CRUD records the details of evaluations, plans, reviews and other such documents that should be released (whether by governments or other commissioning bodies), in the interests of promoting better informed policy, practice and debate.

The new entries are:

A Hospital Information and Performance Program Review and a National Hospital Cost Data Collection Review. According to the Department of Health and Ageing’s annual report, these have been completed and their recommendations are informing improvements in information about the hospital services and costs associated with those services, and in particular improving information on trends in hospital utilisation. The 2009-10 Health Budget provides $39.6 million over 4 years to continue funding for the Hospital Information and Performance Information Program, now renamed the Hospital Accountability and Performance Program. The Budget papers acknowledge the increasing importance of this work in the Government’s commitment to develop comparable performance measures across the public and private sectors and to move to activity-based hospital funding. However these two reviews do not seem to be publicly available. If they are available, perhaps someone could let us know. We are very happy to be proven wrong on these things.

A review of the Rural and Remote General Practice Program. This was conducted in 2005 and is thought to have informed recent changes announced in the Budget but has not been released.

A correction

We’ve also been advised of a slight error in a previous post. David More has pointed out that the National E-Health Strategy, which we previously said was written for NeHTA by Deloitte, was developed for AHMC/AHMAC – managed by the Department of Human Services in Victoria NOT NEHTA.

“This matters as it recommends NEHTA be fundamentally reformed and be much better governed and managed,” he says. You can read much more about these issues at David’s blog.

Other CRUD entries:

• A Report on Incentives and the Australian Health Workforce  – Completed by the Australian Health Workforce Institute in April 2009 but marked “not for public release”.

• Evaluation of the Rural Clinical Schools Program and the University Departments of Rural Health Program
This was done by the consultancy Urbis which proclaims that its detailed report assessed the effectiveness and workforce implications of the two Programs and made 25 recommendations about their future development. Urbis says: “The report was well received by the Department and the sector and has been influential in guiding policy direction in rural health education.” That’s interesting because at least one Croakey source in “the sector” has been trying to get their mitts on the evaluation, without any satisfaction.

• Two reviews of the Rural, Remote and Metropolitian Areas (RRMA) classification system have been undertaken
The most recent one was done in conjunction with the review of “targeted rural health programs” that was behind various changes in the Budget, including the move from RRMA to the ABS’s Australian Standard Geographical Classification (ASGC) system. An earlier review of RRMA was apparently also undertaken some years ago, under Minister Abbott’s reign. So far as Croakey knows, neither review has been publicly released.

• The NSW Radiotherapy Plan  2006-2011
Our source says NSW Health has failed to release this document despite a number of requests (not to mention the fact that we are already three years into the period of the plan).

• Evaluation of the National Suicide Prevention Strategy – Final Report
Prepared for Department of Health and Ageing by Urbis Keys Young
The evaluation is dated April 2006.
(Please contact Croakey if you’d like a copy)

• Summative Evaluation of the National Mental Health Plan 2003-2008
The evaluation is by US consultant Charles Curie and English psychiatrist Professor Graham Thornicroft
(Please contact Croakey if you’d like a copy)

• NHMRC review of public health research
This was conducted by Don Nutbeam and went to the Research Committee last year but has not yet seen the light of day.
(Crikey has run this story about the delay in the review’s release.)

• A national evaluation of the Primary Health Care Research Evaluation & Development program
Our Croakey informant says: “This is a major Department of of Health and Ageing initiative that has substantially increased the national capacity for and actual implementation of PHC research. This has been through capacity building funding to departments of rural health and general practice, direct research grants, research fellowships and the Australian Primary Health Care Research Institute. This is an important program. For example, some of the resultant work and key researchers involved in these activities have contributed directly to informing the current policy reform debate through the NHHRC & Preventative Health Taskforce.”

• Growing the evidence base for early intervention for young children with social, emotional and/or behavioural problems: systematic literature review

Commissioned by the Victorian Department of Human Services. Dated April 2008.
Authors: Melissa Wake, Harriet Hiscock, Jordana Bayer, Megan Mathers, Tim Moore, Frank Oberklaid

• The National E-Health Strategy, developed for AHMC/AHMAC, managed by the Department of Human Services in Victoria

Our informant says this has yet to be released although a brief summary was slipped out quietly on December 22, 2008.

