Saturday 25th April 2009
The National Health and Hospitals Reform Commission (NHHRC) has come up with ideas and innovations that try to anticipate the health system’s future needs.
Better coordination of care and a greater focus on patients underpin a raft of suggestions put forward in an interim report by the National Health and Hospitals Reform Commission.
The Commission was established by the Rudd Government to develop a long-term reform plan for the next five to 20 years. Its goal, according to chairperson Dr Christine Bennett, is a ‘fair health system where we make universal entitlement real’. The Commission’s interim report contains 116 reform proposals spanning almost 400 pages.
The report emphasises primary and preventative healthcare and puts forward bold ideas such as one-stop multidisciplinary clinics, a central electronic registry for health records and a universal dental care system.
On the vexed question of who should run our hospitals, the Commission has come up with a choice of three different pathways that are sure to provoke vigorous debate.
It is not the only contentious issue that has been smudged. The biggest disappointment in the report is the failure to address the government subsidy of the private health insurance industry.
Federal Health Minister Nicola Roxon says the government wanted the commission to think big.
‘This directions paper will give people an opportunity to express their view as to whether some of the ideas are radical and vital, or radical and hair-brained,’ she said.
‘In some areas they are proposing pretty ambitious things that are way, way ahead of where I or the Government’s thinking may be.’
Christine Bennett said the ideas are still realistic.
‘They are designed to serve the health needs of the nation five, 10, 20 years into the future,’ she said.
The good ideas
Primary healthcare centres: or one stop shops with services provided by a multi-disciplinary team of doctors, nurses, and allied health professionals. These centres would be the community’s first point of care.
Medicare for teeth: the NHHRC proposes a universal dental care system – Denticare Australia – funded by taxpayers through an increase in the Medicare levy. People could either choose public dental services or a dental health plan with a private health insurer, which would be paid for by the levy.
Electronic health records: these could be accessed – with a patient’s agreement – by health professionals to ‘improve continuity, safety, reduce errors and duplication and promote patient care’.
Indigenous health: establishment of a National Aboriginal and Torres Strait Islander Health Authority and a more holistic approach to indigenous health and disadvantage.
Better prevention: the commission recommends more resources be allocated to prevention with a suggestion of a new Medicare item for preventions and performance payments to GPs who reduce the rate of smoking among their patients or improve the management of chronic diseases.
Negatives for nurses
Nurse practitioners and advanced practice nurses and midwives have long argued for access to the PBS to prescribe medications and Medicare rebates for their services and to order diagnostics.
The Commission recommended that NPs only have access to the PBS and MBS in areas where GPs are scarce, largely rural and remote areas. Where GPs are not available NPs or a clinic would be paid an ‘equivalence payment’ for those services.
‘The recommendation to allow nurse practitioners to prescribe PBS-subsidised drugs and Medicare-funded diagnostic tests only where GPs are scarce is a weak response that panders to the AMA,’ said NSWNA General Secretary Brett Holmes.
‘If a nurse is capable of prescribing and referring safely in the bush then they are equally capable of doing so in the city.’
Australian Nursing Federation Secretary Ged Kearney welcomed some of the Commission’s reform proposals around aged care such as funding directly to people’s needs instead of aged care places.
‘But the greatest area of concern for the ANF is the lack of recognition of the leading role nurses play in caring for older Australians. The report fails to mention nurses altogether and provides incentives to GPs and geriatricians but nothing around improving wages and conditions for nursing and carer staff.’
There’s an elephant in the room
In an otherwise good report, there is one glaring issue that is dealt with timidly – the role of the private health insurance rebate. Many commentators such as health economist Ian McCauley and Doctors Reform Society president Dr Tim Woodruffe questioned how the Commission’s stated commitment to equity and efficiency could square up with the inefficient and inequitable rebate that now costs the Australian taxpayer a conservative $3.5 billion a year (see box).
Fiona Armstrong from the Australian Health Care Reform Alliance says the report’s biggest failing is the commission’s willingness to accept the ideas of vested interests. She says it has un-reservedly accept-ed that the existing balance of healthcare resources (raised through taxation, private health insurance, and out-of-pocket contributions) is appropriate, even advocating that this unique balance must continue.
‘It would be more appropriate to consider that the government should have full fiscal responsibility for health care but not its delivery. That would avoid the cost-shifting that occurs in the present split,’ she said in The Australian.
‘There needs to be serious questioning of the notion that private health insurance needs to be part of the mix. There is no justification made in the report, nor any acknowledgement of this elephant in the room. For the sake of evidence-based policy, for the sake of efficiency, transparency and fairness, it needs far greater scrutiny in the final report.’
For further details on the NHHRC Report, see Nursing Online on page 45.n
Who should run health?
This is the most controversial issue the NHHRC has been asked to tackle. The Commission has cautiously proposed three structures for discussion:
Scrap private health rebate and give cash to public hospitals
Confidential Treasury briefings to the Rudd Government obtained by the Age newspaper recommend the scrapping of the private health insurance rebate, which it regarded as ‘very poor policy’.
The rebate was introduced by the Howard Government in 1999 to encourage more Australians to take out private health cover.
‘There is no doubt that its $3 billion annual cost to revenue could deliver far better health outcomes if directed to additional capacity in public hospitals,’ the Treasury said.
These costs have subsequently blown out to $3.5 billion a year.
Federal Health Minister Nicola Roxon said the Government would stick to its election promise of keeping the rebate.
The Federal Government has raised the income threshold for the Medicare levy surcharge, which penalises higher income earners who don’t have private cover. Private health insurers fiercely resisted these changes arguing people would dump private cover in their droves. In fact, private health insurance membership grew by 55,000 between September and December last year.
What nurses wanted
The Australian Nursing Federation submission to the NHHRC highlighted the need for better workforce planning and future modelling of the health system’s needs.
The ANF recommended that the Commonwealth Chief Nurse take charge of nursing and midwifery workforce planning and link these to nurse education and clinical placements. It called for extra funding to universities to facilitate these strategies.
These approaches were broadly supported in the report.
The ANF voiced concerns about the access and affordability of high-quality universal health care. It believes that this requires bold measures and reform of funding and workforce practices. The report, it says, falls short of that.
The ANF also called for an extension of nurse roles including for nurse practitioners to be able to prescribe drugs and order diagnostic tests.
The Commission only went half way on this proposal limiting the expansion of the NP role to areas where there was a deficit of GPs.
The ANF called for a greater focus on indigenous health and for better use of information technology in health. These were covered in some depth by the Commission.