include services that are provided in the community, usually after
hospitalisation such as rehabilitation, geriatric evaluation, and
‘step-down’ programs. [56] Currently there is significant
variation between states, major gaps in service provision and a
lack of continuity of care in the sub-acute sector.
According to the Commission, hospitals ‘… are where
most babies are born and where many people die … and it is
crucial that we make the best and most efficient use of these vital
and expensive services’.[57] Many of the recommendations suggest changes to
the organisation and performance of hospitals and the use of
clearly defined targets linked to bonus payments. Improved data
collection and the introduction of national activity-based funding
are considered essential. The interim report also recommends a
single funder for in-patient and specialist medical care to
encourage greater efficiency in the sector and limit
cost-shifting.
The interim report notes that waiting lists for elective surgery
were longer in 2006–07 than in the preceding four
years.[58] It also
notes the shift of surgeons from the public to private sector,
placing greater demands on elective surgery waiting lists. The
interim report supports the idea of contracting surgical procedures
from public to private hospitals and developing specific hospitals,
or units within hospitals, for planned elective surgery procedures.
Potentially this would enable hospitals to reduce over-crowding and
improve access to emergency care.
The reform directions put forward have a strong focus on
accountability, public reporting and data collection and linkage.
In many respects this is no different to what has been incorporated
in the National Partnership Agreements but these recommendations go
much further by explicitly linking performance with bonus payments.
Furthermore, the recently signed National Healthcare Agreement
requires a ‘nationally consistent approach’ to activity
based funding within five years. The role of private hospitals and
how they might be better integrated with public hospitals is not
covered in the interim report. There are around 543 private
hospitals in Australia, many of which could be used as part of the
solution to a more efficient and effective hospital sector.
Many of the reform directions put forward by the Commission
require extensive data collection and analysis by state, territory
and Commonwealth Governments. Currently the health care system
lacks the capacity to capture the data required to implement the
interim report’s recommendations and significant resources as
well as expertise would be required to achieve these goals. It will
be some time before this capacity is available. More data will not
necessarily lead to better health outcomes or more efficient health
expenditure. As a result, it might be argued that more attention
might also be given to how existing data can be used more
effectively and to identifying what additional data is required to
achieve the desired health and administrative outcomes.
The Commission notes that ‘no government—whether
state or Commonwealth—is being held accountable for
non-performance’ in sub-acute services.[59] This, according to the
Commission, has lead to uneven access and disparate services across
Australia and to poor outcomes for patients. As for many of its
other recommendations, the Commission proposes an activity-based
funding model, the development of clear targets and improved data
collection with the Commonwealth having responsibility.
Sub-acute care is broadly defined as multidisciplinary with a
strong reliance on specialist allied health staff and medical
specialists such as rehabilitation medicine specialists and
geriatricians.[60]
To implement sub-acute care in the way that has been envisaged by
the Commission, a significant increase in the health workforce and
in funding would be required. Any achievable improvements to the
sub-acute sector may well reduce pressure on other aspects of the
health care system.
There has been little stakeholder comment about aspects of the
interim report addressing the theme of ‘Connecting
care’. Some of the reforms in this section have already been
implemented to varying degrees by the Rudd Government. Perhaps the
most valuable reform direction, and possibly the most difficult to
implement, is a coordinated approach to the provision of primary
health care. Irrespective of the governance model adopted, this
coordination would require greater cooperation among the medical
professions and a cultural shift towards a systemic,
multidisciplinary approach to primary health care.
The ‘Facing inequities’ section of the interim
report addresses the various inequities of health access, status
and outcomes in Australia. It focuses on four main areas:
Indigenous health, rural and remote health, mental and oral health,
and dental care.
The interim report makes the point that addressing inequity in
the health system is not simply about making sure everybody has
access to the same services or funding. Because overall need for
certain groups is unequal, ‘the level of resources needs to
be proportionate to the greater health problems and
disadvantaged’.[61]
Overall, Australians have high and improving levels of health.
Australia matches or leads other comparable countries on most
measures of health status.[62] For example, Australians enjoy one of the highest life
expectancies in the world (81.4 years), second only to
Japan.[63]
However, particular groups in Australia suffer from
significantly poorer health status than Australians in general.
They include socioeconomically disadvantaged Australians,
Indigenous people, people living in rural and remote areas and
prison inmates.[64]
Factors that contribute to unequal health outcomes are the same
as those that contribute to inequality more generally—age,
sex, ethnicity, gender, social and economic status, disability and
geographical location. While some factors, such as age, are
unavoidable, other factors contributing to inequality, such as
socioeconomic differences, access to educational opportunities,
safe working conditions, effective services, living conditions in
childhood, racism and discrimination, are all amenable to
change.[65]
This section of the interim report, while acknowledging the
broad range of social determinants of health, mainly focuses on the
problem of how elements of the health system might be changed in
order to address health inequality. In this respect, a broad
criticism of this section is that it does not adequately address
the contribution of inequality overall (for example, socioeconomic
inequality) to health inequality.
Consequently, the absence of a clear focus on inequality per se
is probably reflected in the selection of reform areas covered by
this section. While mental health and oral health are obviously
important and bear some relationship to inequality, it is
questionable whether they are issues of inequality or something
else, such as issues of primary care. This is not mere semantics
but rather a problem that goes to the core of the approach taken in
addressing an important and complex issue.
Key recommendations in the ‘Facing inequities’
section of the interim report include:
- the establishment of a National Aboriginal and Torres Strait
Islander Health Authority (which would play a similar role in
Indigenous health to that played by the Department of
Veterans’ Affairs in the area of veterans’
health)• funding
mechanisms aimed at ‘bringing care to the person or the
person to the care’ in remote and rural locations (for
example, through networks of primary health care services,
telehealth services and ‘on-call’ 24-hour telephone and
internet consultations and advice)
- a youth-friendly community-based service, which provides
information and screening for mental disorders and sexual health,
to be rolled out nationally for all young Australians, and
- the introduction of a new scheme, Denticare Australia
(Denticare), for universal access to preventive and restorative
dental care, and dentures, regardless of people’s ability to
pay.
For a full list of reform directions under the theme of
‘Facing inequality’, see the appendix to this research
paper. Following is commentary on each of the main areas discussed
in the ‘Facing inequality’ section of the interim
report, which focuses particularly on the most significant proposal
for structural change, the universal dental health scheme,
Denticare Australia.
The interim report’s ‘Closing the health gap for
Aboriginal and Torres Strait Islander peoples’ chapter
provides an overview of statistical discrepancies, central issues
and recent initiatives. Despite several successful recent
initiatives (for example, the PBS Section 100 arrangements to
supply medicines to Indigenous people living in remote areas), the
interim report presents evidence that ‘health care services
for Aboriginal and Torres Strait Islander people are
under-resourced’ and that services are delivered ‘in a
way that is better suited to the needs of the broader population
rather than the particular needs of Aboriginal and Torres Strait
Islander people’.[66]
The interim report makes a number of proposals for reform, the
most significant of which is probably 8.4:
We propose strengthening the purchasing role to lead the
additional investment in Aboriginal and Torres Strait Islander
health. This could be achieved by the establishment of a National
Aboriginal and Torres Strait Islander Health Authority to purchase
services specifically for Aboriginal and Torres Strait Islander
Australians and their families as a mechanism for closing the gap.
This Authority would purchase health services from accredited
providers with a focus on outcomes to ensure high quality and
timely access. [67]
The interim report does not, however, offer a thorough or
uniformly compelling analysis of how this proposed reform would
work and improve on current arrangements. It is argued that while
the ‘Commonwealth Government’s Department of Health and
Ageing would still have overall responsibility for Aboriginal and
Torres Strait Islander health’:
… the Authority would function for the Aboriginal and
Torres Strait Islander people in much the same way as the
Repatriation Commission/Department of Veterans’ Affairs does
for the veteran community. Initially, the Authority could
potentially use the same contractual arrangements and the same
quality assurance mechanisms as does the Department of
Veterans’ Affairs…
Services would be purchased from Aboriginal Community Controlled
Health Services, mainstream primary health care services and
hospitals, and other services. The Authority would ensure that all
purchased services meet set criteria including clinical standards,
cultural appropriateness, appropriately trained workforce, data
collection and performance reporting against identified targets
such as the national Indigenous Health Equality Targets.
Aboriginal and Torres Strait Islander people would need to
register to receive services funded through the Authority.
Registration would be voluntary, and those not registered would
still be covered by existing Medicare arrangements.[68]
There is no explanation of how this Authority will necessarily
offer more efficient or stringent contractual arrangements and
quality assurance than the Office of Aboriginal and Torres Strait
Islander Health, how Indigenous people might be identified for
registration purposes and how the Veterans’ Affairs model
might be applicable.
The Department of Veterans’ Affairs provides health care
and health servicing programs. However, the Veterans’ Home
Care program is effectively the same as the Department of Health
and Aged Care’s Home and Community Care program, and the
justification for their separate administration for veterans has
often been questioned. The interim report also does not explain how
veteran-style health service entitlements would be an example of a
practical, well-targeted solution to the most pressing Indigenous
health service access problems.