Here’s what the DoHA website says about this strategy which, if it is such a “useful guide to the further development of E-Health in Australia”, and is to help the States and Territories and the public and private sectors “determine how they go about E-Health implementation…”,  ought to be publicly available.

“The National E-Health Strategy developed by Deloitte, together with key stakeholders, provides a useful guide to the further development of E-Health in Australia. It adopts an incremental and staged approach to developing E-Health capabilities to:

• leverage what currently exists in the Australian E-Health landscape;

• manage the underlying variation in capacity across the health sector and States and Territories; and

• allow scope for change as lessons are learned and technology is developed further.

The Strategy reinforces the existing collaboration of Commonwealth, State and Territory Governments on the core foundations of a national E-Health system, and identifies priority areas where this can be progressively extended to support health reform in Australia. It also provides sufficient flexibility for individual States and Territories, and the public and private health sectors, to determine how they go about E-Health implementation within a common framework and set of priorities to maximise benefits and efficiencies.

• A review of the Medical Specialist Outreach Assistance Program

It was commissioned by DOHA back in 2004 but has never been made public despite a number of organisations asking for copies.

If you know of evaluations, reviews and other such documents that should be on the public record, please drop us a line.

Well, it’s still not out and now Professor Don Nutbeam, who chaired the committee which produced the review, has had enough.

Nutbeam, professor of public health, provost and deputy vice-chancellor at the University of Sydney, has taken the unusual step of publicly releasing a letter to the public health community expressing his frustration about the delay.

You don’t have to read too closely between the lines to determine where his message is directed. It sounds like Anderson has been ready to release the report for some time but has been waiting for sign-off from Roxon’s office. It’s all very ironic given some of the review’s recommendations, as outlined in the letter below.

Nutbeam’s concerns will be outlined further in a story at Crikey today.

Letter from Professor Don Nutbeam:

Dear colleagues

NHMRC Review of Public Health Funding in Australia

I wrote a letter that appeared on the NHMRC web site December 2008 explaining that publication of the Report on the Review of Public Health Funding was to be delayed in order that it could be released concurrently with the Draft NHMRC Plan early in 2009.

I’m writing to you again six months on.

Following substantial consultations, wide-ranging feedback and a receipt of a large number of formal submissions during May to September 2008, the report was completed on schedule and provided to NHMRC by the Review Committee in final draft form in October 2008. It was subsequently considered by NHMRC Research Committee in November 2008. A draft response from NHMRC was prepared soon after. I attended the Research Committee meeting, and was provided with a late draft of the formal NHMRC response. Both were very positive, and suggested to me that the NHMRC, led by CEO, Professor Warwick Anderson, were taking very seriously the issues identified in the report, and were diligently responding to all of the recommendations.

The Report provides an overview of the different sources of research income for public health research in Australia, including a particular focus on the contribution of the NHMRC. It also offers an appraisal of the quality and impact of public health research in Australia. It concludes that the quality of research is impressive, both in terms of scientific quality and public health impact. Public health research in Australia is among the most cited in the world scientific literature – by some measures having the highest impact of any of the health and medical research disciplines in Australia. It has lead to important discovery and innovation in tobacco control, prevention of SIDs, preventing skin cancer, and in HIV/AIDS control.

Despite these important gains, the Committee was concerned that both quality and impact of research are threatened by a lack of coordination nationally, inflexibility in funding schemes and assessment processes, and a lack of transparency in the use of research, especially research funded by State and Federal governments.

Among the key recommendations are:

• The creation of a national public health research forum, and national public health research strategy under the oversight of NHMRC to provide better coordination, and more strategic investment in public health research in Australia
• A much stronger focus on intervention research with more practical application in addressing identified public health priorities
• Greater flexibility in funding schemes and important refinements to the peer review process in response to the feedback we received
• Improved transparency through the creation of a national register of public health research, mirroring the clinical trials register supported by NHMRC
• Redevelopment of the role of NHMRC as an important source of credible and independent advice to the public on a wide range of significant public health issues.

