Oct 23, 2012

After all the years of health reform effort and expense, what has been achieved?

An Australian academic was recently asked by an overseas colleague to nominate major health policy or system innovations that have had a positive impact on health care access, quality,

Melissa Sweet — Health journalist and <a href=Croakey co-ordinator" class="author__portrait">

Melissa Sweet

Health journalist and Croakey co-ordinator

An Australian academic was recently asked by an overseas colleague to nominate major health policy or system innovations that have had a positive impact on health care access, quality, outcomes, and/or costs in Australia.

The academic, who wishes to remain anonymous, struggled to come up with any suggestions – and explains why below.

The academic also put out a call to Croakey contributors for suggestions. They’ve provided a wealth of reading and reflections, canvassing issues ranging from the Close the Gap campaign to the lack of measures of the outcomes of health care in Australia.


The request:  From “a troubled academic”

I recently had a disturbing experience.

I was contacted by an overseas friend who was seeking to document “the top 10 important policy or delivery system innovations in other countries – success stories – that [Country X] can learn from.”

The quest was to identify “major policies and interventions that have been implemented nationally or on a large scale in other countries, [and] have had a positive impact on health care access, quality, outcomes, and/or costs”.

“Easy,” I thought.  “After close to five years of health reform (the National Health and Hospitals Reform Commission was launched on 25 February 2008) we must have lots of success stories to share.”

But I drew a mental blank.  I ticked off a long list of reports, strategies and organisational changes, but I struggled with the requirement to demonstrate “positive impact” on access, quality, outcomes or costs.

I e-mailed a couple of eminent academic colleagues and sought their advice.  Perhaps they could suggest some major, impactful innovations?

But they struggled too.

One highlighted successes in areas such as screening (for breast, cervical and, possibly, bowel cancer) and immunisation – but then acknowledged they were largely “old” achievements.

Another suggested “local successes in terms of telehealth, hospital-in-the-home and Aboriginal and Torres Strait Islander health”, but questioned whether they could be seen as translating effectively to the national stage.

I’m modest enough to recognise that I may not be fully aware of all the positive impacts of our health reforms.  And I’m humble enough to seek advice from Croakey’s eminent readership. So I’d welcome some thoughts on how I should respond to my overseas correspondent.

What should I report as Australia’s “important policy or delivery system innovations … that have been implemented nationally or on a large scale [and] have had a positive impact on health care access, quality, outcomes, and/or costs”?


Responses from Croakey contributors

More positive progress is being made than some suggest
Professor Stephen Leeder, professor of public health and community medicine at the University of Sydney and chair of the Western Sydney Local Health District

General point: no-one measures outcomes of health care in Australia in any systematic fashion except in cancer care and clinical trials and a few odds and ends.

Thus there is no satisfactory measure that we could point to say, “this has improved”.

The absence of metrics is a fault of the system: Kaiser Permanente and US Vets et al do know how to do it and they do it.  We don’t.  We don’t even have measures of avoidable mortality (European Observatory).

So in assessing the value of reforms we must look at process and structure.

Local Health Networks have brought hospital networks closer to clinicians and community.  They have decentralised a lot of power and decision-making. This is in line with international best practice. Changes are occurring in service profile.  Virtually every state has a series of programs designed to care for those with chronic illness.  These are new.

Medicare Locals are bringing GPs and community health services together in many places, which makes sense given the empirical evidence that favours such approaches when managing people with chronic problems.  They are starting to tackle quality in GP. They are only 18 months old and are starting from a low base. Anyone expecting miracles should turn to alternative medicine.

There has been an upheaval in the provision of mental health services in the past three years. Much of that is built around programs that have been shown to be effective. Again, much in line with best practice.  Outcomes likely to be positive.

Activity based funding in being introduced and this will sharpen the perception of hospitals about what they are doing, leading them to ask: why, is this the best use of their capacity and more.

Research in clinical settings is being elevated in state department of health funding for hubs, infrastructure, Clinical trials and so forth. Steady progress there.

The personally controlled electronic medical record is starting to roll out. Slow but definite progress.  If you don’t think this will improve outcomes, look at Kaiser.