The interim report argues that many Australians in remote and
rural areas do not have access to quality health care due to a
number of factors, such as geographical isolation, lack of health
services and a higher burden of disease.[69] It suggests that there is a need to
‘build upon existing financing arrangements to recognise
contemporary needs better, noting that people in remote and very
small rural areas are often unable to access traditional general
practitioner or community health services’.[70]
Proposals for doing this include:
- flexible funding arrangements to facilitate locally designed
and flexible models of care in remote and small rural
communities
- better funding for the patient travel and accommodation
assistance scheme and
- a higher proportion of new health professional educational
undergraduate and postgraduate places across all disciplines be
allocated to remote and rural regional centres.
Rural health groups such as the National Rural Health Alliance
and the Rural Doctors Association of Australia (RDAA) have, on the
whole, welcomed the reform directions proposed by the
Commission.[71]
However, the RDAA has criticised the workforce measures in the
interim report as inadequate to address what they argue is a 17 000
shortfall in health professionals in rural areas, including
doctors, nurses and other health professionals. In the absence of a
particular model of reform (including to one or another of the
models outlined in the governance section of the interim report),
it is difficult to comment further on issues related to the funding
and governance of rural health.
The interim report argues that current mental health services in
Australia are ‘inadequate and incapable of meeting present,
let alone future, needs’.[72] Further, it states that while additional
investment is required, ‘the most important reform needed is
to reorient mental health expenditures towards prevention and the
treatment and supports required for those most
vulnerable’.[73] The interim report sees these reforms as requiring two
main approaches:
- targeting resources and efforts towards the most common mental
health problems (for example, anxiety, depression and substance
abuse disorders) and
- an emphasis on ‘stepped-up care’—that is,
‘investing initially in the least intensive and least
expensive treatment in place of a more expensive but equally
effective treatment that might become necessary if the first one
fails’.[74]
These approaches are obviously consistent with the
Government’s overall focus on prevention. Probably the two
most significant ‘key directions’ proposed by the
Commission are:
- that a youth friendly community-based service, which provides
information and screening for mental disorders and sexual health,
be rolled out nationally for all young Australians and
- that the Early Psychosis Prevention and Intervention Centre
(EPPIC) model be implemented nationally so that early intervention
in psychosis becomes the norm.
In general, these proposals have been supported by mental health
sector commentators on the grounds that they expand on existing
approaches that have proven successful.[75]
An important gap in the interim report is the lack of attention
given to the role of primary care in addressing mental
health.[76]
Further, questions about which level of government and which
funding and governance structures should be ultimately responsible
for mental health remain are largely unanswered by the interim
report. Given that one of the most frequent criticisms of
Australia’s mental health system relates to lack of clarity
about responsibilities and the disjointed nature of care, this is
an important issue. This may receive greater attention as the
preferred governance model for the health system overall becomes
clearer further down the track.
The interim report rates the status of dental health in
Australia as ‘varied’.[77] Australia’s ranking for adult
tooth decay among OECD countries is in the lowest third and there
is declining oral health among children.[78] Financial cost is a significant
barrier to timely dental care, particularly for the most
disadvantaged Australians. Around 20 per cent of the population
neither has private health insurance nor uses private dental
services, but instead relies on publicly funded means-tested dental
services where waiting lists are long—up to 650 000 people
are reportedly waiting for public dental care.[79]
Until recently Commonwealth funding for dental care was very
limited.[80]
However, in recent years successive governments have expanded
Commonwealth funding for dental services. The Howard Government
introduced Medicare rebates for dental services for patients with
chronic conditions where their health was being adversely affected
by their dental problems. The Rudd Government has introduced the
Teen Dental Plan and promised to introduce a Commonwealth Dental
Health Program to assist the states and territories improve their
public dental services, once the former Howard Government program
is cancelled.[81]
The interim report makes six recommendations to improve access
to dental health services. The most significant is the
establishment and funding of a universal’ dental health
insurance scheme, to be known as Denticare. The remaining
recommendations concern the introduction of a one-year internship
for newly graduated dentists to address workforce shortages, the
expansion of existing school dental services and additional funding
for improved oral health promotion.
Denticare would fund access to preventive and restorative dental
care and dentures by a 0.75 per cent increase in the Medicare
levy.[82] People
could choose either to join a private dental plan offered by health
insurers or opt to use expanded free public dental services. Those
choosing a private dental plan would have their risk-adjusted
premiums paid by the Commonwealth.[83] The increase in the Medicare
levy—estimated to raise around $4 billion per annum[84]—would be
combined with other existing government dental expenditure,
including the private health insurance rebate, to create a funding
pool that would finance the scheme. The dental component of the
initial cost of Denticare is estimated to be up to $5.2 billion per
annum, with direct government outlays representing an additional
$3.9 billion in spending over and above existing Commonwealth
Government expenditure on dental health.[85]
Those opting for the private dental plan would have 85 per cent
of their dental costs reimbursed, with the option of purchasing
additional health insurance for elective services, such as crowns
and bridges. Funding for public dental services would be increased
so that those without private health insurance would still have
access to a free public dental service, albeit with waiting lists.
The interim report estimates that under Denticare many would pay
less for dental care, with those on low incomes set to benefit
most. The supplementary consultant’s report estimates that,
for the average taxpayer, individual out-of-pocket costs for dental
services would decrease from $8.42 per week to $3.98 per
week.[86]
Thus far, responses to the Denticare proposal have been mixed.
The Government has reserved its position, calling for public
debate, although the Minister for Health has described Denticare as
a ‘fairly radical proposal’.[87] The Opposition’s Shadow
Minister for Health and Ageing, the Hon. Peter Dutton, has warned
that ‘taxpayers would pay billions of dollars in extra
taxes’, without directly condemning the proposal.[88] The Greens have
welcomed the Denticare proposal and called on the Government to
implement it ‘as soon as possible’.[89]
Stakeholder groups have also expressed a diverse range of views
on the proposal. Significantly, the peak dental body, the
Australian Dental Association (ADA), is strongly opposed to
Denticare. It describes the proposal as ‘fiscally
irresponsible’ and ‘unlikely to deliver quality dental
care’, warning that the funding of such a scheme could be
crippling and exceed $11 billion.[90] On the other hand, Professor Hans Zoellner from
the Association for the Promotion of Oral Health argues ‘the
Denticare proposal isn’t as strong as it could be’ and
that a better solution is to ‘simply put dentistry in
Medicare’, otherwise the scheme risks creating a ‘two
tiered system’.[91]
Private health insurers are not agreed on the proposal. The
Australian Health Insurance Association (AHIA) is still in the
process of compiling a more considered response.[92] Health insurer nib’s Chief
Executive, Mark Fitzgibbon, has reportedly described Denticare as
‘inefficient and lack[ing] competition’, arguing
‘the Government should increase the private health care
rebate for those who need it most’.[93]
Other commentators have questioned the cost assumptions
underpinning the proposal, warning these may be higher than those
forecast.[94] Other
concerns include: the limited capacity of the dental workforce to
absorb the increase in demand for services, the bureaucratic
complexity of the scheme, the possibility that it may entrench
views that public dentistry is only for the poor, potential delays
to the introduction of the Commonwealth Dental Health Program, and
the entrenchment of inequity.[95]
The potential cost of the Denticare proposal remains an issue of
concern. Whether an increase of 0.75 per cent to the levy would be
sufficient to wholly fund the additional cost of Denticare remains
to be seen.[96] If
the uncapped costs of Denticare were to exceed estimates, as is
forecast by some commentators, these costs would need to be met
through general revenue (possibly at the expense of other health
funding), increased taxation or further increases to the Medicare
levy. Further, any proposal to increase the Medicare levy almost
inevitably leads to calls for further increases to fund other
health services.[97]
While taxpayers might support higher taxes for the provision of
better health services, it is unclear if they would support a
proposal such as this at a time of economic downturn, or if the
benefits were to be unequally accessed. While the main
beneficiaries would be those on lower incomes, it is not clear if
other income groups would realise an immediate lowering of their
costs for dental care.[98]
The current dental workforce, particularly in the public sector,
would be insufficient to meet the expected increase in demand for
dental services if Denticare were to be introduced. It is therefore
likely that a phased introduction of Denticare would need to be
considered, possibly resulting in some taxpayers having to wait to
become eligible for the scheme.[99]
It is unclear how private health insurers would be affected by
the proposal to part-fund the scheme through the reallocation of
the private health insurance rebate. It is likely that there would
be concerns that it may erode the dental component of private
health insurance membership.[100] The interim report proposes that the proportion
of the rebate which currently subsidises dental care be reallocated
to help pay for Denticare. But how this could be achieved without
undermining incentives to purchase private health insurance is not
addressed. Broader questions about how increasing the Medicare levy
‘wipes out the next round of tax cuts’ and threatens to
counteract other Government consumer spending initiatives, are
likely to be of concern.[101]
Overall, the interim report makes a strong case for greater
equity in access to dental care and increased Commonwealth
involvement in funding dental care based on the considerable
support for greater funding and commitment to addressing oral
health inequities. The proposed Denticare scheme is a complex
proposal that has generated divided opinions. In their final
report, the Commission may yet provide more detail and address some
of the concerns raised.
The ‘Driving quality performance’ section of the
interim report considers the better use of people, resources and
evolving knowledge in the health system. Specifically, it examines
issues relating to governance, priority setting, the health
workforce and integrating research and innovation into the health
system.