It had been my hope that we would have had the opportunity by now to debate the report, its findings and recommendations, and that we may have seen some practical responses to the recommendations by NHMRC and governments in Australia. Instead, the recent budget announced the axing of funding for the Public Health Education and Research Program (PHERP). This Program was regularly referred to in our consultations and in the Report as one of the factors that has supported success in public health research in Australia. We appear to be going backwards not forwards in response to the success of public health research in Australia.

It is not clear to me why the release of the report has been delayed for so long. Any advantage that might have been realized by the release of the report with the draft NHMRC Plan has dissipated in disappointment, concern and suspicion among the public health community.

Whilst I have no reason to believe that there is anything other than an unnecessarily cumbersome bureaucratic process that is causing this exceptional delay, I write this letter in frustration that the goodwill, enthusiasm and commitment displayed by the public health community during the public consultation is not being respected and appropriately rewarded.

As some of you will know, part of my frustration is due to the fact that I will be leaving Australia to take a new position in the UK in August. It had been my hope that I would have been able to participate in a productive discussion with the public health community on the findings and recommendations of the report, and would be able to advocate for the improvements to public health research that are proposed in the report. Regrettably the opportunity for this will be very limited.

You may wish to make your views known to the Minister, Nicola Roxon (Nicola.roxon.mp@aph.gov.au) both about the delayed release of the report, and about the axing of PHERP.

Finally, I would like to take this opportunity to recognise the contribution of my fellow Review Committee members: A/Prof Toni Ashton, A/Professor Emily Banks, Professor Alan Cass, Professor Mike Daube, A/Professor Steve Farish, and Professor Rob Sanson-Fisher. Professor Judith Lumley also contributed to the early meetings of the Committee.

With best wishes
Professor Don Nutbeam

The Alliance held its 10th National Rural Health Conference in Cairns last week. Normally, Croakey doesn’t post press releases verbatim but in this case we figure it’s worth an exception. Below are two statements issued after the conference: a communiqué and a list of priority recommendations.

Croakey hopes that those in Government and other positions of power and influence take particular note of the recommendations to improve food security, to reinstate the Racial Discrimination Act for the Northern Territory, and calling for open publication of Government-commissioned studies relating to the health sector.

Communiqué
The 10th National Rural Health Conference was held in Cairns at a time of unprecedented opportunity for health reform.  A range of key strategic reviews are due to report to the government within the next two months.  The global financial crisis highlights the need for Australia to invest in health promoting policies which have the capacity to reduce national costs on health care in the medium term.

The 920 delegates at the event have therefore called on the Australian Government to work in collaboration with the States and Territories, and with the health sector, to seize the opportunity for system-wide improvement.   Indigenous Australians in particular, and people living in rural and remote Australia, will be among the main beneficiaries of an improved health system overall.

The Conference again demonstrated the cohesion of the rural and remote health sector and the capacity for innovation and the resilience of the people in it.

Despite the enormous challenges posed by the natural and financial environments, people in the rural and remote health sector are confident of their ability to lead health innovation and the development of better ways of providing health services.

People in the rural and remote health sector have great expectations of the governance proposals to be included in the final report in June of the National Health and Hospitals Reform Commission.  Delegates have a range of views on the relative benefits of options A, B and C (and of other possible models) but agree that the best way for improving health in the bush will be one that allows funds for health services to be held and managed at the regional level.

A major focus at the Conference was on the social and economic determinants of health and the social gradient which affects the health of individuals and communities.  In the context of the national health change underway, the rural and remote health sector should be seen as “the best bet” for early investments in new and better ways of delivering health services.  The sector has renewed its commitment to lobbying and advocacy which will bring an end to the locational disadvantage in health status from which people in rural and remote areas suffer.

The Conference again attracted a range of Aboriginal and Torres Strait Islander consumers and professionals.  Members of the rural and remote health sector recommitted to direct advocacy, as appropriate, and strong support for Indigenous bodies for improvements to Australia’s national Indigenous health shame.

