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"...public opinion deserves to be respected as well as despised" G.W.F. Hegel, 'Philosophy of Right'

hospital reform: local governance « Previous | |Next »
April 8, 2010

Health reform proceeds slowly. There is little movement towards health reform being less hospital-centric and more focused on the provision of community-based and preventative care or substantial mental health reform. Hospitals are places where people only need to be because of acute clinical danger (e.g. in trauma and psychiatry), or where rapid assessment requires investigations of the highest technology.

Australia still does not have a comprehensive platform on which to build community-based health services, as the brief flirtation with a nationally mandated community health program initiated in the early 70s was undone by subsequent governments.

MoirAhospitalsjpg. .jpg

The health debate is still about hospitals and it is mostly about the politics of health. Victoria and Western Australia are resisting the Rudd Government's proposal for the Commonwealth to take 60 per cent control of hospital funding by taking it form GST revenue. The debate, or theatre, has been about funding, not the creation of local hospital networks or a shift to activity-based funding.

Little has been said about governance, even though both major parties have advocated a return to the idea of local decision-making for pubic hospitals. Philip Davies points out in The Brisbane Line the local governance works for how hospital services should be delivered:

Figuring out the mix of staff needed to run a hospital, establishing a positive workplace culture, hiring the right doctors and nurses, choosing the equipment they need to work efficiently, and deciding how much to pay them are all issues that a local board would be well-placed to make. Those are arguably the areas where innovation on the part of local boards could have the greatest positive impact on hospitals’ performance.

The aim here should be to free local managers and clinicians from oppressive centralised control and foster innovation in local service delivery. The downside of clinicians playing a key role in future hospital boards is that their professional interests may be at odds with those of the local community. We may have a conflict between the protecting the high incomes of specialists at the expense of the equitable provision of healthcare in a world of limited resources.

Consequently, planning should be done at a state level. Davies says:

Individual hospitals’ roles need to be clearly defined and to fit together to form a coherent whole. Decisions about the location of costly, specialised services cannot be left to local hospital boards, however well informed or well-intentioned they might be. Difficult questions of resource allocation and prioritisation (‘rationing’ if you prefer) are a necessary part of planning health care which we would delegate to non-elected bodies at our peril.

There is a role for government to set standards, allocate resources, define priorities and ensure coherence in services.

| Posted by Gary Sauer-Thompson at 3:53 PM | | Comments (7)


You've forgotten to mention the Rudd Government’s recent announcements aimed at keeping diabetes patients out of hospital by improving their care in the community.

There's not a similar focus on improving the community-based care of patients with mental health problems?

The Rudd Government did announce the introduction of voluntary enrolment for patients with diabetes and linked this with access to additional allied health services and performance payments for the GP.

It is a positive first step.

There have been shifts. The authors of "The future of community-centred health services in Australia: lessons from the mental health sector" in the Australian Health Review (2010, 34, 106–115) highlight the following.

Hospital-centred specialist doctors had historically assumed an almost automatic right of clinical leadership over vertically organised nursing hierarchies. This model has progressively given way to the more flattened organisation of the multiskilled interdisciplinary team which can operate more flexibly from multiple site. This has been developed most extensively by community health teams.

Secondly, an overwhelmingly biomedical emphasis in the hospital domain is gradually giving way to wider models of care, based on mounting evidence demonstrating that there is not just mainly a biological dimension, but also psychological, social and cultural factors which contribute significantly to positive outcomes in most medical and surgical conditions.

Brumby has said that he would not sign up to the Prime Minister's proposal to wrest more control of hospital funding from the states because there was nothing in it for Victoria's health system.

He has an alternative plan

A plan to stick a spanner in the works to further Victoria's self interest not national health reform.

I used to think Bracks was bad enough, but Brumby is the pits as far as I'm concerned, for so many reasons I can't count them.
I wonder if there is anything going on behind the scenes inside Labor involving the likes of Conroy (rightie ally of Brumby and Rudd), Gillard (potential rival to Rudd) and so on.

I note the cartoonists have come to grips with representations of female politicians.
Been necessary, but Moir's latest really gets to the essence of how the system, when run by crafty sods like Howard and Rudd, employs them and deals with their reciprocal complicity.