Twelve Steps to Real Health Reform

Health is a permanent major political battleground in Australia. In 2010, the major development is Kevin Rudd’s massive GST seizure from the states, with the mantra, “most revolutionary health reform since the advent of Medicare”.

Just like the Aboriginal housing scheme, the home insulation program and Building the Education Revolution, the so-called health reform is following a familiar twelve-step pattern:

1. Need to be seen to fulfil an election promise;

2. Major political announcement;

3. Massive funding of project out of proportion to historical precedents;

4. Massive media campaign centred on Prime Minister;

5. Senior ministers then engage in a media blitz;

6. Publication of manufactured consent and praise of groups with vested interests or political ambitions in response to steps 2 to 5;

7. Media and expert scrutiny emerge due to lack of detail in government plans;

8. Public cynicism follows step 7;

9. Fiascos related to reckless spending emerge;

10. Fiascos related to windfalls for lucky government contract holders come to light;

11. Failure of “major government initiative” or “reform” emerges;

12. Damage control measures by government fix-it ministers with Prime Minister nowhere in sight.

The 2010 so-called health reform has not completed all twelve steps, for we are still at steps 8 to 10.

Dr Rosanna Capolingua, a former AMA President, recently concluded that what we have is not health reform but rather GST reform with a health bribe as an inducement to the states, and more importantly to con the general public. She is right.

The federal government promised to assume dominant funding responsibility for health over the states to create efficiencies and stop the blame games. However, by seizing the states’ GST money to fund the 60-40 split of hospital funding, Rudd in effect has done nothing except grandstand to the public, for most of the 60 of the 60-40 was state money anyway. It is no wonder that at COAG in May the states refused to surrender control of the funds, which results in yet another broken Rudd promise. In the final signed-off COAG agreement with the states, the 30 per cent of state GST revenue is not specifically mentioned.

This so-called health reform is following a recurring theme of macro-economic and media manipulation of problems that require micro-economic solutions. Simply throwing money at broken or dysfunctional systems does not achieve reform; in some instances, this one included, it makes matters worse.

In health reform, the stakes and dollars are much higher than the aforementioned bungled government programs, so it is vital that we get it right. Mismanagement of health reform will not only send Australia broke, but also result in many undesirable demographic, social and legal consequences.

So instead of the twelve steps followed by the present so-called reformers, I propose twelve steps to achieve real health reform in Australia.

Step 1

Political approach: more beds

Real reform: what is done with the beds

No one disputes the need for more hospital beds. For too many years, state governments have removed hospital beds, closed wards and hospitals, and not kept up with the growing demand for beds caused by our growing and ageing population. Without more beds our hospitals lack capacity to absorb surges during winter, disasters and epidemics. Without more beds we continue to have bed blocks in emergency departments and long waiting times for elective and emergency surgery.

However, there is too much focus on the number of beds rather than what happens when the patients are actually in the beds.

We will never achieve improvements unless we deploy an adequate number of staff to care for the patients in the beds. The red tape and other impediments clinicians face every day with respect to the timeliness of pathology, imaging (such as CT scans and MRIs), specialist consultations, operating theatre access, rehab-ilitation and discharge planning have to be addressed to achieve real reform. It is at this level where the dead hand of health bureaucracy stifles doctors and nurses. Union awards and medico-legal defensive practices further suffocate our hospital systems and frustrate clinicians day in and day out.

Therefore just throwing money around to open more beds does not go far enough. More beds will simply expand these inefficiencies.

Step 2

Political approach: more aged-care places

Real reform: viability of aged-care institutions

Demography does not lie. Australia is ageing. Families are getting smaller. More and more elderly are becoming dependent on aged-care facilities because of chronic disease and lack of family to look after them.

We have a soaring demand for permanent aged-care placements. More and more elderly are taking up hospital beds because there is simply nowhere else for them to go. Supply of nursing home and hostel beds is not there to meet the demand. Why is this so?

The answer lies in government red tape, which is pushing the aged-care system to the limits of viability. Government agencies, or agencies funded by government, decide who gets placed in the beds; this process is cumbersome and inconsistent.

The more one owns, the more one pays for the privilege of being placed in permanent care. Battlers with modest assets become upset at having to sell the family home to make life in the nursing home affordable, while others with no assets get placed, no questions asked.