Given the global shortage of health professionals and the serious maldistribution within Australia, significant emphasis at the Conference was on ways to improve access to health professionals and the services they provide.  Conference delegates believe that with the right incentives in place and available across all professions, it will be possible to meet the need for services even in more remote areas.  The Budget announcement relating to the scaling of incentive programs was supported in this context.  However, to ensure that workforce shortages are not a constraint on service development, a more rapid adoption of new health professional roles and expansion of existing health professional roles will be necessary.  This will require governmental and professional support and cultural change.

Conference called for early investment in an individual electronic health record, with due provisions relating to confidentiality and the nature of the sort of system required to cover all spatial and demographic realities.

There was strong support for the development of a national rural health plan, and for advocacy to have governments and others in a position to act implement the actions proposed in the range of existing national strategies that relate to health.

For the first time at the biennial National Rural Health Conference, there was a significant emphasis on climate change and its impacts on the health of rural and remote communities and individuals, as well as the demographic and economic changes likely to occur.  It was agreed that there is much to be done to moderate climate change and to mitigate its impacts, and to take advantage of the potential economic opportunities that climate change will bring to rural and remote areas.

People at the Conference noted and welcomed the announcements in the recent Federal Budget, including those relating to incentives for rural general practice, regional cancer centres, MBS and PBS payments for nurse practitioners and selected midwives, and maternity services.

The reservations felt about these Budget announcements relate to the continued lack of equivalence in incentives for recruitment and retention across the various health professions, and some questions about the devil that may be in the detail of the programs as they are rolled out.

Inspirational addresses were heard from a range of Keynote and Concurrent Session speakers, with a small number of special guests from Canada and the US.  The whole Conference was infused with the sense that if there is genuine engagement with communities at the regional level, health consumers and professionals can overcome both short and longer-term challenges and meet their shared aspiration of equal health for people in rural areas.

***
Priority Recommendations

1.    This Conference believes that the time is right for major changes to the structure of the Australian health system. The range of issues covered in the interim report of the National Health and Hospitals Reform Commission, and their complexity, should not distract from the overriding urgency of improving health governance.  Whichever of the options the Commission favours, the new system should be based on the following principles:
•    a national health system, with a regional focus for fund holding and service delivery;
•    genuine community engagement at the regional level in the design, implementation and evaluation of regional and local health services;
•    governance based on appropriate regional areas, which in more remote areas will be relatively small populations determined by natural communities of interest;
•    funding equivalence between all regions, moderated by health need; and
•    delivery of health and related services in an integrated manner.

2.    To help meet rural and remote health workforce shortages and to improve care, the Conference emphasises the need to speed the rate of development of new health professional roles (eg physician assistant, nurse practitioner and advanced allied health practitioner) and the expansion of existing roles (such as ambulance officers, paramedics and Aboriginal and Torres Strait Islander Health Workers) as appropriate.  This will require the establishment and funding of additional positions as well as structural change in the professions and further consideration of revised models for funding health services.  These changes will enable the implementation of the innovative service models needed in rural and remote areas and must be driven by patients and their needs.

3.    Conference called for the early investment in the adoption of individual electronic health records so that people in rural and remote Australia have their health information where and when they need it.  It is critical that people and health services in rural and remote Australia begin to build their capacity using the technologies currently available so they can participate in the improvements in broadband connectivity and adoption of NEHTA standards as health applications improve.  The experience of e-Health-NT provides a working example.

4.    The Conference recognises the great improvements to health which would be made through implementation of existing national strategies related to health.  For example, the National Indigenous Education Strategy includes a number of evidence-based and potentially effective initiatives for this urgent and critical issue. The priority must be on implementing these policies at the local level.

5.    The Commonwealth, State and Territory governments, in conjunction with the NRHA, should develop a national rural health plan to succeed Healthy Horizons, the strategic framework which lapsed in 2007.  The new plan will incorporate benchmarks, targets and programmatic elements along the lines of those already included in State and Territory rural health plans.  This national plan should:
•    have strengthened emphasis on the social and economic determinants of health;
•    reflect genuine national partnerships relating to Aboriginal and Torres Strait Islander health;
•    for the first time, consider the impacts of climate change on health and prepare the rural and remote health sector for these impacts; and
•    draw on the demonstrated capacity of rural Australia to develop innovative and effective services that are underpinned by community ownership and resources that are focused on local needs.