The following discussion focuses on proposed reforms to the
funding and governance of the health system because of their
significance to the overall reform agenda. Consideration is also
given to the proposals regarding health workforce.
The interim report makes it clear that it supports the current
mix of public and private financing in Australia, but it
acknowledges that high out-of-pocket costs (co-payments) in some
areas are a significant problem for many Australians. Rather than
proposing changes to existing safety net arrangements such as the
Medicare and PBS Safety Nets, the interim report concentrates on
new proposals for allocating funding that aim to contain the costs
of health care in the Australian health system. It makes three
recommendations:
- Greater use of activity-based funding for hospitals where
payments are made based on the number of services provided.
Activity-based funding is thought to have benefits because it is
transparent and fair, encourages development of more cost effective
treatment pathways and encourages expansion into areas of high
need. The risks are that some providers, however, may skimp on
quality or shift costs onto other providers in order to reduce
their own costs.
- Introducing ‘pay for performance’ (P4P) measures
for all health services that achieve specified targets or goals.
P4P has only recently been introduced in Australia in Queensland
public hospitals and no data on its effectiveness are available
yet. Internationally, there have been very few rigorous evaluations
of P4P measures and results are mixed. There are some concerns that
the costs of implementing P4P may outweigh the benefits if
small-scale programs are rolled out, and ‘gaming’ by
health professionals to select the healthiest patients is also a
potential risk.[102]
- Increased use of ‘course of care’ funding for
primary care, which is a type of capitation funding. Under this
system, payments are made according to the number of consumers (or
patients) cared for over a period of time. They are used in Health
Maintenance Organizations in the United States, Primary Health
Organisations in New Zealand, and Primary Care Trusts in the United
Kingdom. Course of care funding shares some of the same benefits
and risks as activity-based funding but also encourages delivery of
more integrated care—as providers are paid to deliver all
necessary care to a patient (for example, all maternity
care)—and allows consumers a greater choice of
providers.
The Commission also tackles the controversial issue of health
system governance, or who should run the health system. The interim
report identifies a wide range of areas that would benefit from
national leadership (including safety and quality of health care,
clinical education and training, Indigenous health and regulation
of private hospitals) and several alternative governance
models.
Stakeholder views on health system governance vary widely and,
given this lack of consensus and the complexity of the issue, the
Commission chose to outline three alternative governance options
(Options A, B and C) in an effort to stimulate debate. Some
governance proposals put to the Commission, however, were not
considered (for example, the case for a single national insurer)
and the interim report does not comment on how it made its
selection. Nor does it discuss how any of the options proposed
would mesh with the Government’s previous
‘threat’ to take over hospitals. In the lead-up to the
2007 election, Labor stated that, if elected, it would take over
public hospitals if the states and territories were unable to meet
performance benchmarks by mid 2009, and if there was a public
mandate to do so.[103] The Commission has made no attempt in the interim
report to address any of the possible constitutional implications,
particularly concerning options B and C.
Many stakeholders have expressed disappointment that the
Commission—in accordance with its terms of
reference—has not addressed perceived problems with the
relationship between the public and private sectors. Many are
concerned in particular about preserving the rebate on private
health insurance premiums. Ian McAuley, from the University of
Canberra, claimed the interim report entrenches vested financial
interests in the health insurance industry.[104] The President of the Doctors Reform
Society, Dr Tim Woodruff, questioned the Commission’s
commitment to equity and efficiency because it ignored the
implications of the private health insurance rebate.[105] The chief executive
of the nib health fund, Mark Fitzgibbon, was just as concerned, but
for different reasons. He argued that the current mix of public and
private funding was unsustainable so the balance would have to tip
back towards the private sector in order to meet the growing costs
of health care.[106]
The three options put forward by the Commission are considered
briefly below.
Under this model, the responsibilities of the Commonwealth and
state and territory Governments would be re-aligned. The
Commonwealth would assume all funding, policy and regulatory
responsibility for primary health care and community health
services. It would also pay the states and territories an
activity-based payment for providing hospital care. The health
system would be governed by a National Health Strategy and
underpinned by eight bilateral agreements between the Commonwealth
and each state and territory, much like current arrangements.
While this model preserves many of the elements of the current
system, there are some important changes in hospital funding. The
Commonwealth hospital benefit would be predetermined (for example,
at 40 per cent of the efficient cost of inpatient or emergency
department treatment) and paid per episode of care. The
Commonwealth’s total expenditure, however, would be uncapped.
The states and territories would be responsible for funding the
remainder of the hospital benefit and would ultimately determine
the limits of expenditure.
One of the claimed benefits of this model is that it involves
less disruption to existing roles and responsibilities in health
than the other models proposed, and means that state and territory
governments continue to be accountable for their own health
services. The model may also facilitate the integration of services
because the Commonwealth would be responsible for all non-admitted
care and have shared responsibility for inpatient hospital care.
Continuing to involve two levels of government, however, may not
resolve longstanding challenges and tensions when coordinating
policies and programs, also known as the ‘blame
game’.
Under this model, the Commonwealth Government would assume all
funding, policy and regulatory responsibility for health, and
establish regional health authorities to deliver health services.
National programs such as the MBS and PBS would run in parallel,
and private health insurance arrangements would not necessarily
need to be altered.
The Commonwealth would determine annual budgets for regional
health authorities using activity-based funding methods. Budgets
would be allocated for three-year periods so that regional health
authorities could plan, commission and operate integrated health
services within their region. This may involve linkages with the
private and not-for-profit sectors.
The claimed benefits of this model are that it would
substantially resolve the ‘blame-game’ between
different levels of government and allow for more integrated and
locally relevant care at the regional level. The main risks are
that it would create tensions between the Commonwealth Government
and regional health authorities, and require a major shift of funds
and management expertise from the state and territory level. Making
the Commonwealth solely responsible for health may reduce electoral
accountability (as only one minister would be responsible for
health) and regional health authorities, which would have
considerable power at the local level, may be vulnerable to
‘capture’ or undue influence from major health services
providers.
This option would involve transferring all responsibility for
health to the Commonwealth government and establishing a
tax-funded, compulsory community insurance scheme with a range of
multiple, competing health plans or funds. Most plans would be
privately owned and operated, but it would also be possible to have
a government-owned and operated plan.
In this model, the Commonwealth Government allocates funding to
health plans according to the risk-adjusted profile of their
membership, and health plans would be required to provide the full
range of health services determined by the Commonwealth. Health
services would charge people directly and health plans would
reimburse them for the cost of care. Co-payment levels could be set
at the national level.
The principal claimed benefit of this model is that consumers
would be able to choose the health plan that best met their needs.
Health plans would then have incentives to be responsive to the
needs of members. They would also have incentives to encourage
health promotion and disease prevention, and ensure delivery of
integrated, high quality and cost-effective care as this would
potentially lower their costs. This model would, however, require
large-scale changes to the health system and consumers may find it
difficult to assess the merits of various health plans. Economies
of scale achieved by having a compulsory tax-funded insurer
(Medicare) would also potentially be lost and containing health
costs may become an ongoing challenge as has been the case in other
countries with similar systems (for example, Germany and
France).[107]
There is widespread consensus about the need for reforms to the
Australian health system but many divergent views on the scope and
direction of reform. The interim report proposes a number of
changes to the way health care is funded and governed in Australia
and invites public debate on the issues. It is not clear what the
Commission will recommend in its final report or, most importantly,
how the Government will respond.
When considering governance options, the Government may respond,
for instance, by prioritising what is politically possible. It may
choose a new governance model according to how well it aligns with
the underlying principles of Australia’s health system.
Alternatively, it may choose a governance model that is most likely
to solve persistent problems in the health system. This, of course,
raises questions about which problems should be considered as
priorities.
Of the three governance models, Option A is the least radical
and could be achieved by implementing small-scale incremental
reforms to the current health system. The AMA, one of the most
powerful stakeholders in the health system, has stopped short of
advocating any model in particular, but its support for Option A
can be assumed from its media statements. In a media release, the
AMA stated that it saw ‘no value to the community … in
pursuing some of the tired policies of budget-holding and
restrictions on patient choice and rationing that have failed
patients in the United Kingdom’.[108] Budget-holding is a feature of both
Options B and C.
The Government will find it easier to pursue its reform agenda
with the AMA onside but this does not necessarily mean it will
choose Option A. Many other stakeholders and commentators are
urging the Government to seize the rare opportunity for reform and
implement one of the ‘big bang’ reform proposals,
Option B or C. Andrew Podger, former Secretary of the Commonwealth
Department of Health and Ageing, argues that if the Government is
prepared to do what is required to implement Option A, it might as
well go the rest of the way and do what is needed to implement more
radical reforms.[109] Professor Ian Hickie, Director of the Brain and Mind
Medical Research Institute at the University of Sydney, argues that
Option C–the social insurance model—is the only model
that will allow ‘serious attention [to] be devoted to the
neglected areas of mental health care, treatments for alcohol and
substance abuse or effective long-term health care plans for other
neglected conditions’.[110] Various other stakeholders, such as the
Australian General Practice Network and the Australian Health Care
Reform Alliance, also favour making substantial reforms to the
existing health system.[111]
The Government may choose to take what appears to be a less
politically sensitive approach to reform and push for a governance
model that aligns with the 15 principles for Australia’s
health system previously outlined by the Commission.[112] The interim report
does not provide sufficient detail on the three governance
proposals to allow an assessment of how well each of them is likely
to align with these principles and thus it is difficult to predict
how each model will operate in the Australian context. Any attempt
to predict the proposed model’s operation is likely to
deliver highly contestable outcomes, forcing the Government to take
a strong stand in order to pursue its reform agenda.