Prevention programs have been stimulated through Commonwealth money and an agency established to relate science to practice. New and good. Plain packaging of cigs. Good food labeling in comparison with most countries (see Blewett Report).

So once you get over the embarrassment of realising you cannot directly measure the outcome of anything in Australian health care (and that’s pathetic), you can see things being done that are known to work.

That’s for starters.  I am completely OVER these people who think it’s clever to say, “nothing has progressed.”

What have they done with the opportunities presented to them?

To the grumblers about Medicare Locals etc in my Local Health District, I say, “Here’s your opportunity.  We now have more clinical councils, clinicians on boards, clinician advisers, you name it, than ever.  We have a Medicare Local that overlaps perfectly.  Go and see them!  Work out what you want to do together with them!  We have an MoU with them! You are actually hereby given permission to get off your bum, stop complaining, and use the opportunities presented to you to do something new and exciting!”  They don’t all like it!


Meaningful reform in Indigenous health is underway
Dr Tom Calma, co-chair, Close the Gap campaign

The biggest health reform in Aboriginal and Torres Strait Islander health history is the Close the Gap Campaign for Indigenous Health Equality.

This peak body and people partnership campaign has guided not only the Government and COAG but Oppositions to rethink Aboriginal and Torres Strait Islander health from a public policy perspective.

Enduring partnerships have been forged between Indigenous health peak bodies and service delivery agencies through the Close the Gap Campaign Leadership Group and the National Health Leadership Forum (the 13 major Aboriginal and Torres Strait Islander health peak bodies).

Additionally, the non-Indigenous health sector and human rights advocacy bodies have partnered with Indigenous heath bodies through the Campaign.  These respectful and mutually beneficial relationships have in many ways transformed Indigenous Health.

The Campaign has also realised 170,000 supporters signing up to the Campaign, annually a National Close the Gap Day, professional sporting codes coming behind the Campaign and raising profoundly, social (and cultural) determinants of health.

From the Government’s side, they have committed to a generational strategy to close the gap by 2031 and called it Closing the Gap, they have committed to reporting to the first session of parliament annually on what the closing the gap initiative has achieved, they have identified 6 (health determinant) Closing the Gap on Indigenous disadvantage targets and commenced the development of a multi-sectoral Aboriginal and Torres Strait Islander Health Plan.  New Closing the Gap funds pledged exceed $8 billion of which $1.6 billion is dedicated to chronic disease measures.

There is much more happening in the Indigenous Health space and the foundations are just being laid in real terms but we can say that the ducks are starting to line up.

Finally, for the detractors, the question to ask is, if the Close the Gap Campaign had not been established in March 2006, would we have the Closing the Gap initiative, would government and opposition and COAG be agreeing on the principle of a 25 year strategic approach to Indigenous health and disadvantage and would Aboriginal and Torres Strait Islander representative bodies be co-drivers?

So our friend can tell the world that meaningful Indigenous health reform is in its infancy in Australia and it is happening.


Impossible to know the impact of reforms upon health
Dr Patrick Bolton, a NSW health service executive

1. The objectives of the healthcare system in Australia, and, so far as I am aware other Western nations, have not been specified. In the absence of objectives it is impossible to talk about progress.

2. We don’t have good measures of health outcomes as distinct from health outputs, so, even without an objective, we have no capacity to measure change. An important case in point is the large investment in quality improvement in health without repeating the Quality in Australian Healthcare Study – or something along those lines – to determine whether all this investment has had any impact. This would seem to me to be a failure in public accountability.

I do not think that Australia is unusual in our failure to measure outcomes, but understand that there are systems that are doing this better than us.

3. In the absence of the factors at 1 and 2 it is not possible to demonstrate changes as a result of reforms. However, I am not aware of any analyses that have shown changes as a result of whole of system reform. I think the best that has been demonstrated is outcomes from widespread programs like those nominated below.

4. I recall a BMJ article from about seven years ago when NSW went from large to larger Area Health Services which made the point (accurately or not) that general businesses do not expect to see a net return on investment from system reform in under two years. Since that reform in NSW we went back to health districts two years ago – arguably a second system-wide reform – and are now moving on to outcomes based funding – a third reform. If it is true that we have had three reforms in seven years and that it takes two years to see a return on investment it is difficult to see where the opportunity has been for benefits realisation.


