2012 National Health Reform Summit: the long and winding road
Day 1 – Health Reform
The ACHRA Summit brought members and key stakeholders together for two days of stimulating and vigorous discussion about the future of health reform in Australia. The first day covered the overall health reform agenda and the second focussed on oral health issues. A summary of the main sessions is following.
The Summit was opened by federal Minister for Health and Ageing Tanya Plibersek. The Minister gave an overview of the Government’s health reform agenda and re-iterated her commitment to involving consumers and stakeholders at all stages of the implementation process. She discussed how important access to health care was for people who are already disadvantaged as dental problems can reduce the capacity of people to gain employment and interact socially and professionally with others. She acknowledged the important work done by ACHRA and emphasised her willingness to listen and learn from members’ experiences and views.
Associate Professor Gawaine Powell-Davies from the University of NSW presented an overview of primary health care reform. He argued that primary health care can be defined in many ways, e.g. by the type of care, the location, the conditions treated or the philosophical approach. Similarly, there are a wide range of services which can be included in the definition of ‘primary health care’ but not all of these receive the same level of funding or policy attention.
In Australia, the services included in the definition of ‘primary health care’ (PHC) fall under the jurisdiction of federal, state/territory and (in some cases) local councils. This makes a developing a unified approach to PHC difficult. There is good evidence that overall a primary health care-focussed health system achieves better outcomes for a lower cost and is more equitable than one focussed on hospital-based care.
There is evidence from the UK and NZ that primary health care meta-organisations (like Medicare Locals) achieve positive outcomes, in terms of increased access to care and a greater focus on multi-disciplinary care. We need reform in PHC both because of external pressures (such as an ageing population) and internal problems (including poor coordination between services and workforce shortages).
The current reform agenda addresses some of these issues but overall it lacks a coherent vision for PHC and fails to address some central barriers to improvement, such as fee-for-service. To maximise the potential of the reforms, they need to engage with some of the ‘orphans’ in PHC (e.g. consumer self-help organisations), properly fund Medicare Locals, increase integration and accountability and develop funding systems which incentivise quality care.
Professor Stephen Duckett gave an incisive presentation identifying gaps in the reform agenda and some flaws in its implementation. He argued that there are always competing priorities in health – the key question for AHCRA is how to decide which priorities are the most important and whether that decision is based on equity considerations, ultilitarian values or other principles.
The aim of reform measures is to change behaviours of organisations, health care providers, communities and individuals. This needs to be done with the available levers which impact upon the range of factors influencing behaviour, for example, financial incentives.
There are a number of new organisations but their relationships are not always clear. There are also some major gaps, including workforce, local responsiveness and financial barriers to access. The main focus of reform measures should be improved access, quality and sustainability. All of these are achievable and do not need to be traded off against each other.
Quality has been an issue for some time and has not yet been adequately addressed. Sustainability can be addressed through improving efficiency and developing better workforce policies. Efficiency should not simply be about cost cutting and should not undermine equity. There is also a need for better quality data to support the reforms and measure performance.
There are some outstanding areas which have not been addressed sufficiently by the reform agenda: these include Indigenous health, consumer empowerment, the need to facilitate self-management, mental health, oral health, an integrated safety net, and Early Start.
Professor Fran Baum of Flinders University gave some historical context to the current reform agenda pointing out that it draws on the experience of community health centres, which have largely been forgotten in the mainstream health policy discourse.
Community health centres (such as Aboriginal Health Services) have people with the skills necessary to deliver integrated PHC, including community engagement and multi-disciplinary care. It is important that their knowledge and experience is harnessed in the implementation of the reform agenda.
Professor Baum also discussed the current funding and reporting systems which she argued are overly complex creating an unworkable burden for small health services. This will hinder the successful implementation of the reform agenda and stifle the necessary innovation and local flexibility required to deliver high quality health care.
Primary Health Care can be divided up into curative, preventive, rehabilitative and promotive services. A population health approach focusses on what will improve health overall rather than how to increase capacity of health services. As the main causes of most health problems are economic and social the solutions must also be economic and social (rather than health care focussed). This requires responding to health problems by addressing underlying social, environment and economic factors.
The ‘Health in All Policies’ (HIAP) approach by the SA Government aims to include health considerations in the development of all policies and programs. It was partly prompted by the rising health budget and recognition that this could only be addressed through a comprehensive approach.
HIAP works collaboratively with government agencies to apply a ‘health lens’ to all new policy proposals. It has high level governance and support within government. It provides benefits not just for health but for other sectors as well. HIAP provides an excellent model for promoting population health benefits through all legislation at a national level.
