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People with chronic illness short-changed by fragmented system: federalism paper

The growing chronic disease burden will require not only greater focus on prevention, but also innovative treatment. AAP/Joe Castro

Australia’s health care arrangements do not work well for those with complex and chronic conditions such as diabetes, cancer and mental illness, according to a federal government paper.

These people need co-ordinated care across multiple health settings, but there is no single overarching “health system” in Australia to provide this care.

Instead, health care “is a complex web of services, providers and structures. Some of these parts are not well connected or co-ordinated, especially where different levels of government are involved”.

Roles and Responsibilities in Health is one of a series of discussion papers being put out in the run-up to the government’s Reform of the Federation white paper.

It says that chronic disease is “already the leading cause of illness, disability and death in Australia” and with the population ageing, higher numbers of people with chronic disease can be expected.

The “growing chronic disease burden will require not only greater focus on prevention, but also innovative treatment of multiple chronic conditions and complex health care needs”.

These patients can suffer if their care is not provided in a co-ordinated manner. At present there can be information gaps, fragmented services and duplication of clinical interventions. For example, a person with a serious mental illness may receive services through multiple programs run independently of each other by different levels of government.

In the present carve up in the health area, the Commonwealth is predominantly responsible for primary care, including general practitioners, while the states are predominately responsible for public hospitals.

The paper says the shift from acute to chronic conditions means current arrangements, which focus on acute care delivered through hospitals on an episodic basis, struggle to co-ordinate patient care across settings inside and outside hospitals. They tended to emphasise sickness rather than keeping people well through preventive action.

“This is partly driven by funding flows. Service providers, such as general practitioners and hospital wards, are funded on the basis of activity, which can result in a focus on episodic treatment rather than long-term multidisciplinary care and prevention.”

The handover between primary and acute care is also complex, the paper says. “There is no agreed process between the Commonwealth and the states and territories to manage and co-ordinate funding, policy, governance or the safety and quality of these areas. Each is managed independently,” it says.

“This increases the risk of governments developing policies in relation to their own responsibilities without necessarily taking account of health care arrangements in a holistic way.

"It also exacerbates the incentive for governments to cost shift to the other level of government.”

The paper puts many questions forward for discussion. It lists as threshold questions:

  • What is the appropriate role of government, as well as non-government and private providers, in health care?

  • What should be changes in the allocation of roles and responsibilities between Commonwealth and states?

  • Should any roles be shared, and how can they be clarified and co-ordinated to minimise overlap, duplication and blame shifting and improve delivery?

  • What is working well?

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