On budget day for Queensland, what can be expected from the health cuts?
It’s budget day in Queensland and many will be searching for details of the cuts in the state health department following last week’s announcement that 2754 full time equivalent positions (or 4 per cent of the department’s staff) will go.
Some essential pre-budget reading is this speech by public health leader Professor Mike Daube to Queensland’s Health Media Club last week.
Public health will suffer – and not only as a result of staff cuts and restructuring, Daube says, noting that the Queensland Government seems keen to increase access to guns, liquor and gambling.
Daube ended his speech with a call for the Government to reconsider its plans:
I hope that they will recognise that the health of the community is too important for slogans, arbitrary cuts and ill-thought through restructures. I hope that they will reconsider their decisions to cut health budgets and staff. And for the sake of the health of Queensland and Queenslanders, I hope that they will reconsider the role and structure of public health. Public health is the foundation of our well-being and longevity. If you downgrade, devolve, dismantle, de-staff and defund public health, you put the health of the community at risk.
The post below includes some reaction to the Queensland Health cuts and ends with a report of Daube’s speech.
Health promotion has been devastated
A health promotion professional who wishes to remain anonymous
I left Queensland Health not long before the State election. I had anticipated some upheaval in the agency but am far more disgusted in the LNP Government’s approach than I expected to be.
The LNP has all but wiped out entire professions within the field of public health.
This includes an entire statewide workforce of preventive health workers classified as ‘Health Practitioners’ (not administrative staff), many of whom have worked for many a long year to obtain the relevant required qualifications and many of whom possess multiple degrees up to the PhD level. These skills generally encompass skills in epidemiology and skills from other complex fields.
I can only imagine that the LNP has been under the false impression that Health Promoters, for example, simply disseminate brochures and give unwelcome lectures to people about their personal health choices. On the whole, this has not been the case for decades now.
While it’s admirable that the LNP will inject funds into treating people in hospital care, there is now an apparent lack acknowledgement about the importance of primary prevention. Hospital boards are unlikely to pick up the slack.
Abandoning primary prevention is a serious denial of several key principles that have been held in high regard by the World Health Organisation, scientists, health care workers, researchers and even economists during the past few decades.
The flow on effect of abolishing Health Promotion will mean that related tertiary education programs are unlikely to survive.
This represents an incredible loss of expertise and accumulated knowledge about best practice ways to engage communities in addressing the social, environmental and economic determinants of health.
Journalists need to be asking whether the LNP government understands or values anything about the wellbeing of the community, the characteristics of scientific endeavour or quality versus quantity.
It’s a tragedy that highly qualified, dedicated staff (both at Qld Health and in university settings) will most likely be unemployed for the unforseen future because this Health Promotion is a very specialised skill set which does not lend itself well to the private sector. This is because it’s no longer focussed on individual behavioural counselling to the extent that it used to be in the 1980s.
It appears that the LNP are running the public sector as if it were a private sector organisation such that components that aren’t linked to profit-making enterprises are not valued.
Instead of throwing the baby out with the bathwater, they could have looked at improving productivity. They could have taken a more incremental, responsible approach to change management.
NGOs like the National Heart Foundation and Cancer Council have no hope of filling the hole now left in the Health Promotion workforce. NGOs are likely to struggle without a professional network to support, complement and feed their own workforce.
Unfortunately, there are tricky challenges with managing a Health Promotion workforce which the LNP has put into the too hard basket. For example, Health Promotion needs to be properly funded for process, impact and outcome level evaluation.
However, despite the scant funding for evaluation over the years (such that we may not know what we don’t know), one would hope that it still makes sense that ‘prevention is better than cure’ and we should work upstream to save money downstream.
It’s unfortunate that some Queensland Health Health Promotion activities may have been too-oriented towards ‘big picture’ strategic partnerships which probably makes it very difficult to evaluate this type of activity and demonstrate its value. But that doesn’t mean it has no value.
If only the LNP better understood the limitations of scientific research in this regard. There are other dimensions I doubt the LNP understand…
Health Promoters do important advocacy work to ensure that Government programs in other sectors like urban planning, housing and transport are better for health, safety and wellbeing rather than detrimental. The value of this work may be hard to measure but who knows what issues will be overlooked now as Queensland policy-makers will be blissfully unaware of what they might overlook.
This advocacy work would have been least valued by an LNP Government because this would have been perceived as sticking up for the disadvantaged who are statistically most likely to face health issues – not something the LNP hold close to their heart and probably something they believe should be federally funded.
What’s particularly cruel for all the Health Promoters who have now lost their jobs, the past several has seen them transition away from the administrative pay scale and onto the same pay scale as nurses and psychologists. This was a surprisingly long and painful process for those involved and now they’ll all be wondering why they bothered with it.
While all this might have been taking place behind the scenes, Queensland Health’s Health Promotion team has managed some very high profile achievement. The high profile achievements include: legislation for better child restraints in motor vehicles; safer swimming pools; and leading the way on anti-smoking laws.
However, I am equally impressed by the lower profile work such as the way Queensland has lead the country on the Good Practice Prevention Guidelines for falls given that falls injuries are approximately twice as common and twice as costly as injuries from traffic accidents.
