SWSLHD and Bowral's Health - 15

Better Access criticisms debunked

• By Gemma Collins on  4 August 2011

Criticisms of the Better Access mental health scheme are not justified and it is fulfilling its promise of improving access for patients, a leading psychiatrist says.

Professor Anthony Jorm has admitted he shared the sceptical views of the critics when the Better Access scheme was first introduced but has since changed his mind.

In his submission into the Senate inquiry into mental health which was launched following the Federal government’s planned cuts to the scheme, (see link) Professor Jorm argues that the high cost of the program reflects its popularity with the Australian public and the “previous large unmet demand for psychological therapy”.

He challenges the criticism that GPs are becoming “glorified referrers” through the mental health plans as he insists data shows “patients are generally getting better even though most are not being reviewed by the GP”.

He admits the criticisms relating to a cost blow-out and patient co-payments are justifiable, but argues that co-payments act as a disincentive to the service being overused and without them it could have caused an even greater cost blow-out.

He insists that although uptake is lower in remote areas, the “whole community” has benefited from the scheme and that the “worried well” comprise only a very small minority of Better Access users.

“Better Access has generally fulfilled its promise of improving access, although it needs some tweaking at the edges to reduce remaining inequalities,” he says

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 45

Analysing the 2011 mental health Budget

23rd May 2011

Sebastian Rosenberg   all articles by this author

THE most interesting element of the Budget was not the quantum promised to mental health: $2.2 billion is a reasonable outcome, but only $1.5 billion of this is new money.
Over five years, and as the centrepiece health investment in a tight Budget, there is reason to be appreciative without being overwhelmed.

Fact is, the health Budget grows by around $9 billion each year. At this rate of investment, mental health’s share of the overall health Budget is diminishing.

Another interesting aspect of the Budget was the choices the Government made that reflect willingness to support innovation. There are overdue investments in the Early Psychosis Prevention and Intervention Centre (EPPIC) and also funding for headspace, new services for new clients.
But whether enough funding has been provided to enable their national deployment with integrity of their model of care is less clear.

There is new investment in flexible care packages – $343.8 million – but this funding is supposed to assist 24,000 Australians with severe, persistent mental illness over five years, equating to only $2865 per person per year.

Access to this funding is up for tender, between NGOs and the new Medicare Locals. For the Government, this is a neat way of bringing the nascent Medicare Local enterprises into the community mental health service realm. The risk here is for a continuation of a biomedical approach to these packages of care at the expense of more psycho-social approaches.

The establishment of a pool of incentive funds for states and territories to engage particularly in the development of supported accommodation is most welcome, as is new investment in e-mental health.
There is mounting evidence that for some treatments, e-mental health care is at least as effective as face-to-face services and this is critical if we are to address the needs of remote and regional Australia.

Around a quarter of the whole mental health package is funded by minor administrative changes to the Better Access program, with reductions to the Medicare rebate to GPs and a reduction in the number of subsidised sessions of psychological therapy from 12 to 10 each year.

The Better Access program now costs $10 million per week – the Department of Finance could not ignore it. The fee for service payment model militates against collaborative care.

This is why the Government reassigned funds to the Access to Allied Psychological Services program.

The establishment of a new National Mental Health Commission is exciting, offering a new level of federal scrutiny and accountability over a system characterised by an inability to demonstrate the impact it makes on people’s lives.

Again, however, the Budget papers indicate expenditure of only $12 million over five years, limiting the initial capacity of the commission to really drive new accountability.

The Federal Government has given no indication of its intention to seek state and territory support for a COAG National Action Plan on Mental Health Mk II. As it stands, the Government is bringing around $200 million to COAG, seeking co-investments from the states. By contrast, the 2006 COAG plan delivered $5.5 billion.

This Budget sets out many challenges for the sector but perhaps the most significant challenge is for the political gods to resist the urge to simply now cross mental health off their ‘to do’ list. Now is the time for advocates for mental health reform to be pointing out how much there is still to do.

People with mental illness and their families are used to waiting, often with sad, sometimes tragic consequences. This Budget does not mean that wait is over.

