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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.
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.
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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?