Opinion & Commentary
There’s no real reform for health and hospitals on the horizon
Despite not many surprises being anticipated, all observers are keenly waiting for the final report of the National Health and Hospital Reform Commission to be submitted to the federal government at the end of June. Though the interim report released in February was long and exhaustive, it signalled pretty clearly what the commission’s main recommendations are likely to be.
The final report is highly likely to recommend a Commonwealth takeover of all primary care funding and policy responsibilities from the states. The Super-cum-Mega GP Clinic plan will be endorsed, together with proposals to expand both preventive and coordinated primary care services, probably involving capitation funding for enrolled patients.
What we can expect to see is another report that sticks faithfully to the major themes and slogans of the Rudd government’s declared health reform agenda. In short, we will again be informed that greater public investment in primary care services is essential ‘take pressure off hospitals’ and create a less ‘hospital centric’ health system.
Just what the government will do about the final report is another question altogether, given the new fiscal realities of the post-GFC world. It is highly unlikely that billions of dollars will be made available for capital infrastructure and recurrent funding to create the national network of GP Clinics that both the government and the commission have already endorsed.
If the commission is interested in making a more lasting contribution to the health reform debate, rather than just produce a set of recommendations that are politically tailored to suit the government’s agenda, I would hope the final report takes a stronger evidence-based approach and displays greater respect for evidence.
The refreshing aspect of the interim report was the part that dealt with public hospitals and told part of the truth about the real cause of the crisis in overcrowded emergency departments. The report explained that hospitals which routinely operated above 100% bed occupancy were unable to provide timely unplanned admission for emergency patients due to the lack of available beds.
At last, or so it seemed, policy makers were being levelled with and being told that the critical national shortage of acute beds, due to twenty-five years of public hospital bed cuts, means that hospitals don’t have enough beds to care for an older and sicker population.
Unfortunately, policy makers were also advised to pursue a non-solution.
Disappointingly, the interim report declared that building strong primary care services was the single most important reform priority. It continued to run the line, with scant evidence to support it, that providing coordinated or multidisciplinary primary care in government-funded GP Clinics will keep sufferers of chronic disease and frail elderly patients ‘well and out of hospital.’
The case against coordinated care alleviating demand for hospital care is that a number of studies have shown that the main effect of better coordination is to uncover unmet need and ensure patients receive all beneficial care, including hospital care. This was the main finding of the Australian Coordinated Care trials, a multi-million dollar government Commonwealth program, the results of which, not surprisingly but again disappointingly, do not feature in the interim report.
The commission was at least aware of these concerns and was concerned enough to commission a separate discussion paper on the subject.
The paper confirmed that while it had been postulated that coordinated care would substitute for hospital care by improving the management of chronic conditions, the evidence was equivocal. It was noted that success in small scale trials had not been replicated when translated into larger population based interventions.
The bottom line was that the ‘expected reduction’ in hospital admissions did not occur. The whole notion of investing in coordinated care as a ‘hospital avoidance’ strategy was debunked.
Nevertheless, this did not stop the author(s) of the section of the interim report that dealt with primary care reform from waxing lyrical about the need to provide the ‘right care, in the right setting, at the right time’. The report even went so far as to claim that ‘it is well known that a sound working system of primary health care means avoidable hospitalisations.’ This is well-known only if you don’t read or if you ignore the commission’s own discussion paper.
It is timely to remember that the members of the commission are charged with drawing up a reform ‘blue print’ that is intended to deliver long-term reform and a more sustainable health system. Rather than mimic the government’s slogans, the health debate would be better served if the final report was honest about the gaping holes in the evidence that raise serious doubts about the Rudd government’s pet health policies.
Policy makers across the country would then have no excuse to believe the false promise that primary care-focused health reform will solve the hospital crisis.
Dr Jeremy Sammut is a Research Fellow at The Centre for Independent Studies and author of The False Promise of GP Super Clinics.