6.    The 10th National Rural Health Conference calls for greater equivalence of incentives for education, training, recruitment and retention of rural and remote health professionals across all disciplines.

7.    Those at the Conference welcome the commitment to a new national health workforce agency and the substantial resources allocated to it including for rural placements.  Conference delegates call for ongoing tracking of undergraduate, post-graduate, training and practice trends in rural areas for all disciplines .

8.    The Conference recommends that climate change be recognised as a core issue for health, and that its impact on health policy, planning and service delivery be considered in all health priorities and initiatives.  This should encompass:
•    proactive mitigation strategies;
•    enhanced environmental literacy;
•    incentives for renewable energy generation  and energy conservation (an economic opportunity for rural and remote Australia);
•    health infrastructure (eg hospitals) using best practice renewable energy and energy-efficient design; and
•    a national conference on climate change and health.

9.    The Conference welcomes the Budget commitment to establish ten regional cancer care centres in rural areas.  This initiative needs to be supported by funding for adequate staffing and by effective relationships with smaller communities.

10.    The new National Men’s Health Strategy must include specific measures for rural and remote areas.

11.    As part of a comprehensive primary health care system, the Conference delegates call on the Commonwealth to take responsibility for ensuring that adequate oral health care is available for people in rural and remote areas.  This care should include screening, education and preventative care within routine health checks, acute care where necessary and regular preventative oral health care.  Aboriginal and Torres Strait Islander Health Workers should have a key role in the development, management and delivery of services in their communities

12.    Given the particular challenges that mental illness poses in rural areas, one area in which increased resources and attention would be effective is in prevention and early intervention in the school systems.  This would include additional effort through school counsellors, school nurses, mental health professionals, other allied health professionals and general practitioners.

13.    Conference delegates call for targeted funding for Aboriginal and Torres Strait Islander community controlled health services for initiatives such as smoking cessation and oral and dental health programs.

14.    That the Australian Health Ministers’ Council agree on the means by which patient assisted transport schemes (PATS) will be better funded, more available and more uniform.

15.    Conference calls on the NRHA to develop a position paper on the important role played by arts-in-health in health promotion and community engagement. This paper will help make the case to funding agencies for support of arts-in-health activities.

16.    Natural Disaster policy should include ongoing elements for community capacity building.

17.    Improving food security in remote areas offers a positive focus for investment in community infrastructure, transport, personal health, nutrition, child education, community education, social cohesion and physical and commercial activity.

18.    The Conference calls on the Australian Government to permanently reinstate the Racial Discrimination Act for the Northern Territory.

19.    Governments should publish the results of analytical and evaluative studies it undertakes or commissions relating to the health sector.

The exigencies of the global financial crisis and its consequences always meant that the 2009-10 budget was going to be more about targeted new spending and lots of budget cuts in current programs, but such times can offer a unique opportunity to refocus and recast old policies and spending to achieve better value and better outcomes.

The drive to do this has never been greater. The Rudd Government has yet to deliver on the substantial reforms promised to tackle the prevention and better management of chronic diseases, to provide the outreach, team work and coordination that is needed to ensure physical and mental health and wellbeing, and to address the inequalities and inequities that are inherent in the current system.

However an examination of the health budget shows that this opportunity has been missed.  The bean counters clearly won out over the policy wonks, and to the extent that new policy is made, it seems that this was done by Finance and Treasury, not Health.

This is demonstrated most obviously in the proposal to means test the private health insurance rebate.  While this was aimed at reining in expenditure, which now is almost $4 billion annually, increasing the Medicare levy surcharge to help persuade higher income earners to continue to purchase private health cover takes steps (deliberately or inadvertently) towards new policy about the role of the private system in health care.

In effect, this proposal presages the Government’s response to the financing reform recommendations that will be in the report from the National Health and Hospitals Commission (NHHRC), due next month, but currently still being written.

In fact there are a number of reports on health reform from advisory bodies due within the next few months.  However, there are no measures in the budget to provide the resources that will be needed to facilitate analysis and implementation of the recommendations from these reports from the NHHRC, the National Preventative Health Taskforce, and the National Primary Health Care Strategy External Reference Group.