Alternatively, the Government may take a problem-solving
approach to choosing a new governance model where it evaluates each
model according to how well it solves persistent problems in the
health system. It has already identified a range of
problems—public hospital waiting lists, Indigenous health and
a lack of emphasis on prevention. The problem-solving approach,
however, is also likely to be complex from the perspective of
Government. It will mean the Government will have to prioritise
some problems in the health system over others, a move that is
bound to invite criticism from advocates and interest groups whose
causes and issues might be given less priority.
In the past, most major health system reforms in Australia have
been pragmatic responses to emerging policy problems in health and
the broader social, economic and political environment. Medicare,
for instance, was implemented in Australia by the Hawke Government
in 1984 because it helped solve the growing problem of un-insurance
in Australia and secure the Accord with the Australian Council of
Trade Unions. The Government was willing to bear the substantial
increase in Government expenditure that came with implementing
Medicare because union co-operation was so vital to its economic
recovery plan.[113]
It is impossible at this stage to predict which governance model
will be put forward by the Commission or how the Rudd Government
might respond. If history is any guide, the Rudd Government, like
its predecessors, is likely to respond in a way that balances its
health, social, economic and political goals. While this is bound
to disappoint many, significant reform of Australia’s health
system is necessary and, in the process of reform, a certain amount
of controversy and resistance is inevitable.
Shortages in the health workforce first began to surface as an
issue in the mid 1990s when it was realised that there was no
longer an adequate supply of medical practitioners, at least in
rural and remote areas of Australia. Since the 1990s it has become
increasingly clear that the case of medical practitioners is not
isolated; there are shortages across the health
professions.[114]
These shortages will be compounded as changes in the composition of
the health workforce, noted by the Productivity Commission in 2005,
manifest themselves. These changes are likely to include reduction
in the hours health professionals work, the ageing of the workforce
and the feminisation of some previously male-dominated
professions.[115]
The fact that shortages are not confined to Australia has provided
an added dimension to this problem, given Australia’s
reliance on overseas trained professionals, particularly medical
practitioners.[116]
The interim report restates these issues as well as raising
other issues, such as the difficulties in delivering health
services to rural and remote communities, as a prelude to
identifying the Commission’s ‘case for
change’.
The interim report points out that many see health workforce
issues as being the major problem facing Australia’s health
system. Changes to the health system which involve one stop shops
for primary health services or better care in hospitals will not be
realised if the right health workforce is not available to deliver
them.
Professor Peter Brooks, Executive Dean of Faculty of Health
Sciences at the University of Queensland and Dr Stephen Duckett,
former Chief Executive Officer of the Centre for Healthcare at
Queensland Health,[117] along with others, have consistently argued that
workforce planning needs to take different directions and focus on
different models than in the past, and that health system reform is
dependent on these fundamental moves.[118]
The interim report does state clearly that because our health
workforce resource pool is shrinking, we must think of new ways to
make better use of people, resources and evolving knowledge in the
future. The central aspects in this challenge are related to
delivering an adequate and appropriate workforce. While it begins
to consider ways in which the challenge can be addressed it does
not go far in exploring options, nor does it present innovative
reforms where health workforce related issues are concerned. It may
be that more in depth options and exploration of those options will
be presented in the Commission’s final
report.
The interim report has gone some way towards acknowledging that
simply increasing student numbers in the health professions does
not constitute a comprehensive solution to health workforce
shortages. There needs to be a structured and comprehensive
approach to health workforce training that again is hinted at in
broad terms in the interim report in words like
‘flexible’ and ‘multi-disciplinary’. But it
needs to be stated emphatically that this should reflect an
overarching strategy that encompasses a cohesive health workforce,
not a number of disconnected workforces. What currently exists,
however, often reflects vested interests and traditional
assessments of skill sets required for individual
professions.[119]
Nor does current training accommodate, as noted above, factors such
as the different attitudes future practitioners may have or changes
in the composition of certain sectors of the workforce and the
consequences those changes will have for workforce outcomes.
The interim report recognises that the current system of
‘siloed’ education is problematic. But how this can be
addressed is not explored. This is important, for the lack of
mutual respect and recognition among the various health workforces
is often a major reason for professional dissatisfaction and people
leaving some professions.[120] It is encouraging also that the issue of
clinical training is raised, but discouraging that it is mainly
considered in the context of medical practitioners and little
consideration given to other medical professions.
The interim report’s positive approach to the issue of
workforce diversification, what some detractors have called
‘task substitution’ and what the interim report labels
again as flexibility, is one of its strengths.[121] The options noted, while
brief, emphasise the interim report’s conclusion: there are
‘enormous possibilities’ to be explored, perhaps one of
the most pressing tasks to be allocated to the proposed National
Clinical Education and Training
Agency.
Listing possible tasks for a National Clinical Education and
Training Agency, which include advising on the adequacy of health
workforce education and seeking innovative ways of delivering
initial and ongoing skill sets, has the potential to deliver a
radically evolved health workforce training model—sustainable
and reflective of future needs. At the same time, appending the
idea of innovation to the establishment of yet another health
advisory/regulatory body could mean that innovation is stifled. It
could be simply lost in the innate conservatism of bureaucracy or
swamped by the usual outbreak of ‘turf’ wars which
occur when health professions perceive their traditional roles
and/or power are threatened.[122] It will be a challenge in itself to develop a
model for an agency that will not succumb to these pitfalls and
even more of a challenge to ensure that it actually delivers the
types of reforms suggested in the interim
report.
The recent realisation that workforce shortages are not confined
to ‘the bush’ has not deterred the Commission from
paying considerable attention to rural and remote as well as
Aboriginal and Torres Strait Islander health. The interim report
recognises that overall measures to improve the health of
Australians in the bush must emphasise rural models which can
include greater emphasis on health promotion, early intervention
and disease self-management. There has already been considerable
innovation in workforce measures that encourage professionals to
engage in rural practice,[123] but there is extensive potential to expand on
measures such as remote area nurses, more specialist outreach
services and expert health advice by telephone lines.
Submissions to the Commission emphasised that services in remote
areas need to be based on uniquely rural models. Such models
reflect the fact that medical practitioner services are often not
available in rural communities. Encouraging more doctors to choose
to practice in these areas through measures such as rural training
is one solution, as the interim report acknowledges. But rural
measures also need to involve the use of alternative practitioners
to deliver services traditionally associated with the medical
profession.[124]
This, in turn, demands changes to funding models based on medical
practitioners as service gatekeepers. The interim report’s
proposals support this innovation, with recommendations that,
subject to regulation by appropriate medical bodies, scopes of
practice could be extended.
Health outcomes for rural and remote areas could also be
improved through greater use of information technologies. As the
interim report notes, technology is an effective ‘means to
overcoming limited access to health care, the mal-distribution of
health professionals and provision of expert advice in remote and
rural areas’.[125] The interim report, however, did not identify more
generally in this case for change the potential technology has to
support the expertise of all health workers and to contribute to
the desired sustainable workforce.
It would be difficult to challenge conclusions about the health
workforce made in the interim report. We do need to look at how we
deal with pressures on the health workforce in terms of numbers,
work practices and distribution, to build on what we have and there
are problems within the existing system that inhibit
change.
Many of the workforce recommendations in the interim report have
been initially well received and are likely to continue to receive
general support. The idea of a new education framework which
stresses competency based standards, flexibility, multidisciplinary
approaches and clinical infrastructure that stretches across public
and private settings is hard to criticise. Aspects of this idea are
not new and have been advanced elsewhere. For example, it is argued
by a number of the health academics that medical practitioner
shortages require a multi-dimensional strategy that needs to
include the introduction of new health professionals to supplement
the work of doctors in dealing with changing population health
needs.[126] Some
programs are already in place to accommodate a more expansive
training regime for medical specialists, for example.[127] Similarly,
competency based standards are essential assessment components of
nursing practice.[128] What is new and possibly contentious is the idea that
the education system should, as the interim report puts it,
‘bridge the current siloed model of training’.
It is equally hard to criticise a proposal to involve health
professionals in guiding the direction of health reform and
promoting innovation. And, certainly, the idea of a national
strategy to recruit and train Aboriginal and Torres Strait Islander
health workers is long overdue. Getting all parties to agree on the
extent to which some groups of health professionals should be
involved in directing the health system is another matter; as is
the issue of what ‘flexibility’ or
‘multidisciplinary’ might mean in various contexts.