Reforms have failed to shift focus from providers to consumers
Vern Hughes, National Campaign for Consumer Centred Health Care

What difference has health reform made to health to date?

Your ‘troubled academic’ has not missed anything – what has been called ‘health reform’ over the last four years has not made a scrap of difference to health care access, quality, outcomes, costs, and no-one should be at all surprised by this.

The NHHRC core recommendation – to renovate Medicare by enabling all Australians to choose a health care plan independent of existing health insurers so that aggregates of health consumers would be able to impose a demand-driven, market-based integration of financing and servicing on fragmented providers and practitioners – sank without trace.

It disappeared because neither the Government nor the Opposition understood what demand aggregation and market-driven reform in health care actually means.

Instead of real reform, the Commonwealth Government has introduced no less than eight new statutory authorities to administer our provider-centred system.

None of these eight authorities address the actual forms of health care financing and servicing, and therefore none of them will have the slightest impact upon the consumer experience of care.

Adjustments to the administration of provider-centred systems will only produce altered administrative arrangements in provider-centred systems. That is what this model of ‘health reform’ has yielded. Indeed, it is the only thing it can yield.


Troubling questions need to be raised
David Briggs, Adjunct Associate Professor School of Rural Medicine and School of Health, UNE

It is obvious why your troubled academic is troubled. The National Health and Hospitals Reform Commission date was the start of the process but the National Health Reform Agreement was only signed off by governments in August 2011.

Even the most committed of reformist and health leadership could not turn around an elephantine health system in less than a year!!

Secondly most measures of Australia’s health place us in leading successful country groups!

Our shortcomings are in remote rural and Aboriginal health, chronic disease, critical workforce challenges and, rampant obesity and paranoia about what an ageing population might do to our health system.

As a member of our ageing population I intend to ensure that our health system remains available to us and that the ageing should be valued and not seen as the problem!

The success of the reforms will be seen in the recent establishment of primary healthcare organisations – Medicare Locals – not because they themselves have achieved success yet because most are less than 12 months old, but because their formation recognises that primary health care really is the ‘big end’ of health care where the majority of health care services are provided – 130 million MBS services ($5.3 billion) and 200 million prescriptions ($8.3 billion) in 2010-11 with a further 51 million services ($2.5 billion) in physiotherapy, chiropractic, optical and dental services.

Compare this to 8.6 million hospitalisations and 7.4 million emergency department presentations in Australia in 2009-10.

Medicare Locals and their unique organisational entity together with the National Primary Health Care Framework have the potential to move primary health care forward, provided they remain organisationally nimble and light and recognise that they are there to identify gaps and add value to what are predominantly private and NGO profession based providers and avoid the mire of political and bureaucratic control typical of the Local Health District model and structure.

Like ‘troubled’ I am pessimistic about the Local Health District aspect of the reforms to date.

They have certainly quickly restructured and rebadged but there is little to suggest that there has been any cultural change that might mean a new approach for the acute sector. It remains organisationally large and centrally controlled despite the use of the term ‘local’ and the addition of ‘Boards’, the focus remains on cost control not creating value in acute care from the available resources.

The establishment of 5-6 national bodies to oversight workforce, quality, pricing mechanisms and performance transparency hold promise but will take time.

The replication of similar central bodies at the State level needs questioning. Are a duplication of these activities at State level going to add any greater value above a combined Commonwealth and State/Territory national effort?

The media continues to disclose blowouts in surgical waiting times, obvious budget problems and poor outcomes in access and individual care across the system with little attention to the good news stories.

There must be an obvious reason for this focus given that at least two States have had significant official Inquiries into their health systems not all that long ago.

So I see further reform down the track for Local Health Districts, hopefully based on value creation in service provider roles being central to how State governments finally recognise that this should be central to their role rather than that of a combined cost containment and direct delivery role?

The national bodies providing transparency on cost and performance will eventually force States and territories to recognise that they need to engage in reform that will provide value in care and service delivery ahead of a focus on structures and control.

