While the federal election is still months away, issues of health funding are already dominating the news. A Grattan Institute report released yesterday, for instance, noted the greatest budgetary pressure facing Australia comes from sustained increases in health costs.
Last night, ABC TV’s Q&A featured Health Minister Tanya Plibersek and Shadow Health Minister Peter Dutton who faced up to questions from the audience with the knowledge that their responses must win over voters in this election year.
They were questioned a range of health issues – from hospital funding and health workforce training to organ donation and end-of-life care. We’ve asked our experts to assess their performance.
Hospital funding “blame game”
Stephen Duckett: Health policy in Australia is often seen through the lens of Commonwealth-state relations so it was no surprise that the first question on Q&A was about the funding “blame game”. There was no real answer from either Minister Tanya Plibersek or Shadow Minister Peter Dutton, but then again, what could they say? I’m not going to hold states to account? Things will always be sweetness and light between me and my state colleagues? Yeah, right!
Certainly Commonwealth Treasury got it wrong last year in the way they indexed state health grants, but I think they’ve learnt their lesson and probably won’t do that again.
Commonwealth-state issues will continue while there are unclear or inappropriate dividing lines between state and Commonwealth responsibilities. The new hospital funding arrangements, to kick in 1 July 2014, are an improvement but other problem areas (health professional training, for instance) remain.
Privatised public hospitals
Elizabeth Savage: The Productivity Commission found no efficiency advantages for the private hospital system compared with the public system. Even within public hospitals in New South Wales, there is evidence that higher income patient groups and private patients are advantaged in accessing elective procedures.
One motivation for this is the extra revenue hospitals receive from private patients. If public hospitals were fully privately managed, there is considerable risk that access will depend much more strongly on ability to pay.
Health cost blowout
Hal Swerissen: The government is pinning its hopes on reforms like the national introduction of activity-based funding for hospitals, the introduction of local hospital networks and Medicare Locals. The Opposition supports activity-based funding and some form of local coordination, but isn’t convinced the current organisation is right.
It criticises the inefficiency of additional layers of coordination as waste, putting its emphasis on the delivery of frontline services. The government continues to blame the states for reductions in funding for their hospital systems and, at least in Victoria, will consider bypassing them and to fund individual hospitals for the services they provide.
Kenneth Hillman: Neither answered the question on palliative care well, or with vision. Perhaps the phrase end-of-life care is more appropriate as palliative care is a medical speciality with a narrow interpretation of how, not only our health service is to respond to the tsunami of aged people needing high level care towards the end of their lives, but also how we mobilise the resources of many other services in our community.
We also need to begin an open discourse about ageing, dying and death and how our society wants it managed. And what we are prepared to sacrifice in order to fund it.
As someone who works in the high-technology and high-cost end of hospital medicine, I can see there are enormous savings if we can arrange more appropriate care for people at the end of their life. Instead of what we do at the moment, which is treat the majority of them in acute hospitals.
It’s not necessarily what our society wants and is a large contributor to the unsustainable costs of health care. It requires vision; de-medicalisation of the ageing and dying process; working across all sectors and engaging with our society as we go about it.
Holly Northam: The responsibility rests with the hospital to expertly identify the wishes of the deceased, using all available forms of evidence (such as the organ donor register) and ensure the family are given the support they need to agree to donation. Very few families override the wishes of the deceased if they are known.
Australia should be able to have an 85% consent rate, not the approximately 58% it has at present. The only place for opt-out legislation is to give legal support to medical staff to intervene with the use of organ sustaining technology when a patient is on the point of death.This would also help make the coroner accountable for refusals to allow organ donation to proceed.
GP income, health professional training and Medicare Locals
James Gillespie: The discussion got off on a bad foot with a rather partisan diatribe on class war and GP salaries. This let both the minister and shadow minister off the hook, with no need to explain how the system will handle the large generational change in general practice over the next decade or so.
The flood of new graduates offers some real opportunities to devise better ways of collaborative working across professions and parts of the health system.
Both speakers did make gestures towards improving the integration of primary care and hospital services. Neither went much beyond generalities. But it was good to see that Dutton’s promise to abolish Medicare Locals is getting vaguer each time the question is raised. He is also accepting that many are doing a good and innovative job.
These organisations have been running for less than two years – the majority for even less than that – so it is far too early to make any definitive judgements. The last thing that the health system needs is another major reorganisation.
Peter Broooks: The discussion was very focused on doctors – what about all the other health professionals who assist and work as part of a coordinated team. With the burgeoning costs, we really do need to stop focusing on hospital beds and develop ways of caring for patients in the community.
Health Workforce Australia predicts a surplus of doctors by 2025 (if we build in a productivity gain) and not a deficit. Training should be taking place in the private sector and in primary care and should be funded appropriately.
Training might also be shortened – particularly for some of the specialities – with partnerships between universities and the colleges. Not too much real innovation from either side and no one mentioned the fee-for-service system, which makes the whole thing unsustainable.
Broadband and health
David Glance: It was clear that both ministers are not experts in this area. Telehealth is always equated to videoconferencing and Plibersek ignores that this is already largely in place today, even without the NBN. Telehealth is much more - especially asynchronous Telehealth whereby images and assessments (among other things) are sent to a specialist for review and comment.
Telemonitoring does not require particularly high bandwidth or the NBN and adoption of both this and telehealth is still relatively low – not because of technology but because of lack of training, lack of health processes adapted to this mode of health care and lack of financial support and incentives.
Plibersek was incorrect to suggest that the opposition’s broadband solution would not support telehealth and Dutton was correct to say that satellite would still be the only thing provided to some remote communities in both models of the NBN.
Michael Valenzuela (who posed the question): The minister failed to catch the essence of my question, which was about a plan to prevent dementia. It is only through a co-ordinated national prevention plan that we can have any hope of averting or minimising the truly scary dementia numbers that await us. Rather, she listed a series of funding initiatives related to dementia care and treatment – precisely the kind of response I was hoping to avoid.
The shadow minister at least seemed to understand my question and talked about the dementia “tsunami” coming towards us, and that medical research is very important in that respect. Agreed – but no concrete plan, initiative or strategy.
More generally, I was left with a sense of deep disquiet that neither current minister nor alternative minister was able to articulate a clear and progressive vision for Australian’s health.
Rather, there were lists of issues, transactional arguments and self congratulation. Australia needs a clear vision for our future health.
Private health insurance rebate
Elizabeth Savage: The 30% rebate on private health insurance premiums was a very expensive and ineffective way to relieve pressure on public hospitals. Predictions from the industry that there would be a large reduction in coverage when the rebate was means-tested have proved to be incorrect – coverage has increased.
The age loading applied under the Lifetime Health Cover Policy did increase coverage. However, it did not fulfil the prediction of lower insurance premiums, as a consequence of the pool of insured people being younger and having lower claims. Premiums did not fall.
Removing the 30% rebate from the age loading applied under the Lifetime Health Cover Policy will reduce the cost to revenue of the misguided 30% rebate.