The fundamental question on which there is most likely to be
disagreement, however, is how the different health professions can
work together to deliver a sustainable workforce. Indications are
that initiating even the minimal changes to traditional roles that
the interim report proposes will be resisted in some quarters and
decried as inadequate in others. The AMA has consistently opposed
other practitioners taking over what it sees as the exclusive role
of doctors. The AMA has been opposed to extending Medicare access
to other health professionals[129] and its comments on the interim report indicate
that it has not changed its position.[130] Similarly, the Royal Australian
College of General Practitioners criticises the interim report
because it argues that it does not recognise the central role
played by general practitioners in the health system.[131] The Australian
Nursing Federation, on the other hand, considers the interim report
is not bold enough in its proposals for workforce and funding
reform.[132]
These long-standing, polarised views are likely to pose ongoing
challenges to health workforce reform.
It may be that the greatest strength of the interim report is
also its greatest weakness. In putting forward a bold, extensive
document, in most areas it inevitably suffers from a lack of
detail. The Commission should be commended for putting forward such
a range of proposals; and it does explain that the interim report
was designed to stimulate debate. What is perhaps lacking from the
interim report is a single, focused and overarching blueprint for
reform. Rather than a clear blueprint (or interim blueprint) for
the future of the health system, the interim report tends to
reflect the complex and sprawling nature of the system as it
currently exists.
In reviewing the individual reform directions put forward by the
Commission, it is clear that, if adopted to a significant degree,
additional funding and dramatic increases in the health workforce
will be required. The underlying theme of all the reform directions
is greater Commonwealth responsibility and improved accountability,
yet aspects of this may be contested by state, territory and local
governments. The extent of Commonwealth responsibility for health
will, however, ultimately depend on which governance model, if any,
the Government adopts. The preferred option of the Commission will
not be known until the final report is released.
Although the interim report notes that each of the reform
directions can be implemented under any of the proposed governance
models, it is not always clear how this could occur; for example,
how the proposed arrangements for hospitals would work under Option
C. This may be due, in part, to the lack of sufficient detail in
the interim report to make an assessment about the governance
models.
The lack of detail in some areas of the interim report raises
several other unanswered questions, some of which may be addressed
in the final report:
- what contribution could each of the governance models outlined
in the ‘Driving quality performance’ section make to
clarifying responsibilities and coordinating services in primary
care, dental health and Denticare, hospitals, mental health, and
Aboriginal and Torres Islander health?
- would the new focus on prevention give sufficient attention to
primary prevention and public health—that is, the potentially
more challenging instruments of prevention that reside outside of
the health care system?
- what would be the role of state and local governments in the
provision of primary health care if the Commonwealth has full
responsibility for primary care?
- given the Commission’s focus on a strong public and
private system, what role does the Commission envisage for private
health funds in the provision of primary care?
- are the workforce reform proposals in the interim report
capable of delivering the right numbers of professionals across the
workforce but also deliver appropriate numbers of professionals in
each of the professions and disciplines within those
professions?
Again, these questions may be answered when the final report is
released. What is clear, however, is that the interim
report’s release has generated a debate in health policy in
Australia that is both more extensive and fundamental than has been
seen for some time.
This is an extract from the interim
report (pp. 29–42).
1. Building good
health and wellbeing into our communities and our
lives
1.1 We affirm the value of
universal entitlement to medical, pharmaceutical and public
hospital services under Medicare which, together with choice and
access through private health insurance, provides a robust
framework for the Australian health care system. To promote greater
equity, universal entitlement needs to be overlaid with targeting
of health services to ensure that disadvantaged groups have the
best opportunity for improved health outcomes.
1.2 We propose that public
reporting on health status, health service use, and health outcomes
by governments, private health insurers and individual health
service providers identifies the impact on population groups who
are likely to be disadvantaged in our communities.
1.3 We propose the preparation
of a regular report that tracks our progress as a nation in
tackling health inequity.
1.4 We support the development
of accessible information on the health of local communities. This
information should take a broad view of the factors contributing to
healthy communities, including the ‘wellness footprint’
of communities and issues such as urban planning, public transport,
community connectedness, and a sustainable environment.
1.5 We support the delivery of
wellness and health promotion programs by employers and private
health insurers. Any existing regulatory barriers to increasing the
uptake of such programs should be reviewed.
1.6 We propose that governments
commit to establishing a rolling series of ten-year goals for
health promotion and prevention, to be known as Healthy Australia
Goals, commencing with Healthy Australia 2020 Goals. The goals
should be developed to ensure broad community ownership and
commitment, with regular reporting by governments on progress
towards achieving better health outcomes under the ten-year
goals.
1.7 We propose the
establishment of an independent national health promotion and
prevention agency. This agency would be responsible for national
leadership on the ten-year health goals, as well as building the
evidence base, capacity and infrastructure that is required so that
prevention becomes the platform of healthy communities and is
integrated into all aspects of our health care system.
1.8 We propose that the
national health promotion and prevention agency would also collate
and disseminate information about the efficacy and cost
effectiveness of health promotion and prevention interventions.
1.9 We support strategies that
help people take greater personal responsibility for improving
their health through policies that ‘make healthy choices easy
choices’. This includes individual and collective action to
improve health by people, families, communities, health
professionals, employers and governments.
1.10 We
propose that health literacy is included as a core element of the
National Curriculum and that is it is incorporated in national
skills assessment. This should apply across primary and secondary
school.
1.11 We
encourage all relevant groups (including health services, health
professionals, non-government organisations, media, private health
insurers and governments) to provide access to evidence-based,
consumer-friendly information that supports people in making
healthy choices and in better understanding and making decisions
about their use of health services.
2. Creating strong
primary health care services for everyone
2.1 We propose that, to better
integrate and strengthen primary health care, the Commonwealth
should assume responsibility for all primary health care policy and
funding.
2.2 We propose that, in its
expanded role, the Commonwealth should encourage and actively
foster the widespread establishment of Comprehensive Primary Health
Care Centres.
2.3 We want young families and
people with chronic and complex conditions (including people with a
disability or a long-term mental illness) to have the option of
enrolling with a single primary health care service to improve
care. To support this, we propose that:
• There will be grant funding
to support multidisciplinary clinical services and care
coordination for that service tied to levels of enrolment of young
families and people with chronic and complex conditions.
• There will be payments to
reward good performance in outcomes including quality and
timeliness of care for the enrolled population.
• Over the longer term,
payments will be developed that bundle the total cost of care of
enrolled individuals over a course of care or period of time, in
preference to existing fee-based payments.
2.4 We support embedding a
strong focus on quality and health outcomes across all primary
health care services. This requires the development of sound
patient outcomes data for primary health care. We also want to see
the development of performance payments for prevention and quality
care.
2.5 We support improving the
way in which primary health care professionals and specialists
manage the care of people with chronic and complex conditions
through shared care arrangements in a community setting. These
arrangements should promote the vital role of primary health care
professionals in the ongoing management and support of people with
chronic and complex conditions.
2.6 We believe that service
coordination and population health planning priorities could be
enhanced at the local level through the establishment of Divisions
of Primary Health Care, evolving from or replacing the existing
Divisions of General Practice. These divisions will need to be of
an appropriate size to provide efficient and effective
coordination.
2.7 We propose facilitating
access to care where doctors are scarce. Commencing in remote and
some rural areas:
• Medicare rebates should
apply to relevant diagnostic services and specialist
medical services ordered or referred by nurse
practitioners and other registered health professionals according
to defined scopes of practice determined by health professional
registration bodies.
• Pharmaceutical Benefits
Scheme subsidies (or, where more appropriate, support for access to
subsidised pharmaceuticals under section 100 of the National
Health Act 1953) should apply to pharmaceuticals prescribed
from approved formularies by nurse practitioners and other
registered health professionals according to defined scopes of
practice.
• Where there is appropriate
evidence, specified procedural items on the Medicare Benefits
Schedule should be able to be billed by a medical practitioner for
work performed by a competent health professional, credentialed for
defined scopes of practice.
2.8 In accordance with our
later proposal for the establishment of a National Aboriginal and
Torres Strait Islander Health Authority, we would expect that this
Authority should be responsible for the purchasing of services that
encourage and promote best practice and quality outcomes in primary
health care for Aboriginal and Torres Strait Islander peoples
wherever they elect to seek their health care.
2.9 We support the development
of a person-controlled electronic personal health record. We
will explore the prerequisites and incentives to allow us to reach
this goal in our final report.
3. Nurturing a
healthy start to life
3.1 We propose an integrated
strategy for the health system to nurture a healthy start to life
for Australian children. The strategy has a focus on health
promotion and prevention, better access to primary health care, and
better access to and coordination of health and other services for
children with chronic or severe health or developmental
concerns.
3.2 We propose a strategy for a
healthy start based on three building blocks:
• most importantly, a
partnership with parents, supporting families – and extended
families – in enhancing children’s health and
wellbeing;
• a life course approach to
understanding health needs at different stages of life, beginning
with pre-conception, and covering the antenatal and early childhood
period up to eight years of age. While the research shows that the
first three years of life are particularly important for early
development, we also note the importance of the period of the
transition to primary school; and
• a child- and family-centred
approach to shape the provision of health services around the
health needs of children and their families. Under a
‘progressive universalism’ approach, there would be
three levels of care: universal, targeted and intensive care.
3.3 We propose beginning the
strategy for nurturing a healthy start to life before conception.
Universal services would focus on effective health promotion to
encourage good nutrition and healthy lifestyles, and on sexual and
reproductive health services for young people. Targeted services
would include ways to help teenage girls at risk of pregnancy.
