Australian healthcare reform: in need of political courage and champions

Internationally, Australia’s health system is held in high regard. Our citizens enjoy life spans second only to those in Japan.1 The World Health Organization measures a nation’s health attainment as a composite of the average level of population health and the general distribution of population health or health equality, the level and extent of the health system responsiveness, and the fairness of contributions to health financing by households. According to the WHO’s benchmark — the overall health system attainment index — in 1997, we ranked 12th among 191 nations.1

But all is not well with Australia’s health system. Its edifice is cracking under the strains of a growing mismatch between its capacity to deliver quality healthcare and the changing demands of our communities. Symptoms of the system’s stresses include:

• the free fall in the number of general practitioners who bulk bill,2 and the consequent threat to Medicare’s principles of universality and equity of access;

• the short supply of health professionals, particularly nurses3 and general practitioners;4

• the increasing occurrence of hospital access block and hospital ambulance bypass,5 and the growing elective surgery queues;

• the problem of hospital exit block, reflecting the short supply of community-care services, particularly for older people,6 and the breakdown in social networks;

• the inherent inability of a system organised for acute, episodic care to efficiently provide continuous long-term care;7 and finally

• the conflict between society’s increasing demand for health services, the high cost of technology-driven medicine and new pharmaceuticals, and the political and fiscal imperatives of the guardians of the public purse.

Critical to the viability of our health system are the Australian Health Care Agreements (AHCAs). These 5-yearly political pacts define the joint funding responsibilities of federal and state or territory governments in providing free public hospital services.8 One of the drawbacks of the AHCAs is their impotence in promoting reform. And our health system is sorely in need of reform!

This imperative was recognised by Australian ministers of health in April 2002, when they collectively adopted a reform commitment, underpinned by the principles that the federal and state or territory relationship in health funding should ensure that:

• the provision of optimal care and health outcomes be independent of jurisdictional boundaries;

• the respective jurisdictions work cooperatively to improve the health and wellbeing of the community; and

• the next round of AHCAs (2003–2008) be outcome-oriented.8

Suddenly, the winds of change were stirring in Australian healthcare and fanning expectation of reform. The ministers promptly established nine reference groups to address and advise on issues affecting current healthcare. These briefs included the continuum across preventive, primary, chronic and acute care; improving the interface between aged care and acute care; cross jurisdictional cooperation on workforce training and education; the interaction between hospital funding and private insurance; improving Indigenous health, mental health and rural health; quality and safety; and, concluding this impressive and inclusive list, was information technology and research.8

The nine expert groups met, deliberated, and, in record time, in September 2002, presented to Australia’s health ministers a comprehensive agenda for reform.9 The ministers considered the road maps for reforms, and highways were identified for their implementation, but, to date, the reform vehicles have remained locked up in bureaucratic and ministerial garages.

In the meantime, the ministers have resumed their adversarial political rhetoric, punctuated as always by fiscal bickering and buck-passing. This return to tiresome political form has undoubtedly fuelled widespread mistrust and cynicism among health professionals and consumers.

One outcome of this despair and discontent has been the Australian Health Care Summit held in Canberra on August 17–19, 2003. The Summit was attended by more than 250 delegates, drawn from across the healthcare spectrum. They included academics; administrators; allied health and other professionals; clinicians; consumers, economists; experts in health policy, mental and public health; politicians; and people and health professionals from Indigenous, rural and remote communities. Despite the Summit’s claim to be an independent, bipartisan gathering, the absence of the Federal Minister for Health and Ageing, Senator Kay Patterson, and the minimal representation of the Australian Department of Health and Ageing, were duly noted. Furthermore, the Summit’s claim of independence did not deter lightning forays by the Premier of New South Wales, Bob Carr, and the Leader of the Federal Opposition, Simon Crean.

Despite the politics, what did the Summit achieve? It reaffirmed the egalitarian and socially cohesive principles underpinning Australia’s healthcare (Box). It identified inhibitors of and promoters for health reform, which are detailed in the Summit Communiqué.10 The Summit’s sixteen workshops spawned detailed suggestions for reform. Finally, there was a recommendation for an independent national body to drive health reform.10

However, the real message emanating from the Summit was the depth of desire for healthcare reform among consumers and professionals, and the wealth of innovative ideas and solutions that the healthcare community has to offer when committed to the cause.

If only one message comes from the Summit it is that Australian healthcare reform is in dire need of political champions and cooperative federalism to harness the people and professional power so evident at the Summit. Without the spirit of cooperation, future health ministers may well look back to 2003 and say “we did nothing”.

And that would be a shame.