To dump so many Health Promoters demonstrates total disregard for community wellbeing. It appears the government seeks to turn Queensland Health into the Department of Illness. Just what we need as our population grows and ages!
Indigenous health to suffer
Jack Bulman, CEO, Mibbinbah Limited
For organisations dealing with public health/health promotion, there is a real risk of going back to the ambulance at the bottom of the cliff and not having vision to ensure the preventative side of public health/health promotion.
There is also great risk of who is left in these departments of burning out. This is particularly true in our area of Indigenous Health. The Indigenous side of health promotion will also have great funding decreases and in some cases removed altogether.
What I think needs to be questioned is why are cutting frontline workers being cut at such a great rate and not the middle and upper echelons. Someone needs to be held accountable, so we need to at every chance we get to be lobbying and advocating.
We as an Indigenous Health promotion Charity see this as a set back to the so called Closing the Gap that is continually spoken about. Aboriginal and Torres Strait Islander peoples are still dying much sooner than non-Indigenous counterparts.
Social Enterprise Partnerships in Victoria and convenor, the National Campaign for Consumer-Centred Health Care
Population health and prevention programs seem to have made little impact on Australia’s epidemic of obesity or ongoing levels of alcohol abuse and tobacco-related illness. Presumably, if current programs were effective, the trends would be heading downwards.
Prevention programs in these areas amount to little more than media and education campaigns that largely fail in modifying behaviours, with constant attempts to modify access to products that are harmful if abused. All this rolls on year after year, at public expense, with little impact on health outcomes.
Finding a worker in population health or prevention to acknowledge this is like trying to find a politician who will acknowledge that our political system is dysfunctional.
I disagree with Mike Daube’s statement that “You cannot take hundreds of millions of dollars…and thousands of jobs out of a health system without reducing the quality and quantity of service and care”. Yes you can.
For most Australians, including those with chronic ill conditions, you can take thousands of jobs out the system and not notice a thing.
Our 61 brand new Medicare Locals will employ between 30 and 60 staff each, but the health outcomes of most Australians will not be touched by them one little bit, just as the health outcomes of Australians were not affected one iota by the failed Divisions of General Practice.
Australia’s health system is a provider-centred system, built around the interests of disparate providers and practitioners. Every proposed job cut in one segment of the system will be opposed by the workforce in that area. There are never any exceptions. The media will report the reaction from industry bodies, but not the reaction from consumers. Politicians fully expect the public debate to be conducted by provider industry bodies (the Consumers’ Health Forum in Canberra is not an exception to the rule: it is a creation of welfare and public health provider bodies and lobbies for the interests of public sector provider bodies).
What would a consumer-centred health system look like? For starters, it would mean that proposed cuts (or additions) to government health budgets would not be assessed solely in terms of their impact on service providers and their workforce. Consumers might possibly rate a mention. This would be a radical culture change in the Australian health care debate.
What are the federal implications?
Extract from statement by Dr Peter Davoren, Queensland president, Doctors Reform Society
…“If this is what Federal Liberals feel is great for Queensland, imagine what is secretly planned for the Federal funding of health if the Coalition wins next year,” said Dr Davoren.
“The claim that such huge cuts will not impact on front line services and on the most needy and vulnerable in our community beggars belief and is pure political spin,” said Dr Davoren. Additionally however it will mean reduced public health services for everyone in Queensland as everyone needs public health services working in emergencies, and they can’t work without staff.
“Queensland may well become the unhealthy state soon, but with the Federal Coalition so in tune with this slash and burn approach, it would appear that the health of nation is at serious risk. “
Dr Tim Senior
GP working in Aboriginal health
The impact of the cuts is difficult to predict without knowing exactly which staff are being cut. Though “frontline” staff apparenlty won’t be cut, the definition of “frontline” isn’t explicit. It has the feel of being “staff who see you when you are sick” but it would seem naive to think that these staff could offer safe and high quality services without the support of administration, IT, HR, public health.
Whatever happens, I would expect staff morale to be quite low, and there would be a lot of insecurity around jobs. The most likely impact will be on those who already have the worst health and least access to care.
It is likely that the job losses will impact on staff who work to improve access, safety or quality for groups with special requirements – efficiency would require that the dominant majority groups determine the way services are offered.
Questions that journalists could be asking now and in coming months include: Which positions will be lost? What role did they have in the health service? What is the evidence that this role is not necessary? Who will be doing these duties instead? What duties will they have to drop in order to perform these? What is the evidence on which these decisions are based? What measures are being taken on social determinants of health to offset these losses?
Health organisations should be responding to these cuts by advocating for patients and groups who are likely to be worse off from the changes, and reporting when this happens. There may be a tendency for groups to advocate against any changes that affect their professional group adversely, and I would imagine that responses that are strongly in favour of not adverselty affecting patients will get more traction than comments which are purely negative or could be seen to protecting vested interests.