Sebastian Rosenberg
Senior Lecturer, Brain and Mind Research Unit, University of Sydney

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 42

A conversation we ought to be having about healthcare

May 5, 2011 – 5:40 pm, by Melissa Sweet

Anne-marie Boxall from the Commonwealth Parliamentary Library has written a timely and important article for the FlagPost blog, titled: Paying for health care: how can we sustain it?
It is republished below with her permission, and will be worth revisiting when the post-budget protests erupt.

Anne-marie Boxall writes:

At budget time, the federal health minister has one of the toughest jobs. We got a glimpse into this a few weeks ago when the Government announced that it had decided to defer listing some new drugs on the Pharmaceutical Benefits Scheme even though they work and have been deemed by experts to be cost-effective. The announcement sparked outcry from consumer groups and health care organisations alike.

The Minister found herself in this unenviable position because the amount of money available to spend on health care is finite. This is not just a dilemma that arises at budget time however.
Governments around the world are becoming increasingly concerned about how they will fund health care into the future because in most OECD countries, health expenditure is growing at a faster rate than gross domestic product.

The harsh reality is that we cannot afford to do everything that we want or need to do to improve people’s health, at least not without finding new revenue sources (for example from taxes, the private sector and individuals). As Minister Roxon explained last week, the constraints on public sector financing mean that governments will need to play a more active role in determining what will, and will not, be funded in health care. In health circles, this exercise is known as priority setting.
In a forthcoming Parliamentary Library Research Paper I examine the fiscal sustainability of the Australian health system in more depth. In addition to priority setting, I outline a range of mechanisms currently being used to help control health expenditure and examine how effective they are. I also outline a number of other options that could be considered, including:
• paying health care providers in different ways (there are numerous options but the World Health Organisation considers salaries, setting strict budgets, and using capitation payments to have the most potential for containing costs);
• stimulating competition between the public and private sectors, as long as it drives improvements in the quality of care and delivers better value for money;
• monitoring and exerting greater control over the capacity of the health system (for instance the number of health care professionals and health facilities makes a significant difference to overall health expenditure); and
• ensuring government funds are only used to fund the highest quality and most effective of all the treatment options (physiotherapy, for example, might be more effective for back pain than drugs or surgery).

One thing the paper makes clear is that there is virtually no easy savings to be made in the health care sector anymore. Doing anything to make Australia’s health system more affordable will be tough, so beware of anyone spruiking simple solutions. It is not simply a matter of compiling a list of the most cost-effective or cheapest treatments and funding them first. Other countries have tried this ultra-rational approach and found that decisions provoked so much outcry that they were politically untenable.

In the United States, recent attempts to make resource allocation in health care more rational led to claims that the government was introducing ‘death panels’. In the United Kingdom, the decision to deny access to certain cancer drugs led to similar claims. Even if governments hold out against such protests, often there just isn’t enough evidence available to make an informed decision about which treatments deliver the best bang for the buck.

Making the health system more sustainable is also not as simple as getting those people who can pay more to do so. Individual contributions, such as fees, co-payments and other out-of-pocket payments, already account for about 17 per cent of total health expenditure in Australia.

And there is already compelling evidence that the cost of health care poses a real burden for some people and stops them from getting necessary care (see here, here and here). Shifting more of the cost burden onto individuals would make it even more difficult for people with low incomes to get essential health care, and it would make our health system less equitable.

It would also mean that Australia was moving in the opposite direction to most other OECD countries, which have reduced the proportion of total health expenditure coming from individuals over the last decade. It’s not possible to explain the reasons for this trend without further analysis, but it may be that other countries have come to agree with the World Health Organisation that relying on individual contributions to control the growth in health care costs is a relatively blunt instrument and the least equitable way of funding health care.
With no easy solutions on offer, the only way this or any future government is likely to make our health system more sustainable is to undertake more fundamental and potentially unpopular reform (this would include considering some of the options outlined earlier).

Governments will have to make the public more aware that there are limits on what they can spend on health care. No one will like it when the funding cuts affect them, but it might help if they have some understanding of why. Governments will also have to convince health care providers that changes are needed so that better care can be provided at a lower cost.

If reforms threaten the incomes of health providers, then they may need to innovate and find new and more profitable ways of delivering services.

Governments will also have to initiate a national debate on some of the key issues that underpin the issue of sustainable health funding. Are we, for example, prepared to consider solutions such as paying more tax? Or, do we want to move away from public financing and encourage the private sector and individuals to play a greater role?