Government pays the aged-care institution in a case-mix style (a warning to all with respect to hospitals), so managers of institutions “shop” for patients who will deliver them the most money. But these same patients are harder to look after, meaning the poorly paid staffs of the nursing homes become more burnt out, more frustrated and more likely to be injured and claim workers’ compensation.

Administrators of aged-care facilities are constantly receiving new directives from government and accreditation agencies; more red tape to access the same amount of money. To satisfy the red tape, more staff sit in offices and fewer at the bedside. With the increase in administration staff, it is now too expensive to employ as many nurses as before.

In effect the health bureaucrats are deleting the nursing from nursing home. Note the subtle, yet significant change in terminology: we are no longer to use the words nursing homes, but rather aged-care facilities. One by one, hospitals are being called anything but a hospital; health service is a popular term in 2010 Health-speak.

Doctors, dentists, physiotherapists, podiatrists and other visiting clinicians are so frustrated with the red tape and inefficiencies that many have abandoned visiting nursing homes altogether. It is now estimated that as few as 20 per cent of general practitioners now visit nursing homes. If one takes into account the many small rural towns in Australia where the GPs really have no choice but to service nursing homes, the statistics for regional and metropolitan centres are dire. Governments have lamely attempted to make the Medicare rebates more attractive to doctors for visiting nursing homes; the above figures indicate how weak their attempts have been.

When a medical problem now arises in a nursing home, staff just call an ambulance and send the resident to the nearest emergency department; hundreds of dollars worth of needless tests and bed-blocks often follow.

More aged-care beds will mean more frustration and more Australians receiving sub-standard care. Reducing red tape, restoring the nurses and promoting care within the walls of the nursing home are what is needed.

Step 3

Political approach: more doctors

Real reform: who the doctors are

Political candy: more doctors for Australia. Doctors per head of population in Australia is one of the highest in the world and certainly the highest in our history. There is a tsunami of graduates, as we call it in the profession. From our traditional number of about 1500 graduates per year, Australia is on the way to graduating over 3000 new doctors per year.

Who are Australia’s doctors? From the 1970s until the mid-1990s, most of Australia’s medical students were undergraduates from the top 1 or 2 per cent of secondary school finishers. For reasons that can only be categorised as socio-economic, in the mid-1990s many graduate medical schools emerged. Suddenly a rural background, female gender, indigenous status and other minority status propelled students into Medicine. These postgraduate courses mean the universities had to put in less work, with courses of four years rather than five or six years. Even the universities that retained undergraduate degrees introduced interviewing and testing systems that were more social than academic in emphasis. The Howard–Anderson government funded new medical schools in the late 1990s and early 2000s, so academics had to be “created” to staff the new schools.

Demography does not lie, and nor does mathematics. A cohort of 3000 graduates cannot possibly have the same high academic standards as that of the 1500 that came from the academic elite of our secondary schools.

If Australians are to maintain the medical standards they have grown accustomed to, an exit exam for all final-year medical students should be introduced. This exit exam could be a national exam or one introduced by each university; however, there has to be a final hurdle that includes English literacy, physical examination, as well as theoretical knowledge.

Currently there are too many schools doing too many different things. Too many students are receiving watered-down medical education without enough supervision. Australia needs to set a minimum standard set of skills and knowledge.

Regrettably, the same can be said of nursing training and that of most of the other allied health disciplines.

Step 4

Roxon and Rudd approach: super-clinics

Real reform: super clinicians

Super-clinics have been heralded as the new face of primary health care; a one-stop-shop for all your health needs. The supermarket approach does offer some advantages in convenience, but that is all. When a new supermarket opens, all the checkouts are manned and all the aisles immaculately presented, with prices and range beyond compare. We get sucked into going to that supermarket and the behaviour becomes habit. As time goes on, fewer and fewer checkouts are manned. Queues get longer. Prices go up. The range is more restricted. And so it will be for super-clinics.