The budget does have some welcome new spending, most notably on infrastructure for health services and research, the provision of new maternity services led by midwives, a new rural health workforce strategy, and to allow nurse practitioners access to Medicare items and prescribing rights.

There is $232 million to initiatives to help close the gap in Indigenous health, although the majority of these funds will go to the Northern Territory.  Despite the huge unmet need, Indigenous health programs are not immune from budget cuts, losing $25 million.

The total spending in health over the five years 2008-09 to 2012-13 is $4.7 billion.  This includes spending on Indigenous health but does not include aged care or sport and recreation.  New spending, $3.0 billion of which is from the Health and Hospitals Fund for infrastructure, is off-set by savings totaling $3.3 billion.

Analysing the 2009-10 health budget and tracking the funding commitments is particularly difficult exercise this year.  The budget papers and portfolio budget statements provide a lot of information, but nowhere is there a statement about the total amount of new spending or the total savings made from current programs.  Funding commitments are bolstered by constant references to funding already provided through the Council of Australian Governments (COAG) and to funding commitments that extend well beyond the forward estimates.

Last year the raft of budget cuts were gathered together under the rubric of ‘responsible economic management’.  This year the euphemisms are about ‘modernising Medicare’, ‘improved targeting’ or ‘further efficiencies’.

Realistically, substantial new spending was never a realistic possibility for this budget, and in many ways, the health budget is better than might have been predicted on the basis of new funding commitments.

However, the failure of this budget to link the need to make savings to health policy reforms  – for example, to not just redress the blow-outs in the cost of the Medicare safety net and the Better Access mental health program but improve the functioning of these programs and the health of patients -  means that inevitably it must be judged harshly.

At budget time next year, with an election looming, the Rudd Government may lament this wasted opportunity.

• This article first appeared in the Canberra Times and is republished with Lesley Russell’s permission

This distracts attention from the arguably more important issue that PHI is considered by many to be an inefficient, inequitable way of funding health care. It also seems to undermine community understanding of the importance of universality in health care, and perpetuates the notion of health care as a private good rather than something that confers many public benefits.

Professor Stephen Leeder, director of the Menzies Centre for Health Policy, University of Sydney, has also been contemplating the PHI debate, and writes:

“Just as the bionic eye (”to provide 2020 vision”!) became the attention grabbing media icon (or should that be eye-con?) of Summit 2020, displacing from sight and funding virtually all the other complex and interesting ideas put forward by the health stream at that event, so the cuts to the private health insurance subsidy (PHI) have caught our attention in the current federal budget.

They are seen as the ‘health bit’ in it. But unlike the 2020 Summit, where health policy ideas abounded, the budget has so little to do with health that the PHI subsidy cut is at least something to talk about.

The spread of patrons of PHI is stereoscopically wide, ranging from young people worrying about teeth, accidents and pregnancy through to older people deeply concerned that if they need orthopaedic surgery (and not it alone) electively they may have to wait a long time if they cannot go private.  In the budget, people on lower incomes will continue to be supported if they seek private farinaceous.  By means testing the subsidy for PHI, generally well to do individuals families will pay the full price for PHI, though by avoiding the extra Medicare impost if they join PHI there is still a (sort of) subsidy for it .

I do not think that anyone really knows what the elasticity around pricing PHI is for high income earners.  Cutting the subsidy to them will create a natural experiment.  I would be surprised if the drop outs are cataclysmic.  A few may leave but  not many.  Most will wear the additional cost.

What is more complex is the attitude of the federal government towards the private sector in health care. It is hard to read this in the PHI subsidy cuts.  The puzzle of how we pay for health care has just become a grade more complex as a result.

Let me ask: by retaining the PHI subsidy for less wealthy people, and imposing additional taxes upon the wealthy if they do not join up, is the government endorsing PHI as a public good, or does it see it as a discretionary private good?  If Medicare is funded adequately, why do we need to support anyone who takes on PHI?  Or are we saying that the public hospitals are now of such a poor quality that we will pay the less affluent to take out PHI so that they don’t need to use them?

This is not just an intellectual curiosity: the answer cuts to very heart of how we will shape our reform agenda for health care for the future.  This is one are where more muddle is a real health hazard.  I wonder if the various reform commissions can shed light on what the thoughts are of those elected and paid to consider health policy for the future on this matter.”