Admittedly, a reform agenda along these lines would be politically difficult for any government. However, it is likely to be more effective than the current approach.

To date, governments have tended to view the health system in its components parts because it is so large and unwieldy. As a result, there does not appear to have been an overarching strategy for reigning in the growth in health expenditure. Instead, it appears that governments have had a series of one off battles in various sectors of the health system over time.

Instead, governments could consider viewing the health system as just that, a system, and begin developing a clear strategic plan for how we as a nation will tackle the problem of ensuring the sustainability of the health system.

Given that just about any proposal for constraining health expenditure provokes outrage, when it comes to engaging in battles over health funding, it seems that governments would have little to lose by being strategic about the battles it takes on in order to deliver outcomes in the long-run.

One Comment

1. Dr George Margelis
   Posted May 5, 2011 at 7:33 pm
   
   It is great to see that the discussion has moved on to the real problem, The way we currently pay for healthcare in Australia and many other countries drives the current problem of increasing costs without driving better outcomes.
   Anne-Marie has summarised the option, what we now need is leadership to drive them through. The health cost problem is potentially much more dangerous than many of the other issues the government has turned its attention to. We can try introducing more taxes to help cover the costs, but at some stage you just run out of taxable income, so reform of the system now is really the only option.
   

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 41

Divided in opinion with Medicare Local

Nursing Review of Australia

02 May 11 | Print this story | Send this story to a friend

Announced as part of the 2010 Health Reform, Medicare Locals will be rolled out as early as in the middle of this year. However, groups in the field are still divided in opinion regarding the plan, writes Jeff Li.

In the closing address of the 11th National Rural Health Conference, the Minister for Health and Ageing Nicola Roxon said that through strong engagement with local health services, Medicare Locals will make it easier for rural patients to use the health system and to reduce mismatch between services provided and services needed.

Jenny May, chairperson of the National Rural Health Alliance, says that Medicare Locals is a chance to bring focus to primary care, but stresses that it is important for it to be aware of the needs of the local community.
“There are some principles, if you like, in terms of Medicare Locals that the Alliance feels very strongly about, and they are the need for them to be local, and the need for them to be genuinely consultative and the need for them to be very multi-disciplinary in their approach and to really model a primary health care approach to prevention to early diagnosis and to support the services,” May says.

“There needs to be collaboration between the local players involved in primary care, that comprises general practices, including GPs, practice nurses and others, including aboriginal medical services, the local government sector and numbers of other private or public allied health commissions, who all currently provide primary healthcare services.”

She also says that primary healthcare organisations can collaborate in terms of planning services, identifying service gaps and providing or supporting a range of services.

“I think practitioners, in collaboration with service providers, have a much better idea at a local level, where the gaps in services are. So I think they have much to bring to the table.”

However, Steven Hambleton, vice-president of the Australian Medical Association says that one of his concerns is that general practices will repeat the process in hospitals where doctors and other health professionals are taken out of management and become disconnected with the needs of the patients.
“The overarching concern is that we don’t want to see primary care goes the same way as hospital care in that a bureaucracy gets in the way between patient and doctor.”

“If there is going to be a body of Medicare Locals, there definitely needs to be GPs in there in the majority to make sure that it remains connected to the patients. The GPs have in this space for a long time and has the expertise.”

Hambleton says another concern is the nature of Medicare Locals as fund holders.
He says it implies that there is a definite fund pool and that when it runs out, there is none left. “[It] basically means that there is a great potential for rationing of healthcare at the Medicare Locals level.”
He also says GPs should be providers of medical care and that working with other primary healthcare providers is the way of the future. But he says that patients need to be educated on what services are available and when to seek healthcare.

“We’ve gone from episodic healthcare to chronic disease managed healthcare and are about to proactive chronic disease management, which must be linked in with health literacy from the patients and a lot of self-management. You can’t do that with just one provider. We do work well with nurses; we do work well with health professionals and all parties that contribute to the healthcare of the patient. I guess the key person in all this is the patient themselves.”
Hambleton also says the fact that funding for primary healthcare and community services coming from different pools of fund will reduce the efficiency of the two systems working together.

