How to respond to the national health reform agenda is one of the pressing questions before the new Victorian Government.

Following on from a previous Croakey post giving some free health advice to Ted Baillieu and co, here are some more suggestions from a range of Croakey contributors.

Carol Bennett, Consumers Health Forum

What is your advice to the new Government about the national health reform agenda? Should they remain engaged or “rip it up” as has been threatened?

What political parties say in opposition is often very different from their actions in Government. I would hope that the new Victorian Government will look closely at the generous health care reform package being offered by the Federal Government and accept that health reform is a national issue that deserves support. Even the West Australian Government supports what the reform package is offering and is only arguing over the GST funding model.

If Victoria decides to reneg on health reform, will this have a big impact on primary health care reform, Medicare Locals etc?

This may create some systemic problems for primary care reform but the Commonwealth is the dominant funder of these services in any case. The value of national consistency will be lost if there are variations in what different jurisdictions are willing to deliver or sign on to.

What are the questions you would like to see journalists asking the new Government about health and health reform?

How will the community health model of primary care dovetail with the new Medicare Locals?

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Anonymous (this contributor cannot be identified because of their job)

What is your advice to the new Government about the national health reform agenda? Should they remain engaged or “rip it up” as has been threatened?

They should judiciously accept the best of it and refuse to accept the 4 hour emergency wait time (in the UK it led to increased mortality) and anyway will lead to increased emergency department demand because it’s better than any 3 day wait for a GP.  But overall, the reform can be managed, and already a good deal of the funding has flowed to the hospitals so they need to be very careful here.

But the hospitals agreement isn’t the only one, there are a number of new programs, most of which are pretty good and should be continued – they inject much needed funds and the State can’t afford to move without them.

If Victoria decides to reneg on health reform, will this have a big impact on primary health care reform, Medicare Locals etc?

Medicare Locals are one area they should be judicious about.  The Commonwealth has litttle idea about primary health outside its funding of general practice and it is even worse when it comes to prevention and secondary things like screeening and early intervention.  They should reconsider accepting the add on to the health agreement that says in 5 years the Commonwealth will take a range of things – that should not be agreed (and the Brumby Govt was not agreeing to it)

What are the questions you would like to see journalists asking the new Government about health and health reform?

What do they know about prevention? (Zilch!)

What are the social determinants of health and how could they reorganise machinery of govt to better tackle them and health inequalties?

Do they know the difference between primary healthcare and health promotion, or the difference between prevention and preventive healthcare?

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Health reform advocate Fiona Armstrong

What is your advice to the new Government about the national health reform agenda? Should they remain engaged or “rip it up” as has been threatened?

Vital they remain engaged

If Victoria decides to reneg on health reform, will this have a big impact on primary health care reform, Medicare Locals etc?

Probably not for other states but may disadvantage Victoria and Victorians.

What are the questions you would like to see journalists asking the new Government about health and health reform?

How does the government intend to address the issue of rising health care costs without tackling the issues of prevention and improving health and wellbeing by shifting the focus to primary health care?

How will the government ensure equity in access to health care services without supporting a strong public health sector, including primary health care services?

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Professor Andrew Tonkin, head of cardiovascular research unit, Monash University

Sceptics question whether a national health reform agenda is needed, particularly those who pride themselves on current performance. However, this ignores the increasing pressures that will be placed on the health system by our ageing population, consumer expectations and in relative terms, widening health inequalities.

Any major reforms would have their greatest potential impact with the involvement of all jurisdictions. This is because associated financial and structural changes will only be fully effective if they can cut across regional boundaries.

At present, direct health care costs are dominated by those associated with hospitalisation. In itself, this sector should be more efficient with no fall-off in quality if it was the responsibility of a single layer of government.

However, it is widely acknowledged that increasing emphasis should be placed on prevention of diseases, which frequently co-exist. There is little doubt that this will be best driven from general practice and the community. Hence the potential role of Medicare Locals and a more diversified workforce. Capacity needs to be enhanced and resources flow to where they are most needed.

Again it is generally accepted that these various initiatives need to be underpinned by information and e-health systems which support more seamless and effective transition of patients between different providers.

Although the reforms will come at a cost, the dialogue needs to shift to support selective implementation of treatments which are not only evidence-based but have acceptable cost-effectiveness. In this context, outcomes documented from linkage of administrative datasets can inform appropriate refinement of activities.

Politicians govern for the present but leave a legacy which impacts the future. In my opinion the future health of Victorians would benefit if the new government was an active participant as the COAG health reforms are further pursued.

Among the questions that journalists might ask:

What will the new government do to address difficulties in access such as experienced by Victorians living in rural areas?

If it does not participate in the national reforms, how will the government allocate resources to support prevention activities?