3.4 In the antenatal period, in
addition to good universal primary health care, we propose targeted
care for women with special needs or at risk, such as home visits
for very young, first-time mothers.
3.5 We propose that universal
child and family health services provide a schedule of core
contacts to allow for engagement with parents, advice and support,
and periodic health monitoring (with contacts weighted towards the
first three years of life). The initial contact would be
universally offered as a home visit within the first two weeks
following the birth. The schedule would include the core services
of monitoring of child health, development and wellbeing; early
identification of family risk and need; responding to identified
needs; health promotion and disease prevention (for example,
support for breastfeeding); and support for parenting.
3.6 We propose that, as part of
its set of core services, where the universal child and family
health services identify a health or developmental issue or support
need, the service will provide or identify a pathway for targeted
care, such as an enhanced schedule of contacts and referral to
allied health and specialist services.
3.7 We propose that, where a
child requires more intensive care for a disability or
developmental concerns, a care coordinator, associated with a
primary health care service, would be available to coordinate the
range of services these families often need.
3.8 We propose that all primary
schools have access to a school nurse for promoting and monitoring
children’s health, development and wellbeing, particularly
through the important transition to primary school.
3.9 We propose that
responsibility for nurturing a healthy start to life be embedded in
primary health care to ensure continuity of care and a
comprehensive understanding of a child’s health needs.
Families would have the opportunity to be enrolled with a primary
health care service as this would enable well integrated and
coordinated care and a comprehensive understanding of the health
needs of a child and their family.
4. Ensuring timely
access and safe care in hospitals
4.1 We propose development and
adoption of National Access Guarantees for planned procedures and
National Access Targets for emergency care. For example:
• a national access target
for people requiring an acute mental health intervention (measured
in hours);
• a national access guarantee
for patients requiring coronary artery surgery or cancer treatment
(measured in weeks/days); and
• a national access guarantee
for patients requiring other planned surgery or procedures
(measured in months).
These National Access Guarantees
should be developed incorporating clinical, economic and community
perspectives through vehicles like citizen juries.
Under the National Access Targets
for emergency access, all hospital emergency departments should
meet the triage access targets specified in Beyond the Blame
Game, as well as additional measures of performance in
promptly admitting people from emergency departments where they
need it.
These National Access Targets
operate at the level of individual hospitals.
4.2 A share of the funding
potentially available to public hospitals should be linked to
meeting (or improving performance towards) the access guarantees
and targets, payable as a bonus.
4.3 We propose there be
financial incentives to reward good performance in outcomes and
timeliness of care. One element of this should be for timely
provision of discharge information including details of any
follow-up care required.
4.4 We support the use of
activity-based funding for both public and private hospitals using
casemix classifications (including the cost of capital).
• This approach should be
used for inpatient and outpatient treatment.
• Emergency department
services should be funded through a combination of fixed grants (to
fund availability) and activity-based funding.
• The costs to hospitals with
a major emergency load of having to maintain capacity to admit
people promptly should be recognised in the funding
arrangements.
4.5 We propose that all
hospitals review provision of ambulatory services (outpatients) to
ensure they are designed around patients’ needs and, where
possible, located in community settings.
4.6 To improve quality, data on
quality and safety should be collated, compared and provided back
to hospitals, clinical units and clinicians in a timely fashion to
expedite quality and quality improvement cycles. Hospitals should
also be required to report on their strategies to improve safety
and quality of care and actions taken in response to identified
safety issues.
4.7 To improve accountability,
we propose that public and private hospitals be required to report
publicly on performance against a national set of indicators which
measure access, efficiency and quality of care provided.
4.8 We propose that public and
private hospital episode data is collected nationally using a
patient’s Medicare card number to understand better
people’s use of health services and outcomes across different
care settings.
4.9 We suggest that the future
planning of hospitals should encourage greater delineation of
hospital roles including separation of planned and emergency
treatment, and optimise the provision and use of public and private
hospital services.
4.10 We
propose a nationally led, systemic approach to encouraging,
supporting and harnessing clinical leadership within hospitals and
broader health settings and across professional disciplines.
5. Restoring people
to better health and independent living
5.1 We want to increase the
visibility of, and access to, sub-acute services through more
directly linking funding to the delivery and growth of sub-acute
services. A priority focus should be the development of
activity-based funding models for sub-acute services (including the
cost of capital), supported by improvements in national data and
definitions for sub-acute services.
5.2 We support a dual approach
to funding of sub-acute services, comprising a mix of
activity-based funding with the use of incentive payments related
to improving outcomes for patients.
5.3 We propose that clear
targets to increase provision of sub-acute services be introduced
by June 2010. These targets should cover both inpatient and
community-based services and should link the demand for sub-acute
services to the expected flow of patients from acute services and
other settings. Incentive funding under the National Partnership
Payments could be used to drive this expansion in sub-acute
services.
5.4 We propose that investment
in sub-acute services infrastructure be one of the top priorities
for the Health and Hospitals Infrastructure Fund.
5.5 We need to ensure that we
have the right workforce available and trained to deliver the
growing demand for sub-acute services including in the community.
Accordingly, we support the need for better data on the size, skill
mix and distribution of this workforce including rehabilitation
medicine specialists, geriatricians and allied health staff.
5.6 We recognise the vital role of
equipment, aids and other devices, in helping people to improve
health functioning and to live as independently as possible in the
community. Ensuring affordable access to such equipment will be
considered under reform direction 13.4 that foreshadows further
work on the development of integrated safety nets.
6. Increasing choice
in aged care
6.1 We believe that funding
should be more directly linked to people rather than places, and to
those who are most likely to need care. We propose changing the
limit on provision of aged care subsidies from places per 1000
people aged 70 or over to care recipients per 1000 people aged 85
or over.
6.2 We suggest that
consideration be given to permitting accommodation bonds or
alternative approaches as options for payment for accommodation for
people entering high care, provided that removing regulated limits
on the number of places has resulted in sufficient increased
competition in supply and price.
6.3 We propose requiring aged
care providers to make standardised information on service quality
and quality of life publicly available on agedcareaustralia.gov.au
to enable older people and their families to compare aged care
providers.
6.4 We support consolidating
aged care under the Commonwealth by making aged care under the Home
and Community Care (HACC) program a direct Commonwealth
program.
6.5 We propose developing and
introducing streamlined, consistent assessment for eligibility for
care across all aged care programs.
6.6 We propose that there be a
more flexible range of care subsidies for people receiving
community care packages, determined in a way that is compatible
with care subsidies for residential care.
6.7 We propose that people who
can contribute to the costs of their own care should contribute the
same for care in the community as they would for residential care
(not including accommodation costs).
6.8 We propose that people
supported to receive care in the community should be given the
option to determine how the resources allocated for their care and
support are used.
6.9 We propose that once
assessments, care subsidies and user payments are aligned across
community care packages and residential care, older people should
be given greater scope to choose for themselves between using their
care subsidy for community or for residential care.
6.10 We
propose that all aged care providers (community and residential)
should be required to have staff trained in supporting care
recipients to complete advanced care plans for those care
recipients who wish to do so.
6.11 We
propose that funding be provided for use by residential aged care
providers to strike arrangements with primary care providers and
geriatricians to provide visiting sessional and on-call medical
care to residents of aged care homes.
6.12 We
propose:
• increased use of electronic
clinical records in aged care homes, including capacity for
electronic prescribing by attending medical practitioners, and
providing a financial incentive for electronic transfer of clinical
data between services and settings (general practitioners, hospital
and aged care), subject to patient consent; and
• the hospital discharge
referral incentive scheme (see Chapter 4) include timely provision
of good information on a person’s hospital care to the
clinical staff of their aged care provider, subject to patient
consent.
7. Caring for people
at the end of life
7.1 We propose building the
capacity and competence of primary health care services, including
the Comprehensive Primary Health Care Centres proposed in Chapter
2, to provide generalist palliative care support for their dying
patients. This will require greater educational support and
improved collaboration and networking with specialist palliative
care service providers.
7.2 We support strengthening
access to specialist palliative care services for all relevant
patients across a range of settings, with a special emphasis on
people living in residential aged care facilities.
7.3 We propose that additional
investment in specialist palliative care services be directed to
support more availability of these services to people at home in
the community.
7.4 We propose that funding be
provided for the national implementation of the Respecting Patient
Choices program (advance care planning) across all residential aged
care services.
7.5 We support greater
awareness and education among health professionals of the common
law right of people to make decisions on their medical treatment,
including the right to decline treatment. We note that, in some
states and territories, this is complemented by supporting
legislation that relates more specifically to end of life and
advance care planning decisions.
8. Closing the health
gap for Aboriginal and Torres Strait Islander peoples
8.1 We propose that the
Commonwealth Department of Health and Ageing take a lead in the
inter-sectoral collaboration that will be required at the national
level to redress the impacts of the social determinants of health
to close the gap for Aboriginal and Torres Strait Islander
peoples.
8.2 We propose an investment
strategy for Aboriginal and Torres Strait Islander
Australians’ health that is proportionate to health need, the
cost of service delivery, and the achievement of desired outcomes.
This requires a substantial increase on current expenditure.