“The structural drivers of health reform, which was the Rudd government’s push to have the majority of the funding of primary care all coming from the Commonwealth has been unbound by the current Prime Minister, meaning that it is going to be a lot harder for Medicare Locals to actually achieve to what they originally planned to do in the National Health and Hospitals Reform Commission.”

“We’ve seen Medicare Locals issues accelerated, when at the same time, the structural drivers that pushed the groups in the Medicare Locals’ base together have been lifted. So at the very least, we have to stop the rate of roll out, stand back a bit and do some more planning. With the way things have been rolled out right now, the AMA is not happy with it.”

May agrees that there has been some haste in the process, especially when some of the organisations for Medicare Locals cover a large geographical area with different needs. The NRHA will see with interest on how the applicants for Medicare Locals funding plan to operate and that it has some principles on whether a Medicare Locals bid is successful.

“The important thing from our point of view is to see integration of the best available services in rural areas. Often there is a deficit of any services, and we are keen to see those needs articulated and then met.”

SWSLHN and Bowral's Health - 8

May Budget expected to bring long-awaited GP MRI rebates

3rd May 2011 - Medical Observer

Byron Kaye   all articles by this author

GP REFERRALS for MRIs could finally be granted MBS rebates as the Federal Government confirms it is “reviewing” funding arrangements for radiology ahead of the release of next week’s Federal Budget.

The widely anticipated measures, long advocated by doctors’ groups, would see MRIs subsidised for children under 16.

The changes would mean young patients could more easily recoup most of the cost of the radiation-free, higher-accuracy alternative to CT scans, now seen by experts as the standard for examinations of several spinal, knee, brain and abdominal conditions.

Currently, patients of all ages can receive a rebate of $350–$430, but only when ordered by a non-GP specialist. GPs have been agitating for years to have the rebates available directly from their referrals, arguing the system is inequitable because it discourages lower-income patients from having the investigation.

When questioned about speculation the Government will offer the rebates for GP-ordered MRIs for children, a spokesperson for Health Minister Nicola Roxon declined to comment directly but said the Department of Health was “currently reviewing diagnostic imaging arrangements”.

RACGP vice-president Dr Elizabeth Marles said she would be “very pleased” by any measure to cut children’s exposure to even the low levels of ionising radiation in a CT scan. She predicted that rather than risking a “budget blowout”, the rebate would save taxpayer money by reducing specialist visits.

“It’s not going to be a commonplace investigation,” Dr Marles said.

“If you had significant neurological concerns about a child, you’d get a specialist anyway. By giving them the ability to have an MRI, you’d be able to determine if there were any brain tumours or things like that. You’ve got a better idea from the outset.”

The change may require additional CPD training on appropriate and safe ordering of MRIs and the college would work with Government to develop a program, Dr Marles said.

“We would support some sort of education for GPs so they would be comfortable to be able to use MRIs appropriately.”

GP Dr Brian Morton, chair of the AMA’s Council of General Practice, said it would make “the right test for the right reason” more easily available and would speed up treatments.

GPs could “initiate the management rather than having to wait for the specialist”, he said.

However, Dr Morton called for any rebate for GP-initiated MRI to be extended to include non-child examinations best done with MRI, including for spinal radiculopathy, knee injuries and multiple sclerosis.

Dr Ron Shnier, president of the Australian Diagnostic Imaging Association, said although radiation levels in CT were low, making MRI more accessible to children would improve safety.

Comments:

bubbles
3rd May 2011
5:12pm

Finally! I also hope they are going to consider the CT Coronary Angiogram having some form of rebate as well.

SSWAHS = SWSLHN and mental health in the Southern Highlands - 13

A tick for Opposition’s plans to improve employment services for people with mental illness

April 22, 2011 – 11:09 pm, by Melissa Sweet

With mental health in the news, thanks in part to Tony Abbott’s recent funding promises, below is a Q and A piece with Professor John Mendoza, first published by The Conversation on April 21.

Why do so many mentally ill Australians struggle to maintain employment?

This is a critical policy issue for all Australian governments over the next decade. We’re clearly facing a skills shortage and that’s across the board, it’s not just in the mining sector.

We have to get a lot better at engaging people of working age who are not in employment.

Mental illness, often untreated, is one of the primary causes for the situation that we face.

About 28% of all Australians on the disability support pension have a primary mental health-based disability. Of the remaining 70%, around half have mental health problems as a secondary contributor.

