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health reform: hospitals or primary care « Previous | |Next »
July 30, 2009

A debate about health care is underway in Australia as a result of the National Health and Hospital Reform Commission's A healthier future for all Australians final report. It has organized its thinking around four issues: taking responsibility for health; connecting care; facing inequalities; and driving quality performance.

If the reform agenda is be a big part of the Rudd pitch for the 2010 election, then Ross Gittens warns that we should not expect too much from the Rudd Government, as it has a record of of over-promising and under-delivering. Our health culture is still one in which policies are driven by due process and authority and not by urgency or need.


Currently, the politics of health care is driven by access to hospitals----ie., waiting times for elective surgery and emergency services dominate discussion, the media and elections and ad hoc dab‟ reform aimed, , at one-off improvement rather than the creation of an adaptive, self correcting system, proactively seeking system improvement.

The ground is shifting. Even the AMA is acknowledging that general practice is not just about doctors any more. GPs, they say, must be supported by practice nurses, allied health and preventive health care providers to ensure we build on the strengths of Australia’s primary care network and developing effective e-health systems. How both of these happen is a bone of contention. The common ground is that the one issue that offers the greatest promise for health care reform is connecting care more effectively and that it is primary health care and prevention that provides the pathway for the much better connection of care that is needed for consumers across programs, services and governments.

This common ground is contested by Jeremy Sammut, a research fellow at the Overcrowded hospital system needs structural reform to end bed crisis op. ed. His position is that core concern in the health sector is the critical condition of the public hospital system throughout Australia. He says that the three-hundred page reform ‘blue print’ from the National Health and Hospital Reform Commission:

has identified the major problem. The reality is that Australia’s dangerously overcrowded public hospitals don’t have enough beds to provide a safe and timely standard of care even for emergency patients. Unfortunately, the NHHRC has strongly supported a range of non-solutions. The primary care reforms it proposes will not help our dysfunctional State-run public hospitals cope with an inexorable rise in demand from an ageing population...As more and more people live to older ages, a tsunami of demand will break in public hospitals. Increasing numbers of ‘very old’ patients will inevitably require emergency and bed-based hospital care due to the age-related onset of chronic conditions...

His argument is that the wrong-headed premise of the Rudd Government’s reform agenda is that the Commonwealth must spend billions on a national network of comprehensive general practice ‘Super Clinics’ to take pressure off hospitals.

What Sammut and the CIS are opposing is the argument that there are some structural changes that offer openings for long-term changes in the way health is delivered – away from the acute, hospital-centred model towards a system that puts more resources into prevention and care in the community.

Sammut's position is hospital centric. He argues in favour of rebuilding the hospital system with the Commonwealth taking full control of public hospital funding; introducing Medicare-issued, casemix-calculated hospital vouchers to pay for treatment in either public or private hospitals; state governments re-introducing local public hospital boards with full financial and administrative responsibility for their facilities; and closing down the area health services and use the money saved to fund vouchers and open and staff more hospital beds. It is a policy to reduce the health bureaucracy and put the savings into increasing beds in public hospitals.

Public hospitals need money to undertake reforms to become more efficient and safer for acute care. the case is compelling. It's now 15 years since the landmark Quality of Australian Health Care Study which found that 16.6 per cent of all hospital admissions were associated with an adverse event - half of which were considered "highly preventable". In March, Professor Jeff Richardson, of Monash University's Centre for Health Economics, updated those figures. He likens the number of such events today at approximately equivalent to one jumbo jet crashing every two weeks, each resulting in the deaths of 350 Australians. The cumulative unnecessary deaths since the publication of the QAHCS report would exceed the number of Australians killed in World War 1.

However, it is also the case that the health profile in our society has changed from episodic care to chronic health conditions (obesity, diabetes, mental illness, musculoskeletal conditions, ageing) and that the system is structured around hospitals providing relevant interventions for acute episodes. These chronic conditions are better managed within the primary care sector. Professor Hal Swerissen says:

The public hospital system should not be the first point of contact. It provides the backstop for the primary and community care system. If the first tier of the health system is not working well, then the hospital system will be put under stress.Not only will a stronger primary care system improve people’s quality of life by preventing disease, disability and distress, it should reduce pressure on the public hospital system

The better the comprehensive care plan (integrating many different specialities), then the fewer acute episodes that should occur is the argument. Better access to primary healthcare will mean reductions in obesity and smoking and earlier and better treatment of chronic diseases, such as diabetes. Hence the need to shift away from the acute, hospital-centred model towards a system that puts more resources into prevention and care in the community.

| Posted by Gary Sauer-Thompson at 9:44 AM | | Comments (3)


I am surprised by the dentists opposition to the proposed $3.6 billion-a-year Denticare Australia scheme since dental or oral health is a major problem for people on low incomes.

Denticare would offer universal access to preventive and restorative dental care and dentures to be funded by an increase in hte Medicare levy by 0.75 per. The proposal would allow people to choose between private and public dental health plans, both of which will be funded by the scheme.

The Australian Dental Association argued the Denticare scheme would deliver limited services such as teeth cleaning, extractions, fillings and dentures, but neglected more invasive procedures. Is that so? What is their alternative?

There is nothing on their website.

Government –answerable departments – are increasingly dedicated to short term ministerial tasks of appeasing politically effective groups. Historically the bureaucracy has comprehensively failed to reform important elements of Australia‟s health system or even to ensure that the health system is safe----eg., the issue of adverse events in the Australian health system referred to by Jeff Richardson of Monash University's Centre for Health Economics above.

Richardson inference is that the health bureaucracy is capable of major failures and are increasingly questionable bodies for the short, or even medium term, direction of the health system.

It's useful to consider the way court physicians during a couple of Chinese dynasties operated (cannot remember which, and it may be apocryphal, but even so, it's a neat idea): given significant benefits ... until a member of the imperial family got sick.