Since the election, the Turnbull government has received a great deal of advice on how to counter the pervasive public scepticism about its ongoing commitment to the universality of Medicare.
While the impacts of the so-called Mediscare campaign, the Medicare rebate freeze and the “zombie” policies left over from the 2014-15 budget have driven these calls for Coalition action, the real issue is that the previous Abbott-Turnbull government had no health policy agenda, other than budget cuts and the covert exploration of privatisation and competition in the delivery of health-care services.
In this new term, the government must do more to deliver the health-care system we need for the 21st century – not just to improve its standing with voters, but to meet the health needs of all Australians. Much of this can be achieved through new ways of thinking about policy development and implementation rather than new spending.
Even so, some new funds will be needed. The government and its bean counters must move beyond seeing the health-care budget as a drain on finances and treat it as an investment in the health, productivity and prosperity of the nation. This approach will help concentrate efforts on evidence and value rather than ideologically based, slash-and-burn approaches.
1. Patients must be the centre of the health system
The health-care system exists primarily for the benefit of patients, but their voices are so rarely heard. Every policy, budget measure and proposal must be considered through the patient lens.
That does not mean the impacts on providers (hospitals, clinicians and health insurers) should not be considered; they are also stakeholders and usually the decision-makers. But the government’s first instinct has been to consult with privileged groups such as the Australian Medical Association and private health insurers, rather than with the public, patients and providers at the coalface.
Importantly, viewing health reform through a patient lens will help policymakers identify disadvantaged groups so they can target their specific needs.
2. Invest in health promotion, not just illness treatment
Prevention is as much a responsibility of government as it is for individuals. This is particularly the case for obesity.
As a nation, we all bear the substantial and growing economic and social costs of obesity and its consequences, especially diabetes. Every day, 12 Australians have an amputation related to diabetes at a cost of A$875 million a year. Almost all of this is preventable.
The investments made in prevention must be proportional to the burden of disease in terms of resources and commitment. Concerns about sensible budget policies must override ideological concerns about the nanny state.
3. Make health-care reforms sustainable
This means ceasing the start-stop approach of small-scale pilot programs that never go beyond three years and are evaluated only after they are concluded in reports that never see the light of day. Real reforms will also require time frames well beyond those of the election cycle.
Labor has proposed a promising way forward: a permanent Australian Healthcare Reform Commission, which would include a new Centre for Medicare and Healthcare System Innovation to embed continuous reform into the health-care system.
This type of approach – where models can be seamlessly developed, implemented, assessed, adjusted and expanded – is essential for reforms such as the government’s proposed Health Care Homes trial to better manage chronic disease, and for complicated issues such as mental health reforms.
4. Apply a whole-of-government approach to health
The health and well-being of the population depend on issues well beyond the health portfolio and require a health-in-all policy approach in all government portfolios. This is a matter of leadership and cultural change, not new expenditures and regulations.
“Wicked” issues such as obesity, mental health, healthy ageing and Closing the Gap on Indigenous disadvantage can only be effectively addressed through such whole-of-government approaches.
5. Data is key
Research, data analyses and evaluation are key to health-care reforms.
The antipathy of the previous government to evidence-based policymaking was exemplified by the scrapping or downgrading of key agencies and the defunding of the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy and the Better Evaluation and Care of Health (BEACH) study.
These losses must be rectified, but it is also time for the Department of Health to start mining the archives. There are mountains of reports, papers and evaluations, together with significant, policy-relevant primary health care research commissioned by the department through the Australian Primary Health Care Research Institute, to be used in improving the delivery and financing of health-care services.
At the same time, there should be a moratorium on shunting off difficult problems to committees as an excuse for inaction. There will be occasions when it is necessary to convene advisory groups. That should be done using the experts who will provide the advice that is needed, not the usual hacks who provide the advice the government wants.
So where do we start?
I rate the following as the key issues:
the renewal and revitalisation of the commitment to Close the Gap, with the inclusion of a social justice target and meaningful involvement of Indigenous communities
federal leadership in the implementation of mental health reforms to improve access to treatment and care, and to tailor responses to individuals’ needs. Such mental health reforms have been left to flounder between the National Disability Insurance Scheme and the Primary Health Networks
the effective implementation of patient-centred medical home models of care for people with chronic illness. This means patients have a regular general practice that coordinates all their primary, specialist and allied health care
fast-tracking the review of the 5,700 items on the Medical Benefits Schedule, removing items that aren’t evidence-based or no longer reflect good clinical practice, and adding necessary new items. Progress on this important work is too slow
tackling inequalities in access to specialist out-patient care, including high rates of out-of-pocket costs
containing the cost blow-out of the private health insurance rebate and ensuring health insurance provides value to consumers who purchase it.
In 2007, my colleagues and I outlined the challenges to health care facing the incoming Rudd government. Regrettably this nine-year-old document could serve the same purpose today, so little has changed.
Will Prime Minister Malcolm Turnbull now bring to the health-care sector the innovation he says holds the key to Australia’s future?