8.3 We propose establishing a
function to build and expand organisational capacity for Community
Controlled Health Services to provide and broker comprehensive
primary health care services. We would welcome feedback on the
appropriate auspicing body or agency for such a support
function.
8.4 We propose strengthening
the purchasing role to lead the additional investment in Aboriginal
and Torres Strait Islander health. This could be achieved by the
establishment of a National Aboriginal and Torres Strait Islander
Health Authority to purchase services specifically for Aboriginal
and Torres Strait Islander Australians and their families as a
mechanism for closing the gap. This Authority would purchase health
services from accredited providers with a focus on outcomes to
ensure high quality and timely access.
8.5 We propose that
accreditation processes for health services and education providers
incorporate, as core, specific Indigenous modules to ensure quality
clinical and culturally appropriate services.
8.6 We propose additional
investment includes the funding of strategies to build an
Aboriginal and Torres Strait Islander health workforce across all
disciplines and the development of a workforce for Aboriginal and
Torres Strait Islander health.
9. Delivering better
health outcomes for remote and rural communities
9.1 Flexible funding
arrangements are required to reconfigure health service delivery to
achieve the best outcomes for the community. To facilitate locally
designed and flexible models of care in remote and small rural
communities, we propose:
• funding equivalent to
national average medical benefits and primary health care service
funding, appropriately adjusted for remoteness and health status,
be made available for local service provision where populations are
otherwise under-served; and
• expansion of the
multi-purpose service model to towns with catchment populations of
approximately 12,000.
9.2 We propose that care for
people in remote and rural locations necessarily involves bringing
care to the person or the person to the care, through:
• networks of primary health
care services, including Aboriginal and Torres Strait Islander
Community Controlled Services, within naturally defined
regions;
• expansion of specialist
outreach services – for example, medical specialists,
midwives, allied health, pharmacy and dental/oral health
services;
• telehealth services
including practitioner-to-practitioner consultations,
practitioner-to specialist consultations, teleradiology and other
specialties and services;
• referral and advice
networks for remote and rural practitioners that support and
improve the quality of care, such as maternity care, chronic and
complex disease care planning and review, chronic wound management,
and palliative care; and
• ‘on-call’
24-hour telephone and internet consultations and advice, and
retrieval services for urgent consultations staffed by remote
medical practitioners.
We propose that funding mechanisms
be developed to support all these elements.
9.3 We propose that a patient
travel and accommodation assistance scheme be funded at a level
that takes better account of the out-of-pocket costs of patients
and their families and facilitates timely treatment and care.
9.4 We propose that a higher
proportion of new health professional educational undergraduate and
postgraduate places across all disciplines be allocated to remote
and rural regional centres, where possible in a multidisciplinary
facility built on models such as clinical schools or university
departments of Rural Health.
10. Supporting people
living with mental illness
10.1 We
propose that a youth friendly community-based service, which
provides information and screening for mental disorders and sexual
health, be rolled out nationally for all young Australians. The
chosen model should draw on evaluations of current initiatives in
this area – both service and internet/telephonic-based
models. Those young people requiring more intensive support can be
referred to the appropriate primary health care service or to a
mental or other specialist health service.
10.2 We
propose that the Early Psychosis Prevention and Intervention Centre
model be implemented nationally so that early intervention in
psychosis becomes the norm.
10.3 We believe that every acute
mental health service should have a rapid-response outreach team
for those individuals experiencing psychosis.
10.4. We propose
that every hospital-based mental health service should be linked
with a multi-disciplinary community-based sub-acute service that
supports ‘stepped’ prevention and recovery care.
10.5 We
strongly support greater investment in mental health competency
training for the primary health care workforce, both undergraduate
and postgraduate, and that this training be formally included as
part of accreditation processes.
10.6. We propose
that each state and territory government provide those suffering
from severe mental illness with stable housing that is linked to
support services.
10.7 We
want governments to increase investment in social support services
for people with chronic mental illness, particularly vocational
rehabilitation and post-placement employment support.
10.8 As a
matter of some urgency, governments must collaborate to develop a
strategy for ensuring that older Australians, including those
residing in aged care facilities, have adequate access to specialty
mental health and dementia care services.
10.9 We
propose that state and territory governments recognise the
compulsory treatment orders of other Australian jurisdictions.
10.10 We propose that
health professionals should take all reasonable steps in the
interests of patient recovery and public safety to ensure that when
a person is discharged from a mental health service that:
• there is clarity as to
where the person will reside; and
• someone appropriate at that
location is informed.
10.11 We propose a
sustained national community awareness campaign to increase mental
health literacy and reduce the stigma attached to mental
illness.
10.12 We propose there must be more
effective mechanisms for consumer and carer participation and
feedback to shape programs and service delivery.
11. Improving oral
health and access to dental care
11.1 We
propose that Australia should have a scheme ‘Denticare
Australia’ for universal access to preventive and restorative
dental care, and dentures, regardless of people’s ability to
pay.
11.2 We
propose that ‘Denticare Australia’ be based on a mixed
approach of public and private cover. The additional costs would be
funded by an increase in the Medicare Levy of 0.75 per cent of
taxable income, with people opting either to become a member of a
dental health plan (with a private insurer), or to use public
dental services.
11.3 We
support an equitable approach to financing a universal dental
scheme. Under the proposed approach, the funding of dental services
will be linked to ability to pay through an increase in the
Medicare Levy. We estimate that under this approach:
• Many people will pay no
more than they currently pay for dental care; the increase in
Medicare Levy of 0.75 per cent of taxable income will be smaller
than existing out-of-pocket costs for dental services for many
people.
• People on low incomes will
pay considerably less and have much better access to dental health
services.
11.4 We
support the introduction of a one-year internship scheme prior to
full registration, so that clinical preparation of oral health
practitioners (dentists, dental therapists and dental hygienists)
operates under a similar model to medical practitioners.
11.5 We
propose the national expansion of the pre-school and school dental
programs.
11.6 We
propose that additional funding be made available for improved oral
health promotion, with interventions to be decided based upon
relative cost effectiveness assessment.
12. Strengthening the
governance of health and health care
12.1 We
propose a range of functions that should be led and governed at the
national level, including leadership for patient safety and quality
(including service accreditation), health promotion and prevention,
professional registration, workforce planning and education,
performance reporting, private hospital regulation, and technology
assessment.
12.2 We
propose that the Commonwealth should take responsibility for policy
and funding of all primary health care.
12.3 We
propose to give further consideration to the following three
options for reform
of governance:
(A) Shared responsibility with
clearer accountability. Retain both Commonwealth and state and
territory involvement but re-align responsibilities between them,
with the Commonwealth:
• becoming responsible for
all primary health care funding and policy; Reform Directions
39
• paying to states and
territories a significant proportion per episode of the efficient
costs of inpatient treatment and of emergency department treatment
(set at, say, 40 per cent); and
• paying, using a casemix
classification, 100 per cent of the efficient costs of delivery of
hospital outpatient treatments.
This would be established through a
National Health Strategy covering all health policies and programs,
underpinned in turn by eight bilateral agreements between the
Commonwealth and each state and territory.
(B) Commonwealth to be solely
responsible for all aspects of health care, delivering through
regional health authorities. Transfer all responsibility for
public funding, policy and regulation to the Commonwealth, with the
Commonwealth establishing and funding:
• regional health authorities
to take responsibility for former state health services such as
public hospitals and community health services, in parallel to
continued national programs of medical and pharmaceutical benefits
and aged care subsidies.
(C) Commonwealth to be solely
responsible for all aspects of health and health care, establishing
compulsory social insurance to fund local delivery. Transfer
all responsibility for public funding, policy and regulation to the
Commonwealth, with the Commonwealth establishing:
• a tax-funded community
insurance scheme under which there would be multiple, competing
health plans for people to choose from, which would be required to
cover a mandatory set of services including hospital, medical,
pharmaceutical, allied health and aged care.
13. Raising and
spending money for health services
13.1 Health
and aged care spending is forecast to rise to 12.4 per cent of
gross domestic product in 2032–33. We believe that:
• major reforms are needed to
improve the outcomes from this spending and national productivity
and to contain the upward pressure on health care costs; and
• evidence-based investment
in strengthened primary health care services and health promotion
and prevention to keep people healthy will help to contain future
growth in spending.
13.2 We
want to see the overall balance of spending through taxation,
private health insurance, and out-of-pocket contribution maintained
over the next decade.
13.3 We
propose a systematic mechanism to formulating health care
priorities that incorporates clinical, economic and community
perspectives through vehicles like citizen juries.
13.4 We
will explore new safety net arrangements that are more integrated,
cover a broader range of health costs and are family-centred to
protect families and individuals from unaffordable high
out-of-pocket costs of health care.
13.5 We
believe that incentives for improved outcomes and efficiency should
be strengthened in health care funding arrangements.
This will involve a mix of:
• activity-based funding
(e.g. fee for service or casemix budgets). This should be the
principal mode of funding for hospitals;
• payments for care of people
over a course of care or period of time. There should be a greater
emphasis on this mode of funding for primary health care; and
• payments to reward good
performance in outcomes and timeliness of care. There should be a
greater emphasis on this mode of funding across all settings.
We further propose that these
payments should take account of the cost of capital and cover the
full range of health care activities including clinical
education.
