Opinion & Commentary
Hospital boards trump bureaucracy
Health policy did not receive the attention it deserved during the federal election campaign. This was disappointing because there is a clear difference between the way the government and the opposition will tackle the contentious issue of public hospital administration.
The Gillard Government's Local Health and Hospital Network policy is in keeping with the planning philosophy that has dominated for the last 30 years. It reinvents the idea that hospitals must form part of bureaucratically-run regional health networks that include community care facilities to ensure communities have a full range of health services.
Tony Abbott's announcement that a Coalition government would scrap regional bureaucracies and re-establish local hospital boards was condemned by many health commentators and lobby groups as simplistic and anachronistic. Yet now the parliament is hung, the Opposition Leader's plan to put local community members back in control of their hospitals might help him win the support of the country independents determined to get a better deal for rural health services.
No one knows how the negotiations with Labor and the Coalition will play out. Both parties agree that rural hospitals should receive a combination of fixed and activity-based funding to ensure their viability. But I suspect, based on the events of recent decades, that the Gillard Government's local networks will not prove attractive to the elected representatives of rural seats in NSW and Queensland.
Under the regional structure created in the 1980s in NSW and 1990s in Queensland independent hospital boards were abolished and centralised bureaucratic management was imposed over local hospitals. This has proved deeply unpopular in rural communities because residents rightly associate the administrative upheaval with the start of the funding and bed cuts that have reduced services and led to hospital closures in many communities.
The bad news for Labor is that its plan will essentially preserve that hated system. The worse news is the recent announcement there will be 15 LHHNs in NSW. The 'new' system will restore the arrangements in place prior to 2005 when then Health Minister Morris Iemma cut the number of area health services to eight. This is rearranging the deckchairs on the Titanic with a vengeance.
This comes in the wake of the shutdown of another rural hospital by NSW Health. The emergency and in-patient services at Gulgong Hospital in the west of the state are to be closed and replaced with a community care facility.
There is no question rural communities need improved health services across the board not just adequate hospital services. The national GP shortage has hit the bush especially hard. The decision to 'close a hospital, and open a community health centre' might therefore sound like a half-glass full policy. But it actually illustrates the philosophical divide that separates the Gillard and Abbott policies.
Politicians of all persuasions pay at least lip service to reducing bureaucracy and ensuring hospitals are managed closer to the ground. They are aware that the public hospital system is crippled by budget blowouts and shortages of basic services because, as Abbott rightly said during the campaign, there are too many bureaucrats and not enough beds for patients.
However, federal and state politicians on both sides of politics, including Abbott's colleagues in the NSW State Opposition, reject local hospital boards in favour of continuing with administratively complex and costly health networks. This is partially based on the misconception the area health bureaucracies provide regions with comprehensive healthcare services.
This is a myth. State community health services have never taken responsibility for the non-hospital clinical care of most patients. Instead, the cost of has been shifted onto the federally funded Medicare scheme. Most community health services provide non-patient focused public health type services which diverts funding away from essential hospital services.
The reality is that the political support for regional 'networks' has little to do with ensuring local communities, in either urban or rural areas, have a good mix of clinical services. What it mostly reflects is the medical politics that underlies the policy debate.
Since the 1960s, public health academics have won the ear of policymakers by promoting the 'population health' ideology that is the foundation of the regional networks philosophy. This ideology is anti-hospital, heavily in favour of multidisciplinary community-based services, and has had a pronounced effect on health administration and university-based nurse education. The heavily-unionised nursing and community health workforces have the political clout to influence policy outcomes in a pro-public health direction. Turf-protecting state bureaucrats perennially regurgitate the ideology to justify the retention of area health bureaucracies and discredit the more efficient alternative—a return to local boards.
Country people tend not to like academics, unions, and bureaucrats. Someone who has just pushed a first term government to the brink of extinction doesn’t need gratuitous political advice. But as he courts the country members, it might be worth Abbott's while to point out that political factors, rather than good policy, is behind the government's decision to stick with the approach that has failed their communities for a generation.
It might also be worth stressing that promises of more community services under Gillard's rebranded State Government-controlled LHHNs never have and never will solve the shortage of general practitioners. By contrast, once the management is devolved to community boards, rural hospitals would be free to operate as the hub around which to rebuild other services.
For example, outpatient departments (which have fallen victim to cuts by state bureaucracies) could be reopened or expanded, particularly as outpatient services will be funded by the Commonwealth under the new National Health Care Agreement. This might help to neutralise the superficial appeal of the government’s Super Clinics, especially as the bush will not have to wait for the federal bureaucracy to get its act together and implement that much delayed program.
Jeremy Sammut is a research fellow at The Centre for Independent Studies.