The national (health/political) implications are unclear at the moment. It is plausible that a lot of the QLD health functions will be taken up by (Medicare funded) GPs, just as a necessity in filling a gap. There has been some commentary that the policies pursued by the Newman QLD government are those that an Abbott federal government will be drawn to. This remains to be seen, and the different responsibilities of federal and state health make comparisons difficult.
In the context of closing the gap in health outcomes between Aboriginal and Torres Strait Islander Australians and non-Aboriginal Australians, it is not certain how these job losses will fit in with the COAG agreement commitments.
I doubt that what health groups advocate will have much influence on this decision now (though I claim no expertise in this!) but it is really important that the effect of these decisions is measured and reported loudly and widely.
Other State and federal governments will be tempted to do the same, and being able to say “It’s been tried. This is what happened” will be very important.
To some extent, the UK experience in the NHS will inform what we see happening in QLD – in the NHS a huge budget cut accompanied by massive retructuring and the loss of a large number of professional health leaders has resulted in a bleak outlook, an inability to recruit to the new structures and, perhaps, the loss of the Health Secretary’s job!
Finally – I do wish the word reform wasn’t allowed to be used in this context. There should be a difference between “reform” – meaning changing the way the health system is managed, run and delivered – and “budget cuts” – designed to make the service cost less. Of course the 2 may occur at the same time, but it doesn’t look like this is an attempt at reform!
Reform might start talking about social determinants of health or education, housing, employment, social and transport policy in the context of these job cuts. I haven’t seen any talk in that area.
Thanks to clinical nurse and health writer Jane Barry for providing this report from the recent Queensland Health Media Club function.
Professor Daube defends public health
Jane Barry writes:
Professor Mike Daube’s address to the Health Media Club left no one in doubt where his allegiances lie. Preventative healthcare is the primary means of ensuring community wellbeing, longevity and quality of life for all. Though the current State Government’s cuts to reorganisation of Queensland Health, Daube claims, are more ‘of a slow-motion disaster in the making’ than a way of improving our overall health service.
Historically Queensland has not spent the same amount on health as other states, but in recent years this has changed to where we are now investing around the national average. Unfortunately, this increase has not reflected a drop in Queensland’s rates of smoking, alcohol consumption and obesity, the trilogy of factors primarily responsible for population mortality and morbidity.
Daube said: ‘These and other public health problems are not just waiting for a single magic bullet; they need comprehensive approaches from regulation to public education and community programs.’ And it is within the areas of public health such as communicable disease, environmental health, immunisation, health promotion, road safety, and public health nutrition where, he claims, aside ‘… from the occasional crisis this is the work we need to keep us and our communities safe and healthy.’
Daube said: ‘We have learned that in public health, as in other areas, the more you invest in evidence-based activity, the better your outcomes will be.’
Devolving a range of public health activities to seventeen Area Boards, instead of maintaining centralised services, will only add to existing ‘reorganisation fatigue’, Prof Daube said. It may ‘sound good in theory but there is no way that seventeen boards will have the expertise to address all the issues and problems they will face,’ he said. Disputes over territory, funding, priorities, resources, staffing, not to mention communication issues between NGOs and government sectors will create real problems.
‘Public health does not lend itself well to this kind of broad-brush devolution,’ he said. ‘The expertise required, in areas from communicable disease to environmental health to addressing our modern epidemics, requires central expertise and direction – both to identify appropriate priorities and to implement action. You will not have that level of expertise in seventeen areas.” He added that “it is fundamentally important that Queensland retains a strong, central public health group; without that you are putting present health of the community at risk – and also its future health.’
The evolution of health improvement overall, is largely due to the advocacy of public health organisations. But the current government is now planning censorship of NGOs receiving more than 50 per cent of state funding, in order to stop them from advocating for state or federal legislative change. Even web links to other organisations such as the Cancer Council, the AMA, the Heart Foundation and WHO will be halted, lest these connections threaten to destabilise public confidence.
Daube’s analysis is that the new conservative government is ‘developing plans and policies on the run’. There has been little consultation, analysis, planning, reviews or reflection on what has been working well and deserves to remain unchanged.
Importantly, deeming as more authentic only those health workers spending 75 per cent or more time with the public, devalues those with considerable skills and expertise. Repeatedly using the word ‘frontline’ – essentially a military term, to justify health expenditure is meaningless Daube claims; and this approach ‘will create chaos and reduce the capacity for expert oversight in crucial public health areas’. Viewing areas such as pathology, pharmacy, epidemiology and public health as being somehow “inferior services” is both intrinsically risky and extremely short sighted.
Apart from anything else, staff cutting and redundancies create ‘climates of fear and aren’t much fun’. Put simply, Daube says ‘these people keep our communities safer’. Without funding them accordingly we are at risk of placing even more pressure on our overloaded health system, which is already struggling.
Building good public health services takes time, money and expertise to be effective, though doing this is undoubtedly valuable.
Far from being the prophet of doom, Daube was optimistic in his summary by saying that the media are pretty good advocates for preventive health. Having both private and public conversations around what can be done is always worthwhile, he added, particularly when it comes to the vital areas of health promotion and prevention.
Australian Medicare Local Alliance directors announced – and some creative thoughts on what we might expect of them