The rate of employment for people with mental health conditions in OECD nations is nearly three times the rate of employment than Australia. Needless to say, Australia does very poorly in this area.

There are a number of reasons for this and the announcement by the Federal Opposition starts to address some of these issues.

***

How does the Coalition’s announcement build on existing infrastructure?

We’re already spending a lot of money increasing employment services for people with mental health disorders.

Commonwealth spending on disability support pensions and employment-related programs is around $5 billion. This provides income and support for people on the disability support pension, Newstart allowance and other benefits who are there because of mental health problems. But we’re not getting good outcomes from that spending.

What today’s announcement does is target a couple of specific areas where we know we can do better.

It’s not just a matter of preparing a person with significant mental illness to enter the workplace.

We need to place people in a workplace where they can receive support. A truly supportive work environment is where the culture recognises the way mental illness presents and manifests.

These workplaces support the employer to help keep that person engaged, modify activities, train co-workers on how to deal with mental health episodes and crises if they occur, and retain that person in employment.

The mental health blueprint, released last month, calls for a minimum investment across 30 targeted programs over four years.

We’ve got to lift our current rate of mental health funding as a proportion of total health spending – from around 6% towards 12% to 13%.

That’s a very big ask and no government of any persuasion is going to be able to do that in one or two terms. I think the Coalition is mindful that what was announced today is not enough.

***

Will we see more than just a bidding war from today’s announcements?

I have to be optimistic that this announcement is more than a bidding war. I certainly believe what the Coalition took to the last election and what they’re building on today could bring about real improvements.

The Rudd Government and, to an extent, the Gillard Government are “blowhards” when it comes to mental health. They’ve talked long and hard but they’ve delivered almost nothing.

Suicide prevention was the cornerstone of their mental health policy leading into the last election, with promises of spending $274m over four years.

In the first year, they’ve spent $10m. There’s a bit of a credibility gap when you say you’re going to deal with an issue and in the first year you spend only 2% of the funding that you’ve allocated.

The situation is similar when we look at the Headspace initiatives for increasing early intervention sites around the country.

Labor is spending most of the money not in the second term, but in the third term of government if they’re re-elected. I think that is gilding the lily on this issue.

We need to see the investment flying through fairly evenly, but building up over the four-year budget cycle.

Tony Abbott has basically picked out elements of the blueprint that were released by the working group last month. Many of the working group’s members are advisors to the Federal Mental Health Minister Mark Butler.

These are things members of this group have said privately to the government about what needs to be done.

Tony Abbott has said, very wisely, we know we’ve got a problem with employment participation for people with mental illness and I’m going to target that because it’s one of the areas where investments will produce dividends. The impact on the budget in the longer term will be a positive one.

We know employment participation is critical to people’s recovery, in lifting them out of poverty and helping them regain their sense of self.

Certainly social inclusion is improved dramatically by participating in work. So I think it’s a wise investment, it’s a smart policy, and it won’t cost the budget bottom line in the first instance.

Over the longer term, it will save an enormous amount in terms of the money we’re spending at the moment on disability support pensions and the like.

We’re spending this money now but without getting any movement on people going back to employment.

• John Mendoza is the Director of ConNetica Consulting Pty Ltd. He is the former chair of the the National Advisory Council on Mental Health (appointed by the Rudd Government in June 2008) and resigned in June 2010 citing a lack of vision or commitment to the issue.

One Comment

1. Murf
   Posted April 22, 2011 at 11:49 pm

   If we’re going to get people who have mental health issues back into the workforce (and most of us who’ve been employed before are really keen to get back to it), we need to start training CentreLink not to send away unemployed females who don’t qualify for a benefit. I haven’t even been able to talk to anyone- just a quick dismissal on the phone, several times over the past 12 years (when I’ve had the occasional part-time job). They say “Use your professional networks- we can’t help people like you. We don’t have the sorts of jobs you’re looking for”. Slam. How can we have networks when we’ve been out of work for months or years? Huh? Will we just happen to bump into an employer who won’t run a mile as soon as we mention mental health issues? Better to keep it to yourself when there’s no one to back you up. Also, no one seems to realise how soul-destroying it is for females who have always been financially independent, to suddenly tie their fate to someone else because there are no supports in the community for them to fall back on. It makes mental health issues worse. Someone has to have a good think. Get back to me when there’s some news.