What is worse, and we have aged care as the prelude (see Step 2), all indications are that primary care funding will move more and more towards outcomes-based funding, patient enrolment and capitation of payments. For example, the government proposes that practices will receive about $1200 for each diabetic patient the practice enrols; that $1200 is a yearly sum for the entire patient’s care. So if you’re a diabetic who happens to have a myriad of other problems, watch out! You may have to shop around for a clinic willing to invest in you, for a one-problem diabetic will make the clinic more profit than one who has high blood pressure and skin cancers.

Therefore in the super-clinic model, the patient will walk in as the consumer and walk out as the product. The provider of the service, the super-clinic, becomes the consumer who selects who it wants to treat, rather than who needs the treatment.

A real danger exists that super-clinics will soon be added to the insulation batts and Building an Education Revolution fiascos. The number of clinics that have been opened in the term of this government is low compared to what was promised. And when taxpayers finish asking Kevin Rudd and Wayne Swan about taxpayers’ money going to the mining super-tax propaganda, they may turn their attention to the fact that super-clinics are spending our money advertising for patients to leave their usual GPs in favour of the super-clinic. These clinics were meant to be meeting unmet demand for GPs; so why the need to advertise? Perhaps they are advertising because some of the new clinics are within walking distance of existing GP practices. If only the government would open some petrol stations next to existing petrol stations—we might then have cheaper fuel!

The real health reform would be better training and resources for our existing health-care providers so that comprehensive care can be provided within existing, established therapeutic relationships.

Step 5

Political approach: specialisation

Real reform: generalisation

We live in a society enamoured with specialisation. In sport, one is no longer a back, but a left back; not a mid-fielder, but an attacking central mid-fielder. The local mechanic now will only repair Mercedes and Porsche, and not your Toyota or Hyundai. Your lawyer might only do tax law or environmental law.

In medicine it is even worse. Not only do we have specialists, but sub-specialists and beyond! The orthopaedic surgeon may now not only specialise in knees (sub-specialist), but arthroscopic knee surgery (sub-sub-specialist). Your gynaecologist may now perhaps treat not only cancer cases (sub-specialist), but only uterine cancer (sub-sub-specialist).

Because of the immense training and equipment needs super-specialisation demands, two features of specialisation are increased cost and the need for referral. Specialists charge more for their expertise and need someone else to decide if their services are the right ones.

Politicians love keeping the company of specialists, as it makes them feel as though they are at the cutting edge. Funding an ovarian cancer institute sounds a lot more politically cool than funding a suburban general practice. Doctors love becoming specialists because the money is better, the hours are better and one can work within a narrow comfort zone.

Things have become so out of hand that now only about 24 per cent of young doctors choose general practice. When one looks at the 76 per cent that choose specialties, a large number become sub-specialists.

However, with specialisation comes fragmentation, which is the enemy of good patient care. Continuity is the cornerstone of good clinical care and can only be provided by a generalist. A sine qua non of health reform is therefore the promotion of generalisation. This has to go beyond just training more GPs. We not only have to train doctors as generalists, but also keep them as generalists. There are too many perverse incentives in Medicare and our hospitals to specialise.

The recent announcement of activity-based funding for hospitals may be a long overdue re-calibration towards doing something rather than doing nothing; however, we need to be careful that it does not lead to more fragmentation of care.

Real reform has to level the playing field between generalists and specialists and give generalists a proud place within our hospital systems once again. Here our rural hospitals can serve as a national good example; without generalists such hospitals would not survive. We need doctors and nurses who can handle multiple patient problems, not just a few. Patients and hospital budgets cannot afford the delays and costs that specialisation brings. 

Step 6

Rudd and Roxon approach: maximum of four hours in emergency departments

Real reform: make emergency departments emergency departments

How anyone thought of a policy like this is beyond the comprehension of doctors. The government has taken one of the worst pages of Britain’s NHS and incorporated it into Australia’s health reform program.

A recent Medical Journal of Australia article by Dr Antony Nocera, an emergency physician, was prophetic in that it highlighted all the problems of such a policy even before it was announced. Dr Nocera refers to virtual beds, pretend admissions and other interesting forms of fantasy health administration that will be used to make the numbers work.