13.6 We
believe that funding arrangements may need to be adjusted to take
account of different costs and delivery models in different
locations and to encourage service provision in under-serviced
locations and populations.
13.7 We
believe that additional capital investment will be required on a
transitional basis to facilitate our reform directions. In
particular, we propose that:
• priority areas for new
capital investment should include: the establishment of
Comprehensive Primary Health Care Centres; an expansion of
sub-acute services including both inpatient and community-based
services; investments to support expansion of clinical education
especially in new and underdeveloped settings; and targeted
investments in public hospitals to support reshaping of roles and
functions, clinical process redesign and a reorientation towards
community-based care; and
• capital can be raised
through both government and private financing options.
The ongoing cost of capital should
be factored into all service payments, as outlined above.
14. Working for us: a
sustainable health workforce for the future
14.1 We
propose supporting our health workforce by:
• improving workplace
culture, management and leadership skills at all levels of the
system. We would welcome feedback on proven mechanisms to achieve
this; and
• implementing models that
formally involve all health professionals in guiding the future
directions of health reform and place value on their ongoing
commitment to delivering care (e.g. Clinical Senates and
Taskforces).
14.2 We
propose facilitating access to care where doctors are scarce.
Commencing in remote and some rural areas:
• Medicare rebates should
apply to some diagnostic services and specialist medical services
ordered or referred by nurse practitioners and other registered
health professionals according to defined scopes of practice
determined by health professional registration bodies
• Pharmaceutical Benefits
Scheme subsidies (or, where more appropriate, support for access to
subsidised pharmaceuticals under section 100 of the National
Health Act 1953) should apply to pharmaceuticals prescribed
from approved formularies by nurse practitioners and other
registered health professionals according to defined scopes of
practice.
• Where there is appropriate
evidence, specified procedural items on the Medicare Benefits
Schedule should be able to be billed by a medical practitioner for
work performed by a competent health professional, credentialed for
defined scopes of practice.
14.3 We
endorse a new education framework for all education and training of
health professionals including:
• adopting a competency-based
framework;
• moving towards a flexible,
multi-disciplinary approach to the education and training of all
health professionals;
• establishing a dedicated
funding stream for clinical placements for undergraduate and
postgraduate students; and
• ensuring clinical training
infrastructure across all settings (public and private, hospitals,
primary health care and other community settings).
14.4 We
propose the establishment of a National Clinical Education and
Training Agency:
• to advise on the adequacy
of projected provision of health professional education in the
university and vocational education sectors within each major
region;
• to purchase in partnership
with universities, vocational education and training, and colleges,
clinical education placements from health service providers,
including payments for undergraduates’ clinical education and
postgraduate training;
• to promote innovation in
education and training of the health workforce;
• as an aggregator and
facilitator for the provision of modular competency-based programs
to up-skill health professionals (medical, nursing, allied health
and aboriginal health workers) in regional, rural and remote
Australia to perform tasks and address health needs met by other
health professionals in major metropolitan areas; and
• to report every three years
on the appropriateness of accreditation standards in each
profession in terms of innovation around meeting the emerging
health care needs of the community.
14.5 We
support national registration to benefit the delivery of health
care across Australia.
14.6 We
propose implementing a comprehensive national strategy to recruit,
retain and train Aboriginal and Torres Strait Islander health
professionals at the undergraduate and postgraduate level
including:
• setting targets for all
education providers, with reward payments for achieving health
professional graduations;
• funding better support for
Aboriginal and Torres Strait Islander health students commencing in
secondary education; and
• strengthening accrediting
organisations’ criteria around cultural safety.
14.7 We
propose that a higher proportion of new health professional
educational undergraduate and postgraduate places across all
disciplines be allocated to remote and rural regional centres,
where possible in a multidisciplinary facility built on models such
as clinical schools or university departments of Rural Health.
15. Fostering
continuous learning in our health care system
15.1 The
Commonwealth Government should increase the priority of health
services research to facilitate the uptake of research findings
into practice. Increasing the availability of part-time clinical
research fellowships across all health sectors to ensure protected
time for research may contribute to this endeavour.
15.2 We
further propose that infrastructure funding (indirect costs) follow
direct grants whether in universities, independent research
institutes, or health service settings.
15.3 We
believe that the National Health and Medical Research Council
should consult widely with consumers, clinicians and health
professionals to set priorities for collaborative research centres
and supportive grants which:
• integrate multidisciplinary
research across care settings in a ‘hub and spoke’
model; and
• have designated resources
to regularly disseminate research outcomes to health services.
15.4 To
enhance the spread of innovation across public and private health
services, it is proposed that:
• the National Institute of
Clinical Studies broaden its remit to include a
‘clearinghouse’ function to collate and disseminate
innovation in the delivery of safe and high quality health
care;
• health services and health
professionals share best practice lessons by participating in
forums such as breakthrough collaboratives, clinical forums, health
roundtables, and the like; and
• a national health care
quality innovation awards program is established.
15.5 To
help embed a culture of continuous improvement, we propose that a
standard national curriculum for safety and quality is built into
education and training programs as a requirement of course
accreditation for all registrable health professionals.
15.6 A
permanent, independent national body should be established to lead
the way on safety and quality. Its role should include: design and
definition, by the end of 2009, of indicators that can be used to
monitor the safety and quality of care; and the development of a
national patient experience questionnaire, and patient-reported
outcome measures.
15.7 To
drive improvement and innovation across all areas of health care,
we believe that a nationally consistent approach is essential to
the collection and comparative reporting of indicators which
monitor the safety and quality of care delivery across all sectors.
This process should incorporate:
• local systems of supportive
feedback, including to clinicians, teams and organisations in
primary health services and private and public hospitals; and
• incentive payments that
reward safe and timely access, continuity of care (effective
planning and communication between providers) and the quantum of
improvement (compared to an evidence base, best practice target or
measured outcome) to complement activity-based funding of all
health services.
15.8 We
also propose that a national approach is taken to the synthesis and
subsequent dissemination of clinical evidence/research which can be
accessed via an electronic portal and adapted locally to expedite
the use of evidence, knowledge and guidelines in clinical
practice.
15.9 We
believe that all hospitals, residential aged care services and
Comprehensive Primary Health Care Centres should be required to
produce an annual public report on their quality improvement and
research activities, including reporting on actions arising from
investigation of adverse events.
[1].
The Fraser government introduced a
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[11].
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[12].
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Healthy Australia’ goals are a rolling
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prevention.
[23].
NHHRC, A healthier future for all
Australians: interim report, p. 54.
[24].
NHHRC, A healthier future for all
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[25].
NHHRC, A healthier future for all
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[26]. NHHRC, A healthier future
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[27]. L Russell, G Rubin and S
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[28]. Russell, Rubin and Leeder,
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health?’, p. 718.
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health?’, p. 718; and S Corbett, ‘A ministry for
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[44].
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expanded responsibilities and a greater focus on provision of
primary care.
[45]. N Miller and L Shanahan,
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[46]. See, for example, the address
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Rosanna Capolingua, to the National Press Club: R Capolingua,
‘Advocating for patients in health reform’,
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2009, http://www.ama.com.au/node/3320.
[47]. Capolingua, ‘Advocating
for patients in health reform’.
[48].
NHHRC, A healthier future for all
Australians: interim report, p. 88.
[49]. Currently aged care is funded
according to the number of places set by the Commonwealth
Government.
[50]. Catholic Health Australia
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media release, 22 February 2009 viewed 16 March
2009, http://www.cha.org.au/site.php?id=1691.
[51]. The Hogan Review was completed
in 2004 and examined the long-term operation of residential aged
care services. It made a range of recommendations, notably
increased flexibility in planning arrangements and greater
competition in the sector. It also advocated the introduction of
vouchers. See: WP Hogan, Review of pricing arrangements in
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Lesley Russell from the Menzies Centre for
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[119].
For example, some medical colleges, notably the Royal
Australian College of Surgeons, have been accused of deliberately
restricting entry to specialist courses. See: A Fels and F
Brenchley, ‘An unhealthy monopoly’, The
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2 March 2009,
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It is also argued that nurse practitioners do not have the
necessary diagnostic and training skill sets to be allowed to
augment the care they provide through access even to limited
prescribing rights. See: ‘General practice nurses good for
health’, GP Network news, issue 5, no. 13, 8 April
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Dr David Lindsay from James Cook University has alluded to
an aspect of this—the medical profession’s objection to
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[123].
For example, the establishment of rural clinical schools
designed to encourage medical students to take up a career in rural
practice by enabling them to undertake extended clinical training
placements in rural locations, as well as various other incentives
for medical students and practitioners, such as the Bonded Medical
Places Scheme and the Rural and Remote General Practice Program,
which provide funding to improve the recruitment and retention of
general practitioners in rural and remote areas. Other initiatives
have also been introduced to encourage allied health professionals
to practice in the bush. These include the establishment of a rural
dental school at Charles Sturt University, a rural pharmacy
workforce program and a continuing education program for rural
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See: Jolly, Health workforce: a case for physician
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and international context undertaken by Dr Rod Hooker, including
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The Australian Medical Association (AMA) has stated:
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be supported. No other class of health practitioner is sufficiently
trained in the roles of medical practitioners to meet the health
needs of the community’. AMA, Health workforce
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