The Federal Government last week released, with little fanfare, the Issues Paper on Health to inform the White Paper on the Reform of the Federation. See the media release from Prime Minister Tony Abbott and this snapshot of the “threshold questions” to be addressed.

In response, the Australian Healthcare and Hospitals Association today released a statement saying the reform process provides the opportunity to better align responsibilities for the delivery of primary and hospital care services to patients, but that there’s little consideration in the Issues Paper on Health of the need to match funding with service delivery obligations.

See the post below from a health policy analyst who wishes to remain anonymous on what’s in, out, and important in the Issues Paper. Here, also, a focus on the chronic health issues in the Paper from The Conversation.

See also the Issues Paper on housing and homelessness, also released last week.

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“William Foggin” writes:

All governments struggle to put the important before the urgent, and the Abbott government seems to be having more trouble than most.  One of the symptoms of this has been the gradual slippage of the timetable for the White Paper on the Reform of the Federation.

While the initial timetable envisaged discussion papers in spring 2014, a Green Paper in autumn 2015, and the White Paper in late 2015, the timing seems to have slipped to the point that the White Paper will not be released until early 2016.  And the discussion paper on health, which was to have been released in the final months of 2014 (https://federation.dpmc.gov.au/issues-paper-1) has only now been released in the final few weeks of the year.

The discussion paper itself (available at http://federation.dpmc.gov.au/ ) is not very exciting reading – possibly because it reflects contributions and comments from state and territory governments and the Commonwealth bureaucracy.

But it is interesting in that it presents a consistent view that divided responsibility between the Commonwealth and the states for program funding had led to suboptimal outcomes. For example, “while not all of the pressures facing Australia’s health care arrangements are a result of the split of government roles and responsibilities, clarifying the roles and responsibilities of the Commonwealth and the States and Territories could improve the operation of our health care arrangements”.

This is consistent with the general aspirations set out in the Prime Minister’s media release from June (https://www.pm.gov.au/media/2014-06-28/white-paper-reform-federation) and the accompanying terms of reference.

The Prime Minister wishes to “reduce and, if possible, end duplication and make interacting with government simpler. We need to clarify roles and responsibilities for States and Territories so that they are, as far as possible, sovereign in their own sphere.”  And the terms of reference state that:

“consideration will be given to:

  • the practicalities of limiting Commonwealth policies and funding to core national interest matters, as typified by the matters in section 51 of the Constitution;
  • reducing or, if appropriate, eliminating overlap between Local, State and Commonwealth responsibility or involvement in the delivery and funding of public programs;
  • achieving agreement between State and Commonwealth governments about their distinct and mutually exclusive responsibilities and subsequent funding sources for associated programs; and
  • achieving equity and sustainability in the funding of any programs that are deemed to be the responsibility of more than one level of government.”

A few points emerge when thinking about how these aspirations apply to health.

Firstly, while it is easy to claim that the Commonwealth health department duplicates the states’ and territories’ health departments, this is overly simplistic.  Many Commonwealth health department staff work on national programs, such as Medicare benefits, the Pharmaceutical Benefits Scheme (PBS) and the Personally Controlled Electronic Health Record (PCEHR), or provide national regulatory services, such as the Therapeutic Goods Administration (TGA).  It is true that there are overlaps with the states in areas such as mental health and Indigenous health, but these staff would be in a very significant minority.

But it is also true that there is duplication – or even ‘octupalation’ – between the eight states and territory health departments.  There are eight chief health officers, eight hospital funding groups, eight hospital licensing bodies, eight public health directorates, and so on.  And there are eight different legislative regimes: including for example eight different Human Tissue Acts governing consent to organ donation (despite a commitment on the part of the states to introduce uniform legislation).

Second, the Commonwealth involvement in health is explicitly supported in section 51 of the Constitution.  Indeed, it is included in subsection (xxiiiA), which is one of only three amendments to the Constitution to expand Commonwealth powers over the last 113 years.  (The other two being the inclusion of section 105A relating to state debts and the amendment of section 51(xxvi) to allow the Commonwealth to make laws with respect to the Indigenous population.)

There is thus a stronger constitutional basis for Commonwealth involvement in health than there is for many other programs – such as the school chaplaincy program.  It is certainly not the case that health is a sphere within which states should be sovereign, according to the Constitution.

Third, because health is covered by section 51, enumerating subjects upon which the Commonwealth parliament may legislate, it is open to both the Commonwealth and the states and territories to be involved in the area.  It is not an area where there are “distinct and mutually exclusive responsibilities”.

Returning to the discussion paper, although it recognises that that the problems of the health care system will not be solved by reorganising which government pays for which service, it ignores the likelihood that reducing the overlap in responsibilities runs the risk of entrenching divisions in the health system.  The transition between acute care and community care is already problematic for many older, sicker patients.  Simply reorganising which government pays for which service will not improve the transition process, and may even exacerbate the existing problems.

• “William Foggin” is the pen-name of a health policy analyst who wishes to remain anonymous.

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