Take this, from GP Dr Kerri Parnell, the editor of Australian Doctor, a magazine for GPs.

She writes in the latest issue: “Within a month of the Medicare Safety Net being introduced in 2004, I’d heard of several obstetricians who’d automatically jacked up their fees, some to $5,000 per delivery. Presumably they slept at night because the extra costs would come from government coffers, not their own patients’ pockets”.

I expect the sound of pathologists crying poor will attract just as much sympathy from large chunks of the health and medical sector.

But you’ve got to hand it to those pathologists. The Australian Association of Pathology Practices, which represents private providers, has done a very nice job in their press release of framing the cutbacks as an attack on patients.  Mind you, the strategy hasn’t worked too well for the obstetricians so far.

Now compare and contrast the following two statements – the first from Minister Roxon and the second from the National Health and Hospitals Reform Commission.

Minister Roxon’s media release “Investing in the Health Workforce – Backing Our Doctors, Nurses and Midwives”
“The Government will recognise the valuable role and skills that nurses bring to the health system and to the broader community through:
·        providing access to the MBS and PBS for nurse practitioners, at a cost of $59.7 million over four years. This will improve the flexibility and capacity of Australia’s health workforce, and improve patient access to services; and
·        providing eligible midwives access to the MBS and PBS for the first time, expanding choice for women, at a cost of $66.6 million over four years.
These measures will improve the flexibility of the health workforce, and facilitate better access to services for patients.”

From the NHHRC Interim report “A Healthier Future For All Australians” (p104):
“We are not proposing that nurse practitioners or other health professional services be directly eligible for fee-for-service rebates under Medicare. Under current arrangements, simply adding additional professionals whose service would be eligible for rebates under Medicare would increase the total volume of services covered by Medicare and significantly increase total outlays, with the benefit and distribution of care in terms of improving health of the population unlikely to be commensurate with the increase in outlays.”

Nor does the Budget seem to put much account by the National Primary Health Care Strategy now under development, although a draft is expected to be ready for the Minister soon.

So many have been working so hard to help set the Government on the road to meaningful health reform.  The NHHRC, for one, is staying mum on how closely the Government is listening. This is its version of a  “no comment” response when asked about the above discrepancy.

Said a spokesman: “The NHHRC Interim Report was an ‘interim’ report.  The Commission’s recommendations to the Government will be in its Final Report, which is due by end July 2009.”

“I think Yvonne Luxford may be wrong  in her comment, on Croakey, that “the much needed Prevention/Public Health Agency has not come to fruition”.  The Health Portfolio Budget Statement says (on Page 94):-

The COAG National Partnership Agreement on Preventive Health funds four key programs to support activity in this area. First, a National Preventive Health Agency with the remit of providing evidence-based policy advice to Health Ministers and managing national-level social marketing activities.

And commits the department to:-

The establishment of the National Preventive Health Agency in 2009-10. (Page 95)

However:-

The Department will establish and support the ongoing administration of the agency (Page 59)

Which suggests the Agency will be set up within the Department.  I suspect many advocates for such an Agency will find that hard to take.

It certainly falls well short of the vision set out by Rob Moodie and others in their paper for the NHHRC. Given that Moodie is the Chair of  Preventative Health Taskforce, it’s tempting to ask whether this is a move to water down their recommendations before they emerge.

There are a few other nasties hidden away in the Budget papers too:-

• ‘Hearing services – introduction of hearing threshold’ – saving $33.9 million over 5 years – with no clear explanation of what that means in practice
• Big cuts (totaling more than $120 million over 5 years) to the previous Government’s Australian Better Health Initiative
• A cut of $34.8 million attributed to “further efficiency” in e-health programs
• A cut of $31.9 million by reducing “duplication in research effort” in diabetes.  Why was there duplication in the first place?  Isn’t diabetes a priority?

Stephen Leeders’s comment in an earlier Croakey post,“Pity about the special funding for public health education being abolished” is well-made, especially considering that one of the “Key strategic directions” under Outcome 1 (Population Health) is to “strengthen the evidence base for prevention of disease, build public health workforce capacity, and improve child, youth, women’s and men’s health.”