The problem with emergency departments nowadays is that real emergency medicine is only a small part of their work. Australian emergency departments fulfil all the following roles:

• convenience general practice when patients cannot be bothered to book to see a GP or do not want to pay to see a GP

• dumping ground for police who do not want to arrest low-level criminals with drug and alcohol or mental health problems

• dumping ground for social welfare agencies for people with social problems that they cannot or do not want to handle

• back-door admission office for specialists who cannot find a hospital bed for their patients

• dumping ground for GPs for patients needing admission to hospital who are not really suffering emergency conditions

• dumping ground for nursing home staff when they think a resident’s doctor is too hard to call.

It is little wonder that emergency department waiting times are long and bed-blocks are normal. Emergency physicians are burnt out and too often exit the specialty for anaesthetics, intensive care or even rural medicine, where such problems are less or non-existent.

Disincentives have to be created in order for emergency departments not to be abused. Such disincentives may include payment for patients who are not genuine emergency patients and fines for agencies that dump people into emergency departments.

There are endless publications notifying doctors and nurses of punishments and fines for doing the wrong thing; it may be time for patients and agencies to have similar responsibility thrown upon them. Then you could truly use the word revolutionary!

Government has also sold the public the concept of non-doctors accessing Medicare. One of the justifications put forward for this is that somehow this reform will reduce the load on emergency departments and hospitals. Given that the new providers accessing Medicare are by definition more narrow in their scope, all one can see happening is a cost blow-out and more referrals to emergency departments, as patients present to them with problems outside their skill range.

Since psychologists have been able to access Medicare, the Medicare budget has blown out in this area, and psychiatrists have never been busier. And so it will be in all the other allied health reforms in Medicare, emergency medicine included. Another populist strategy has been the twenty-four-hour hotline, where a patient can ring a nurse for advice, in the hope that this will prevent an emergency department visit.

But why is government not investing in true pre-hospital care reform? Why not man ambulances and the twenty-four-hour hotlines with appropriately skilled doctors who can deal with the problems outside the hospital walls? The answer is simple: appropriately skilled means appropriately paid and appropriately autonomous, something health administrators cannot tolerate.

Step 7

Roxon and Rudd approach: nanny state preventive care initiatives

Real reform: real prevention through education and poverty reduction

The ever-growing numbers of health administrators in this country have to find ways to justify their existence. Many of them sit in offices devising new methods of preventive health. The three cornerstones of these measures are paperwork, taxes, and restrictions of personal freedom.

The ultimate responsibility for a person’s health lies with the individual. No amount of paperwork, tax or law will stop someone engaging in deleterious behaviour if that individual does not understand why the behaviour is wrong.

Only a sound education system and a sound economy will deliver better health outcomes. Real reform means patients taking more responsibility for themselves—yet another anathema for health administrators who want everybody sucking at their collective bosom in public and in private.

Step 8

Political approach: the e-health revolution

Real reform: the three Rs

The great polymath George Steiner quite rightly cited the computer as the greatest development for the human race since the mastery of fire. Despite this, we still struggle to manage fire in many instances, especially in the Victorian public service!

Computers offer doctors wonderful opportunities to improve patient care and to deliver this care more efficiently and reliably. Our government proposes to spend billions on e-health initiatives. This is admirable, but are we ready for such a big investment? Overseas experience tells us that massive investments in e-health that are rolled out over a short period have often failed to bring about the clinical improvements and timelines thought possible. Concerns over patient privacy, clinician privacy and the potential for excessive government interference have not been dealt with adequately or transparently.

We also have to keep in mind that many doctors, especially the growing number of overseas-trained doctors, often struggle with the basics of the English language, technical jargon and even simple exercises like writing prescriptions.

E-health is truly a greatly needed reform, but let’s walk before we run.

Step 9

Political approach: rural health initiatives

Real reform: correctly defining rurality

Both Labor and Liberal have made many attempts to improve access to health services and health outcomes for rural communities. Good intentions but poor execution. Kevin Rudd boldly created a new portfolio and minister solely for rural health. He also expanded retention payments for rural doctors working in rural areas. This sounds fine in principle, but it will cost the government millions of dollars while making it in fact harder for struggling communities to attract doctors.

The reason why this policy will fail is that it has loosened the definition of rurality to include many regional centres and some metropolitan areas. As a result, many small, one-doctor, inland rural and remote towns now have to compete with large towns when it comes to attracting doctors.