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Senior health services manager Dr Patrick Bolton (not from Victoria)

I am not sure that the case that
a)  the current health system is “broken” and/or
b) there is a plausible alternative that is better
have been made.

Certainly the current set of changes proposed by the Commonwealth have every sign of being patched together on the fly in a piecemeal fashion which seems likely to make things worse, not better. Even if a proposed change might make things better, the cost of change needs to be considered.

So, for a place like Victoria where as I understand it the change has not progressed beyond the planning stage, I would have to say that at least taking time out to reflect on what is proposed and think about whether it is worthwhile can only be a good thing.

In NSW the approach seems to be one of scorched earth: leave nothing for the incoming enemy and bugger the peasants trying to scrabble a living from the dirt.

If Victoria does reject the changes, then this will make it easier for NSW to do likewise.

If three states, including the two most populous, reject the changes, one has to hope that this will be taken as a real indictment on them.

It may be optimistic of me to hope that this would lead to some better thought through and evidence based changes. The only problem with a rejection of the proposed changes is that the rejection is motivated by the same ill considered political grandstanding that led to to the proposal being so weak in the first place.

It is difficult to comment on the impact of a Victorian rejection of reform on primary care. This is because the proposed Commonwealth primary care model is so nebulous as to be meaningless.

Of course we want Medicare Locals to manage integrated care for people with chronic disease, but this is the same as saying we want our kids to grow up intelligent, handsome and successful. The unanswered question is how it will be achieved.

The Commonwealth’s discussion paper was silent about proposed mechanisms by which Medicare Locals would drive change and also how they would be accountable. The elephant in the room around “primary care” is how much any government is prepared to challenge the current model of primary *medical* care.

There are hints that a community health based model might be considered, but at the moment the language of primary care is busily being colonised by medical practitioners.

I’m all for consultation, but we elect governments because they have policies, not because we want them to act as consultants, showing the community their watch and asking them what time they think it is. Zero multiplied by any number is still zero.

I think there are two questions that politicians should be asked. These are:

1. What are their policies on healthcare, and

2. Why do they believe these will work?

Unless their answers to these two questions are credible, they should resist the temptation to tinker with the healthcare system.

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Dr Tim Woodruff, Doctors Reform Society

The first thing for the new Victorian Government to do about health reform is to establish the facts about the deal struck between the Federal Government and the previous Labor State Government.

There are two quite separate parts to the deal. The first is the reforms, which include the GST fiddle and the guarantee of a 60/40 split in recurrent funding.

Questions which need to be answered include: how will this guarantee alter the fact that on present trends, State Governments will eventually go broke paying for public hospitals?

If the Federal Government is simply matching what States spends (60/40), this does nothing to growth.

Why has the Federal Government not committed to a return of the historic 50/50 hospital funding split whilst waiting for the new scheme to start?

In the long term, the new funding arrangements are almost certainly better for the States because there is a guarantee of matched spending rather than reliance on a historic agreement so it would seem very sensible to remain engaged.

Many of the other changes are good in principle but may well do nothing for patients. Thus, the insistence on hospital performance targets is great if they are appropriate targets, properly audited, and with hospitals provided with the resources to perform.

The Baillieu Government has committed to the first two points and has even recognised the stupidity of hospital waiting lists which ignore waiting times to outpatient assessment (which neither the Brumby or Gillard Government have done). Without resources however, the targets simply lead to gaming.

But it is at the level of primary care that most patients experience the health system and its failings. The rhetoric is ‘central funding, local control’, a concept which one would expect the new State Government to applaud.

Unfortunately there is little evidence of any significant increase in local control even when Medicare Locals are established. They will only have control over a very small part of primary health care spending and one could argue that Victorian primary health care providers are much closer to the source of funding control now (Melbourne) than they will be under the new scheme as decisions on funding will be made in Canberra.

In addition, Medicare Locals are charged with ‘filling the gaps’ rather than addressing the basic causes of the gaps ie the structures of the whole system which lead to gaps in services eg the continuation and expansion of fee for service remuneration which contributes to geographical barriers to access and causes financial barriers to access.

Information is as crucial to assessing and planning primary health care and population based health as it is to hospital care. There is a commitment to data collection in primary care which should be applauded by the new State Government. Victoria already collects large amounts of data at this level for its own purposes but having it nationally co-ordinated has merit.

One major component missing from the Federal Government’s commitment to such data collection and publication is data on spending.

One can’t plan further spending or expect meaningful input from consumers and the public without matching performance with spending.

This would require exposure of the inequitable spending of Medicare funds to the most healthy areas, thus highlighting the structural deficiencies which contribute to our health inequalities.

The Baillieu Government should remain engaged in the reform process as there are many excellent ideas in the proposals. Developing those ideas to practical usefulness requires much more discussion, taking into account what already exists in Victoria and improving on it.

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