Seems a bit odd if we’re now focused on prevention and facing the threat of further pandemics.”

If our Croakey source is on the money, we can expect to be hearing more about these issues…

1. Hospitals have done well.

2. Indigenous health: continuing support for closing the gap is wellreceived. Continuing support for the Expanded Health Services Delivery
Initiative in NT is welcome. We need this strategic approach toimproving PHC services nationally, not just NT. The big money is in the COAG initiative. I question the ‘organ specific approach to ears, mouth & eyes. We really need the primary health care services up to scratch in a well planned way first.

3. Rural health: some bureaucratic streamlining of the many programs. The devil will be in the detail – the implications for the actual
programs are unclear. It is also unclear what the move from RRAMA to ASGC means for services in re-classified areas. The associated press
release sounds like everybody will benefit with increased incentives for doctors. But will there be losers as feared pre-budget? There are increased cash incentives for doctors in remote areas & thoserelocating from metro. There is no evidence to suggest these are effective. There is increased support for international medical graduates, more GP registrar places, increased funding to support medical clinical placements. Nurse practitioners access to MBS welcome. Not much (if anything) for allied health – a big need in the bush.  There is a commitment to a strategic national plan for rural health. Given Healthy Horizons is long expired, action on a national rural health plan is overdue.

4. Health, training & research infrastructure: a number of ruralinfrastructure programs have been funded. That’s great. It’s not clear
what proportion of infrastructure funding has gone to rural locations compared to metro. Looks like bulk of infrastructure funding has gone to
capital cities for major hospital, education & research centre building projects. Basic infrastructure still lacking in the bush.

5. Changes to private insurance rebate overdue. Many of us would be happy with its abolition

In summary, the budget has some big ticket infrastructure items, more for acute care and then its tinkering around the edges with increased cash incentives for doctors in the bush and not many obvious losers on the face of it. Where is the pain? The big unanswered question, especially for remote & rural areas with poor health outcomes and poorer access to services, relates to overall system reform.  After many decades of incremental change, we have high expectations of our political leaders to bite the bullet with fundamental structural reform.

Watch this space as the major policy reports – NHHRC, Preventative Health Taskforce, Primary Care Policy – land on the Minister’s desk mid
year.

The health budget contains a lot of positives. Bearing in mind the major spending initiatives of the last 18 months, including  the new Australian Health Care Agreements (reversing the serious neglect of public hospitals by the Howard Government) and Indigenous health services, the Government deserves congratulations for including additional spending measures that will address capital shortages and workforce problems and improve cancer services particularly in regional and rural areas.

Many of the savings measures are also eminently sensible, requiring greater cost effectiveness through the MBS and PBS.

Yet there are missed opportunities. Maybe we are setting the bar too high, expectations raised by Mr Rudd’s rhetoric. And to be fair the NHHRC has yet to present its final report. Nonetheless, I had hoped for a package that bore more resemblance to the directions the NHHRC set in its interim report, and involved steps that might move towards its longer-term governance options.

There is nothing much for primary care, so no move even towards the NHHRC’s Option A (full Commonwealth takeover of primary care), nor anything for better regional planning that might set a platform for either Option A or B (full Commonwealth takeover with regional management).

And the means testing of the PHI rebate might make opponents of PHI happy, but it does nothing for coherence of what is already a hopelessly complex and confusing public/private insurance system, and certainly does not help those who would like to see Australia move towards the NHHRC’s Option C of managed competition. If high income people are to pay more whether they have PHI or not (those without PHI face a higher Medicare levy surcharge), why on earth not just stop their tax cuts – the budget bottom line would have gained more, and the Government could have done more sensible things to reduce rebate costs such as limit it to Medicare eligible services.

A financial crisis is also an opportunity to address more difficult issues, like rationalising co-payments or sorting out residential aged care financing.

Nonetheless, under the circumstances, it would be churlish not to give the Government a muted tick overall.

Andrew Podger is a consultant as well as National President of the Institute of Public Administration Australia and Adjunct Professor at the Australian National University. He is a former Health Department secretary and public service commissioner who served both Labor and Liberal governments.