It is a pity that ‘troubled’ also needs to remain ‘anonymous’ because what we need is more people like ‘troubled’ who are prepared to ask the questions and for more public critical enquiry based on good evaluative studies as to what might work, where the priorities might be and less obeisance to the normative rational status quo that holds centre stage in our health system.

My recent experience overseas suggests that no matter what country we are talking about, the challenges we each face are remarkably similar and that there is a lot for us all to learn from a reflective, comparative discussion about those challenges and our differing contexts.

So at least ‘troubled’ need not add the label ‘alone’ !


Identifying some barriers to national innovation
Dr Anne-marie Boxall, director of the Deeble Institute

I agree it is very hard to think of important national policy or delivery system innovations.

One reason is probably because most health services are delivered by the states and territories. It might be better to look for innovations in the jurisdictions.

I am sure some innovations in the states and territories could be rolled out nationally, if supported, but sometimes innovations are solutions to local-level (or state-level) problems and therefore not relevant nationally.

Having said all this, I do think there are opportunities for innovation at the national level – especially in areas such as ensuring quality and safety, and improving access and the efficiency of the system.

We seem to have lost sight of the system as a whole in Australia, and the role of national policymaking.

In my view, national policymakers should be freed up from administering programs and projects so that they can tackle the big picture issues and questions in health. Maybe then we’d be more easily be able to identify some examples of policy innovation.


No evidence that health reforms having an impact
Public health physician Associate Professor Peter Sainsbury

Fundamentally there are four (rational) reasons for implementing health care reforms:

1. To improve population health (in its broadest sense) and health outcomes. Whether or not improvements are ‘personally’ obvious to the general population and/or patients is immaterial. For instance, it isn’t obvious to me in my day to day life that life expectancy has improved in the last, say, 5 decades but statistics demonstrate that it has and I’m very happy about that both for me and my fellow Australians. And it might not be obvious to someone who has a hip replacement that the post-operative course is less distressing now than it was 30 years ago or that the prosthetic hip will last longer but both of these developments have occurred and it would be difficult to argue that they aren’t good things.

2. To improve the satisfaction of the general public and/or patients with health services. In contrast to (1), this is by its very nature obvious to Josephine and Joseph Blow, whether it is because they get better from an illness because of good treatment or because they feel healthier from stopping smoking as a result of help they received from the health services or because they got prompt treatment or because health staff were nice to them or because they feel secure in the knowledge that a good health service is available to them and others when they need it or whatever reason.

3. To utilise health care resources more efficiently, either to be able to provide more health services with the same amount of money or to save money (public or private) that someone can spend on other things.

4. To improve staff health and satisfaction. In the best of all possible worlds this would have benefits in one or more of the above three reasons but even if it didn’t it would in itself be a good reason to initiate health care reform, provided it didn’t undermine any of the above three.

So can we produce evidence that recent health care reforms have resulted in improvements in any of the above?

That is an empirical question and I’d be happy for colleagues to enlighten me but it isn’t obvious to me that any such evidence exists.

There’s been lots of talk (about the need for reform and reasons why we are changing this or that) and lots of movement (new organisational structures, new priorities and performance agreements, new systems of measurement and payment, etc.) but no convincing evidence of improvement in the any of the above four that I’m aware of.

That’s not to say that some improvements in the above four reasons haven’t occurred in recent years (life expectancy continues to rise, smoking continues to fall, etc) but are the reforms responsible?

So to my mind it isn’t surprising that your ‘trouble academic’ is disturbed.

What’s even more disturbing though is that we’re implementing lots of reforms and there’s a good chance we’ll never know if they were worthwhile.


Real reforms are still needed
A public health official who wishes to remain anonymous

As for health reforms we haven’t actually had any yet.  We have seen a few new Commonwealth agencies with a remit to do something – usually without an evidence base.

I would argue we still need a Wanless type inquiry to chart the best value interventions in both clinical and public health, and I would happily sit on such an inquiry, having been centrally involved in the prevention negotiations and a patient of our largely non-evidence based care system over the past year.


PBS reforms have made a difference
Dr John Dowden, Australian Prescriber

I think the PBS reforms have had an impact on the price of some medicines and this is estimated to have had an effect on costs.


