Crunch time for Australia's health

John Dwyer

Together with a number of like minded colleagues I have, since 2003, been proposing structural changes for our health care system. I wish to present here a summary of my approach and recent thinking based on what I consider to be the likely political responses to suggestions for reform.

We share the wish to have in Australia a health system wherein all Australians have timely access to safe, high-quality health care, based on need not personal financial wellbeing. Such a vision requires that our health system is patient, focussed with all aspects of care integrated, indeed, seamless.

It is the wretched jurisdictional inefficiencies associated with the division of health related responsibilities between the Commonwealth and the States that provides the biggest obstacle to integration. Political intransigence (poor leadership, to be honest) has robbed us time and time again of the chance to reform the system.

It is almost thirty years since the paper edited by Shane Solomon and endorsed by all health ministers (State and Federal) promised to fix this great divide. Many of us feel that the new Labor government offers a "last best chance" for achieving this goal in the foreseeable future. But what of the political realities today?

Even the Howard government recognised that, if we were designing a health system from scratch, we would have the Commonwealth responsible for a system that would be implemented by Regional Health Authorities (RHAs). In February 2008, the Rudd government established the National Health and Hospitals Reform Commission (the Commission) to provide a 'blueprint' for reforms to the Australian health system. On 16 February 2009, the Commission released its interim report, A healthier future for all Australians.

The Commission's "Option B" comes close to a "lets start again" approach. In my opinion we need a variation on Option B, the most attractive of the three options, for two reasons.

Firstly, after discussions with a number of health ministers and two premiers, I am convinced that the States will not give up their responsibility for hospital care despite the public utterances to the contrary by some leaders.

The Rudd government has made it clear that if the States don't meet benchmarks that clearly indicate that their hospitals are performing better by the middle of 2009, Canberra will take over financing and therefore control of public hospitals. Under such circumstances, States surrendering their hospitals would be deemed to have failed their constituents even though the benchmarks in question are very poorly defined.

At the Commonwealth end, I do not believe the government wants to ask Australians to approve the necessary constitutional changes required for federal government control of the health system (not just financing).

No federal health minister would willingly wish to become embroiled in almost daily newspaper reports of hospital dramas across the whole nation! My fear is that, by calling for such a restructuring, we are likely to make a very major challenge just too hard. A compromise that solves these problems but achieves our major goals is required.

Secondly, it has become ever clearer across the globe that any quality health system must pay much more attention than heretofore to the full breadth of issues that determine the health of individuals and the community; the "social determinants of health".

For this to occur, States and Territories need a "Health Minister" with a small department to promote the networking of health initiatives across all major policy plans. (Education, workplace, urban design, transport, industrial laws etc).

We do NOT want this health minister or his/her department involved in the day-to-day delivery of health services. How can we keep States and the Commonwealth involved but still have an integrated health system controlled by one bureaucracy?

[Click here to read the full paper]