SWSLHN and Bowral's Health - 1

Challenging accepted wisdoms about young peoples’ health and wellbeing

April 22, 2011 – 1:19 am, by Melissa Sweet

Mental health is in the political limelight in the lead-up to the federal budget, with the Government and Opposition both promising support for mental health services.

The researcher and writer Richard Eckersley argues that we need to develop a much broader understanding of mental health and wellbeing in young people. In particular, he challenges the conventional narrative around the social determinants of health.

***

Challenging the accepted wisdom about young peoples’ health

Richard Eckersley writes:

The widely accepted story of young people’s health in developed nations is that it is continuing to improve in line with historic trends and the progress of nations. Death rates are low and falling, and most young people say they are healthy, happy and enjoying life. For most, social conditions and opportunities have improved. Health efforts need to focus on the minorities whose wellbeing is lagging behind, especially the disadvantaged and marginalised.

There is another, very different story. It suggests young people’s health may be declining – in contrast to historic trends. Mortality rates understate the importance of non-fatal, chronic ill-health, and self-reported health and happiness do not give an accurate picture of wellbeing. Mental illness and obesity-related health problems and risks have increased. The trends are not confined to the disadvantaged. The causes stem from fundamental social and cultural changes of the past several decades.

The contrast between the old and new stories is graphically illustrated by these Australian statistics: about 40 per 100,000 young people (aged 12-24) die each year and the rate is falling; 26,000 per 100,000 (26%) (aged 16-24) suffer a mental disorder each year and the rate has probably risen, perhaps steeply. Which statistic says more about young people’s wellbeing?

Stories inform and define how governments and society as a whole address youth health issues, so which story is the more accurate matters. The usual narrative says interventions should target the minorities at risk. The new narrative argues that broader efforts to improve social conditions are also needed. The old story may still generally hold true in developing nations, but the issues raised in the new story are also of increasing importance to these countries as modernisation and globalisation impact more on the lives of their young people.

A central dimension of the changed trajectory in health over recent decades, and which underpins the new story, concerns the declining significance of material and structural determinants of health and the growing importance of existential and relational factors to do with identity, belonging, certainty and purpose in life. There is a shift in emphasis from socio-economic causes of ill-health to cultural; from material and economic deprivation to psychosocial deprivation; from a problem of material scarcity to one of excess. With this has come a shift in significance from physical health to mental health.

This argument is not to suggest sharp, categorical distinctions and clear breaks from the past. Physical and mental health are closely interwoven and interdependent. Physical illness, including infectious diseases, still matter. Disadvantage and inequality still matter. Indeed, the cultural changes of past decades may well have exacerbated their effects by making material wealth and status more important to how people see and judge themselves. Environmental problems such as climate change have serious implications, including the risk of possible catastrophic effects on human health.

The contrast between the old and new stories of young people’s health and wellbeing is part of a larger contest between the dominant narrative of material progress and a new narrative, sustainable development. Material progress sees economic growth and a rising standard of living as the foundation for a better life; sustainable development seeks a better balance and integration of economic, social and environmental goals to produce a high, equitable and enduring quality of life.

Material progress represents an outdated, industrial model of progress: pump more wealth into one end of the pipeline of progress and more welfare flows out the other. Sustainable development reflects (appropriately) an ecological model, where the components of human society interact in complex, multiple, non-linear ways. Not only does sustainable development better fit the new story of youth health, it is likely to achieve better outcomes in relation to the old story’s focus on socio-economic disadvantage and inequality because it less intent than material progress on economic growth and efficiency.

The health of young people should be a focal point in the larger contest of social narratives. They should, by definition, be the main beneficiaries of progress; conversely, they will pay the greatest price of any long-term economic, social, cultural or environmental decline and degradation.

If young people’s health and wellbeing are not improving, it is hard to argue that life is getting better.

• This is an edited extract from: Eckersley, R. 2011. A new narrative of young people’s health and wellbeing. Journal of Youth Studies. First published 13 April 2011 (iFirst) (http://dx.doi.org/10.1080/13676261.2011.565043). An author version is available at www.richardeckersley.com.au

• Richard Eckersley is a director of Australia21 Ltd, an independent, non-profit research company and a visiting fellow at the Australian National University.