Steps in the right direction
Professor Lisa Jackson Pulver, Chair Indigenous Health, Professor Public Health, Director, Muru Marri Indigenous Health Unit, School of Public Health & Community Medicine, UNSW

I can’t go past the Closing The Gap agenda that the Government runs. Although there are costs, large sums of money are flowing into some important areas of Aboriginal health.

There are others that are missing out though. But that’s not the question.

We don’t see massive changes – but we are seeing some. These – especially the changes in participation in education – will see across the next decade, shifts in health. We are seeing children starting to grow more resilient across time.

The other biggy is how we are measuring Australia’s progress. We don’t use GDP as the be all and end all anymore. We use many more textured metrics to understand how people are going, and how we – as Australia – perform in the world.

So – there are some big steps in the right direction, that we should offer up as part of how the fabric of our society is becoming more inclusive, well and just.


Some wins on the board but a long-term perspective is needed
Dr Tim Senior, GP working in Aboriginal health

The three possible innovations would be:

1. The Closing the Gap PBS Co-payment for Aboriginal and Torres Strait Islander people. I’m not sure if there are figures released yet or not, but anecdotally this measure is very popular and has increased access to PBS medications for Aboriginal and Torres Strait Islander people – I gather it’s still not at parity.

2. The Australian Primary Care Collaboratives. This was based on a model from the US and UK (where I think there were also good results obtained) and brought to Australia. There is published evidence, though it probably isn’t level 1 evidence, that there have been impressive improvements in diabetes and CVD care and in access in participating practices.

3. Plain packaging legislation. No evidence yet, on health outcomes, but no doubt a significant policy change with the potential to improve health enormously – especially as its real strength will be in preventing the recruitment of new smokers, the majority of whom are teenagers.

My thought, though, is this. In thinking about these policies, I have realised quite how sketchy the evidence often is of positive change as a result of policy. I suspect, too, that 5 years is actually too short a timeframe to be measuring on (though is longer than our electoral cycle).

For real changes, we will be looking at the social determinants of health (there is evidence that this is where the big wins are to be had, rather than health system change) but 5 years isn’t long to be seeing improvements in mortality or in factors that have trangenerational effects.

So. Maybe we should just agree to interpret that as good news!


Cancer services have seen real improvements
Professor Paul Harnett, Director, The Sydney West Cancer Network

I suggest your supplicant investigate the issue of multidisciplinary teams in cancer care.

There has been a real paradigm shift in larger centres with the establishment and progressive development of multidisciplinary teams.

There is no doubt this leads to advantages and improvements. These have been formally required in NSW at least since 2003 (in a document I and others were heavily involved in).

These improvements are not window-dressing, they raise safety, care, training of younger staff, and potentially improved and patient-valued research.

I would stress multi disciplinary teams ARE NOT the only way to get superior care, nor are they sufficient in themselves, but there is an interesting story to tell there.

Also, there are further upgrades that can be done to multidisciplinary teams, which will continue the upward trajectory.


Tobacco control
Professor Mike Daube, Public Health Advocacy Institute of WA

Plain packaging – and the rest of the tobacco program!


Primary health care reform matters
Health economist Professor Gavin Mooney

While I may be biased in being a consultant to the Tasmania Medicare Local and while accepting that these new primary care organisations are far from perfect in the way in which they have been introduced, they do contain two important components of reform.

First they provide a much-needed attempt to bring greater coherence and coordination and hence better access for patients to Australian primary care.

And second in giving a boost to the primary care sector which is now more community focused and driven, they represent an effort to take some of the health service power away from the hospital sector, to allow more say on the part of the community in how their health services are run and to recognise that, if the social determinants of health are to progress, these have to be driven by a resurgent primary care sector.


Regulatory reforms
Professor Merrilyn Walton, University of Sydney

National health practitioner regulation has to be a significant policy initiative.


Gains from immunisation
Dr Julie Leask, Senior Lecturer and Postdoctoral Research Fellow in the School of Public Health, University of Sydney and Senior Research Fellow at the National Centre for Immunisation Research & Surveillance

Immunisation doesn’t have to be seen as a job lot. If you take a certain vaccine program such as HPV vaccination there are measurable health gains.

