Australian healthcare reform: ailments and cures

Despite their protests that it was a “hold-up” and that it “may tragically be the death warrant for some people”,1 last month our state premiers capitulated and signed the 2003–2008 Australian Health Care Agreements (AHCAs). Since then, the healthcare crisis has all but disappeared from the front pages of newspapers and television screens, but, for the community, the crisis remains a daily reality. The desire for healthcare reform, so evident at the recent Australian Health Care Summit,2 will continue, and the demand for the AHCA’s reform blueprint3 to be implemented will only increase in the face of the ongoing inertia of our health ministers. In short, there is now widespread expectation of less political rhetoric and more action.

However, sustainable reform requires a change in the political and professional landscape of Australian healthcare. In a keynote address at the Australian Health Care Summit, leading health reform expert John Menadue diagnosed the ailments of our healthcare system, and proffered some cures. His address, Healthcare reform: possible ways forward, appears in this issue of the Journal (page 367)4 as the first in a series of selected addresses to the Summit.

Menadue’s diagnostic skill comes from his role in promoting healthcare reform as chair of the New South Wales Health Council,5 and, more recently, as chair of the South Australian Generational Health Review.6

It would seem that Australia’s healthcare system is not at all well. In the upper echelons of healthcare, Menadue has identified a multitude of ailments, including:

• endemic political buck-passing across jurisdictional divides;

• lack of public honesty by governments as to what the healthcare system can provide given its limited funding; and

• a preoccupation on the part of health ministers and their advisers with media management and health micromanagement, much to the detriment of more significant healthcare issues.

In essence, our health system is overpoliticised. Short electoral cycles, constant ministerial turnover and the body politic’s demand for instant solutions are not compatible with reforming a large and complex system.7

At a middle level the ailments include:

• isolated healthcare professionals who run insider debates with little involvement of the community;

• a system that is hospital-centred at the expense of primary care, population health and community-based care; and

• a pervading executive ethos of decision paralysis.

Menadue’s diagnosis of Australian healthcare is that it is institutionalised, introverted, and wary of innovation and change — a system constantly crying out for “more money please”.4

However, all is not doom and gloom. Menadue also offers possible cures. Most prominent among these is to have Commonwealth and state governments involve the community in setting priorities in healthcare spending. After all, it is about their health and their tax dollars!

Reform means change, and change is always difficult to achieve, but a real life example of healthcare reform and change management has been in train in NSW since 1999 (see Box). In that year, the then NSW Minister for Health, Craig Knowles, initiated a major review of the state’s health system by two independent bodies comprising health and other experts, consumer representatives, and headed by prominent individuals from outside the health system. After an extensive and consultative process, the overarching recommendations from one of these bodies, the NSW Health Council, were the need for metropolitan-wide planning of clinical services (including the role of district hospitals in clinical networks) and increased engagement of senior clinicians in planning and administering health services.5 The NSW government promptly accepted the major thrust of the report, and the health minister initiated a cascade of processes to improve healthcare delivery in the greater metropolitan region (see Box).8 The change process is driven by the Greater Metropolitan Transition Taskforce (GMTT), an independent external body established to monitor progress and facilitate progress (see Box).

The principles for achieving reform and managing change evident in this NSW experience include:

• a health minister with vision and political clout;

• use of respected outsiders to lead independent bodies in exploring frameworks for reform through extensive and inclusive consultation;

• timely acceptance of major recommendations by the government;

• delegating implementation of change and progress monitoring to an independent body, outside the bureaucratic stream, but with “buy in” of professional expertise; and, most importantly,

• giving “experts” the freedom and time to achieve the task.

Overriding all of this, however, is the need for a collective political will for meaningful reform.

The AHCAs have been signed and our health ministers have an interlude of no more than 4 years. Over a year ago, all our health ministers agreed on an agenda of reform and change.10 If there is no meaningful movement within the next year or so, patients, doctors, nurses and other health professionals have every right to say “a plague on both your houses”.11