There is copious data to indicate which localities are more in need than others. Real reform would see bureaucrats spending the time to create fair incentives to attract doctors to the areas of greatest need. Such incentives need to be not only retention grants, but also inbuilt within the Medicare schedule to reward the risk and complexity that comes with working in such settings.

Step 10

Labor approach: Closing the Gap and the Apology

Real reform: a Veterans’ Affairs model

We often despair when watching documentaries about Third World countries: disease, poverty and premature death. I am sure that in overseas countries they show documentaries about the plight of our indigenous people. And I am also sure that one of the contrasts made in these overseas documentaries is that in the finest hospitals of Sydney and Melbourne doctors perform some of the most sophisticated medical procedures in the world, while in our remote Aboriginal communities people die at very young ages from very preventable and very treatable conditions.

Rudd’s famous Apology and Closing the Gap initiatives have yet to score the runs necessary to label them a success. The Aboriginal housing initiative is now rarely mentioned, but ranks as probably the first of this government’s economic bungles.

Medicare has introduced an indigenous health initiative whereby Aboriginal patients enrol with a practice in order to access free pharmaceuticals and free allied health services. This program is costly and heavy in paperwork and is unlikely to close any gaps.

For most Aboriginal patients, access to health services is limited because of money and because of the rules and regulations governing the services. The Department of Veterans’ Affairs has a very successful model for veterans and their dependants. Veterans carry a Gold Card, which allows their doctors to refer them to almost all allied health services, private hospitals and specialists, as well as a range of pharmaceuticals and devices much more comprehensive than the Pharmaceutical Benefits Scheme. Rather than having to enrol patients and undertake burdensome paperwork, the doctors who look after veterans enjoy a modest (5 to 20 per cent) bonus with respect to the Medicare fee.

Such a model for Aboriginal patients would be a true reform, as it is voluntary and allows doctors and patients to choose what is best for the patient when it is best for the patient. Gaps would really close with such a system.

Step 11

Rudd and Roxon approach: end of the blame game

Real reform: a single funder who is the single controller

What has transpired over the last year will do nothing to end the health blame game between the federal government and the states. The federal government supplies 60 per cent of the funds and the states administer the funds. If anything, the blame game will intensify, as the states resent their GST money being ripped from them. As soon as a funding crisis emerges, which is only a matter of time, the blame game will be alive and well, with a new verse being chanted by the states, “You stole our GST, you big bullies!”

Only a single funder, who is also the single controller, will end the blame game. Rudd has us all believing that the sole funder should be the federal government. However the Constitution, the states and the people of Australia may have other views.

Any government can be the single funder-controller: federal, state or local.

True reform would be to remove the government from the equation altogether. We would all pay lower taxes and a more efficient system would develop where patients and doctors decide for themselves. Governments could help needy patients by funding the patient rather than funding their own inefficient health departments.

Step 12

Political approach: rhetoric

Real reform: honesty

Beginning with the public hospital system founded in colonial times, through to the Medicare era, Australian governments have increasingly welded themselves to the concept of free health. Such is the political sensitivity of such matters that Michael Wooldridge once quipped that he would rather scrap the old-age pension than scrap bulk-billing.

The public have now come to expect most of their health care to be free or heavily government-subsidised. Apart from those with children at state schools, health is seen as the most tangible evidence of what our tax money is being spent on.

Demography never lies. We are an ageing population, with greater numbers of welfare dependants and an increasing incidence of expensive, chronic disease. If health care is to remain free and heavily subsidised, it has to be rationed. For rationing to remain politically palatable, it has to be served with lashings of rhetoric: blame-shifting (federal versus states), scapegoats (greedy doctors and pharmaceutical companies), grandstanding (apologies and new ministries), and alarmism (swine flu and systems in crisis).

What a reform it would be for governments to be honest about the limitations of a free system and about their insatiable desires to remain in control of every facet of health care! It is only when politicians are willing to properly consult the real experts, share or part with control, and allow adequate private funding of health that we will achieve real health reform.

Dr Aniello Iannuzzi is a rural doctor in New South Wales, far from Sydney where he studied Medicine and Arts. He is the author of Being Human: For Human Beings (Fontaine Press, 2007).