In 2007, Australia was the first to publicly fund a national HPV vaccination program for females 12-13 years of age, with a catch up for those up to 26 years. Following the roll out of the program, National data have shown health benefits in terms of reduction in rates of pre-cancerous lesions and warts among females.

There has also been some health benefit to males due to herd-immunity, with the exception of men who have sex with men, a group who also would particularly benefit from prevention of HPV-related cancers.

In 2013, Australia will introduce HPV vaccination of adolescent males which will extend the benefit directly to them. It is expected extending the program to include males will also result in health benefits to females who may not already be vaccinated, once again through herd immunity.

As was said to me at a roundtable discussion in Washington DC recently where they sought to emulate Australia’s success with coverage, “we have a cancer vaccine – the holy grail of cancer prevention – and only one third of our teens are having it”. This contrasts with our coverage at 70%.

The financial incentives for parents to vaccinate (or lodge an exemption) were split into two periods in around 2009 which may have been the cause of a sudden increase in immunisation of 5 year olds which was too low.


(A belated addition to the post on November 12; inadvertently omitted by Croakey in initial posting..)

Short-term electoral focus is a health hazard
Professor Linda Shields, School of Nursing, Midwifery and Nutrition, James Cook University, Townsville

If we can’t think of reforms now, things are going to get a lot worse. Indigenous health already suffers from a plethora of projects, studies, etc. that are funded for 2-3 years, when funding for 20 years is needed to bring about real and sustainable changes. Of course, funding for projects at present is the length of an electoral term so it is hard not to be cynical about intentions to “reform” Indigenous health.

On a more local level, the awful uncertainty in Queensland at present will put many potential reforms on hold. Whole health promotion units in rural areas have been wiped out by job cuts. While it was said that no frontline (“bedside”) nursing jobs would go, this has occurred.

Stay tuned: The next post will feature a positive response to the academic’s request, from a Medicare Local  perspective



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2 thoughts on “After all the years of health reform effort and expense, what has been achieved?

  1. Margelis George

    A number of the recommendations of the NHHRC were around the better use of technology in healthcare, leveraging the significant investment in the NBN as a core infrastructure for the delivery of such services. The PCEHR and telehealth were the only ones acted upon, although even those have been done poorly and as a result with limited effect.
    The PCEHR holds great promise, but only if it is used as a tool for enhanced healthcare delivery, and not just a repository of limited data. Part of that is due to the lack of clinician involvement in the design, and the failure to drive the innovation around new models of care that utilise the PCEHR.
    Telehealth is another example of how short term goals have over ridden any long term strategic view around reform. Since its introduction in July 2012 it has been trimmed significantly twice to the point that it is now a mere vestige of what was proposed in the 2010 election. Whilst investing $40 billion to develop the required infrastructure to deliver telehealth to all Australians they have also cut the reimbursement so that the bulk of the population cannot access it. The message to those who have sought to innovate based on the initial policy appears to be stop, it looks like you are costing us money in the short term, even if you are helping people stay in their community and avoiding expensive hospitalisation in the long term.
    It would appear that the failure of the ehealth initiatives is as much due to a failure to visualise what a reformed healthcare system looks like as it is due to a failure of ehealth leadership at any level.

    Dr George Margelis

  2. Stephen Duckett

    An interesting issue is posed in the question from ‘a troubled academic’: when should we expect to see results from reform? ‘Troubled academic’ dates the start of the reform process from the announcement of the Reform Commission. I wouldn’t have expected to see much reform before the Commission’s first meeting so why not that date? Or maybe from the Commission’s Interim Report when directions began to be clearer etc.

    For hospitals, do you date the start of the process from when agreement was reached between the Commonwealth and states as to the reform directions on (2 August 2011 National Health Reform Agreement), 1 July 2012 after which the Commonwealth money flow to the states is described differently or 1 July 2014 when additional money flows to the states and different incentives (on states and the Commonwealth) are created?

    We shouldn’t expect instant changes in what is a quite complex area! The 24-hour news cycle has not served politics well, quarterly financial reporting by companies has not served the economy and investment decisions well, tight timelines to see major results (and in the absence of discernible change abandon and start something else?) similarly doesn’t serve policy reform well.

    Stephen Duckett

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