Thursday, March 04, 2010

The Australian Government's health care changes

In Australia's new national health policy to be I made some initially jaundiced comments on the Australian Government's health care change proposals driven by my feeling that the Government was responding to trying to do too much by doing more! My wife felt that I was becoming boring on these issues. I suspect that she is right!

It is Wednesday night as I write. By the time this post comes up early tomorrow, the Australian media is likely to have saturation coverage on the proposals if today's initial response is any guide. Here, for example.

I will let the coverage unfold before I make major comments. I don't like just reporting, preferring to add some form of value through analysis. But a few very brief comments now.

My own thinking on this issue is conditioned by two things.

The first is the concerns that I have been expressing about the Rudd Government's difficulty in managing process. The proposed health changes are all about process and are set firmly within the modes of thought applied by the Government in other policy areas. Given that I have been banging away at what I see as the weaknesses in the Australian Government's overall approach, I suppose that it's inevitable that my first reaction is one of caution.

The second thing conditioning my thinking are the problems that I have seen over time in the delivery of health services within regional Australia, exemplified most recently by the Bellingen hospital case. One of my arguments there was that decisions based on the cost efficiency of service delivery could also impose costs on patients that needed to be taken into account. In the Bellingen case, the need to need for patients to travel to the bigger Coffs Harbour Base Hospital instead of going to the local hospital imposed time and travel costs. It also meant some reduction in access, especially for poorer patients without cars.

Patients might get better service at Coffs in more complex cases, but this was probably not true for the generality of conditions.

A very particular difficulty that arises in rural areas is that reduced local health services have flow-on effects in other areas. For example, it can make it more difficult for older people to stay in their own communities, while also making it more difficult to attract new families.

One difficulty that people have already pointed to in the proposals is that the case-mix approach, direct fixed payments to hospitals for particular services, is likely to favour bigger institutions or networks over smaller ones, thus continuing existing trends.

Mr Rudd has apparently suggested that this might be dealt with via special payments, but I do not know the details here.

I don't think that its either physically or financially possible to have a health system that guarantees the same level of care to all Australians regardless of location or economic circumstance. Access problems linked to time and cost alone preclude this. Here I have felt for a while that we need a new approach, one that starts on the ground and then focuses on the linked questions of availability and standards, not standards as measured in current ways with their institution or systems based focus, but standards linked to the actual availability of health services to individuals. You might have the best hospital system in the world measured by standards of cost and care delivered, but that is little consolation if you cannot access that system.

The Australian health system is remarkably complex and quite rigid, with problems in one part cascading through the system over very long time periods.

A Commonwealth minister decides that there are too many GPs are leading to over servicing and cuts training places. Ten years later, major GP shortages leads to a scramble to catch up. A NSW Government decides on efficiency grounds to reduce the number of emergency departments and as part of this reduces the number of registrar positions. A few years later, the number of certain classes of physicians in training in NSW drops to a quarter of the New Zealand figure. And so it goes on.

I do not envy the Rudd Government in trying to change such a complex system. I have little interest in the headline politics on the issue. The thing that I am interested in is what it will actually mean for people in Bellingen, Bourke, Armidale or Blacktown. I have no feel for that yet.

I am going to take a break for a few days not just from public policy, but also from posting here, although I will respond to comments. It's not just that I need to catch up on some things, I am becoming bored with myself, stuck in a rut!

Talk to you again next week.


Jayne said...

If he gets the mental health system overhauled he might get the preventative measures in order to save time, money and lives.
The casemix funding model is used here in Vic but the mental health system, like everywhere (including private) is tanked.

Jim Belshaw said...

I have to agree on mental health, Jayne. Part of the problem here as I see it, and it's a classic case, is the way decisions can be made in isolation of the flow on effects.