Professor Baum also cautioned against developing or promoting a ‘crisis mentality’ in health through media statements and other communications. Developing and maintaining a ‘crisis mentality’ in health may not be productive in promoting the need for a strengthened PHC sector and a focus on social determinants. Manufactured crises can play into the interests of existing power bases in health which often resist the need for reform.
AHCRA Chair Tony McBride posed the question ‘Has the reform agenda achieved its aims?’ Overall, he argued that there have been many measures introduced which deliver significant and lasting changes. However many of these were changes to structures and processes and the impact of these on health outcomes cannot yet be determined.
There is a significant focus within the reform agenda on improving efficiency with a number of measures focussed on this outcome. There are also a number which aim to improve fairness and equity, although it is not clear how that will be measured.
There are not many measures which focus on stronger prevention and early intervention and very few on promoting consumers involvement and engagement in health care. Overall, for the reform agenda to reflect AHCRA’s priorities there needs to be an increased focus on equity/fairness, consumer/community engagement and prevention/early intervention.
AHCRA needs to focus on how to advocate for these issues in order to influence the implementation process over the next 1-2 years.
The discussions at the Summit focussed on the need for primary health care to be placed at the centre of the Australian health system. Members agreed that this should be one of AHCRA’s key priorities in its advocacy and other work. The social determinants of health were also discussed as crucial factors in affecting people’s health but which are often ignored by health policies and programs. Participants stated that they supported a stronger consumer focus, with consumers taking on a more significant role in all aspects of health care decision making. They also strongly supported a system of universal affordable oral health care. Achieving both these goals was seen as relying on actions to improve equity.
Day 2 – Oral Health
The second day was titled ‘Why has dental health been getting the brush off?’ and was hosted jointly by AHCRA along with the NRHA, ACOSS, AHHA and PHAA . Participants represented over 80 health consumer and provider organisations and came together to agree on how best to secure better dental health care in Australia.
Overall, participants supported a universal dental health scheme. However, they recognised that this may be a long-term goal with a number of smaller interim steps that needed to be considered first. All of those at the meeting accepted that the additional resources promised by the Federal Government should be provided as entitlements to those in greatest need. This includes low and middle income families, Aboriginal people and Torres Strait Islanders, and people in rural and remote areas.
There was strong agreement on the need for a greater focus on oral health promotion, including through public health measures relating to fluoridation and food and nutrition. There was a discussion about the possibility of a national funded campaign to promote a universal dental care system. To achieve this, participants felt that clearer evidence will be required about the community’s needs and how best to meet them in different settings. They strongly supported an approach to oral health care that places it within patient-centred primary care. They also argued for a flexible approach to funding so that the oral health workforce can work in partnership with other health care settings, such as GP clinics, aged care facilities and in services for people living with a disability. Oral health funding and infrastructure programs need to be flexible enough to support the more widespread adoption of alternative service approaches ( for example through public/private partnerships, co-located multidisciplinary teams, and mobile services).
A communiqué was issued by the Summit participants and representatives from the event took it in person to deliver to the Health Minister’s Office.
[h4line]Tuesday, 14 August 2012, The Brassey Hotel, Barton, ACT[/h4line]
This year’s Summit focussed on assessing progress to-date with national health reform, especially primary health care, and setting the advocacy agenda for AHCRA.
The Summit was followed by a lobbying day in Parliament House.
Day 2: – ‘Why has dental health been getting the brush off?’ jointly run by NRHA, ACOSS, AHHA, PHAA and AHCRA. See www.ruralhealth.org.au for full proceedings.
A delegation from the Oral Health Forum arriving at Parliament House to deliver the communique to Minister Plibersek’s office: Martin Doolan (SA Dental Service), Andrew McAuliffe (AHHA), Tessa Boyd-Caine (ACOSS), Gordon Gregory (NRHA), Tony McBride (AHCRA) and Michael Moore (PHAA).
Health reform: The long and winding road
Tuesday, 14 August 2012, The Brassey Hotel, Barton, ACT
|Welcome to Country: Matilda House|
|The Hon Tanya Plibersek, Minister for Health
Official OpeningPlay (MP3)
|Associate Professor Gawaine Powell Davies, CEO, Centre for Primary Health Care and Equity, University of New South Wales
What does success in primary health care reform look like? PresentationPlay (mp3)
Download Presentation (pdf)
|What broad reforms are most necessary in the next three years? Which are the specific priority reforms? What are the most realistic? Where should AHCRA focus its limited resources? Professor Stephen Duckett, Health Policy, La Trobe University and former member National Health and Hospitals Reform Commission Presentation|
|Professor Fran Baum, Southgate Institute for Health, Society and Equity, Flinders University Presentation|
|Outcomes Overview of Day 1 (pdf)|