SWSLHN + SLHN = SSWAHS

The NSW State Government's approach to health, immediately after the election, gets a big tick from Socrates for terminating the incumbent Director General of Health, Ms Debra Picone.

Her departure is possibly the first of many who will depart from a Health Department, populated as it was by the previous government and Minister, of political appointees who had their snouts in the trough to obtain the best outcome for themselves and their pet projects.

Now to the last thing the previous NSW government did before it was shown the door in March. On the 1st of January 2011, the Health Minister announced that the new Local Health Networks (LHNs) had commenced in NSW. This meant that the previous Area Health Services had, in many cases, been divided into (marginally) smaller LHNs.

For us in the Southern Highlands it simply reverted back to the partition of SSWAHS into the old Central Sydney AHS and the old South West Sydney AHS, with this time, an additional layer of bureaucratic governance with a CEO overseeing a cluster of such LHNs.

Now here was the catch. Previously the old SSWAHS had streamed their clinical services to provide their specialist services across the entire jurisdiction of the SSWAHS. This meant, for example, that cancer services, cardiac services, mental health services, etc, would be provided to, and be accessible by, all residents in the SSWAHS.

After initially stating that the Area-wide clinical services will still provide access to all the residents of the old SSWAHS it now seems that the current administration of the Sydney LHN (the old Central Sydney AHS) is suggesting that they have sole right to all the clinical services within the Sydney LHN jurisdiction. Put simply, that means no resident of the Southern Highlands can expect to have access to the clinical services located at Concord Hospital, Royal Prince Alfred Hospital, Sydney Hospital, Balmain Hospital and St Vincent's Hospital.

This may seem very little loss to residents in the Southern Highlands as we still have access to Campbelltown Hospital, Camden Hospital, Liverpool Hospital and Bankstown Hospital as well as our own Bowral Hospital. The reality is, however, there are not a sufficient range of medical specialties in Bowral, and Camden Hospitals and the distance to Bankstown Hospital is considerable.

So, for example, suppose someone in the Southern Highlands requires treatment and residential care for an acute mental illness. Bowral Hospital has a couple of beds available for people with a sub-acute episode which does not require involuntary treatment. The beds are embedded within the whole complement of available beds in the hospital so they could be available, but then again, they may not. And what if the person requires an involuntary treatment and admission?

In the old SSWAHS people from the Southern Highlands requiring specialist treatment in one of the old clinical streams went first to Campbelltown Hospital and then to Liverpool, Concord, RPAH and Bankstown hospitals wherever the specialist beds were available. With the new LHNs our residents will be limited to Campbelltown, Liverpool and Bankstown hospitals.

Another feature of the old SSWAHS was that the local health funding for Bowral Hospital and its Community Health Services was drawn back into the specialist Clinical Divisions to fund, among other things, the budget over-runs of the big northern hospitals. It was also used to fund the budget over-runs and other capital costs associated with the building and renovations of the big northern hospitals. At the same time, Bowral Hospital survived on the donations and fund-raising of the local people, businesses and community groups to fund our two renal dialysis chairs and the refurbishment of the children's ward.

It is, perhaps, not unexpected that a SSWAHS Executive, that was appointed by the previous NSW Labor government, was drawn mainly from the old Central Sydney AHS. After all the previous Labor Minister for Health has her seat in Marrickville - central to Central Sydney AHS. The SSWAHS CEO, his Deputy and most of the Directors and Executive members all came from Central Sydney AHS. Some, but not all have headed back to the Sydney LHN taking with them the bulk of the funding and the capital works developments of Concord Hospital and RPAH.

As I have said in the blog many times, SSWAHS administration has overlooked Bowral Hospital and the Southern Highlands, probably because it was seen as a "safe" Liberal seat. Now that we have a new Liberal/National coalition government we appear to be again overlooked because we are an even "safer" Liberal seat!

By now some of you may be wondering why the title of this blog posting has changed to SWSLHN + SLHN = SSWAHS. Well, it does seem as the wheel may have turned full circle again. An informant has told me that the Federal Labor government is unhappy about the additional layer of bureaucracy imposed on the NSW health system with the LHNs and the LHN Cluster overseers. It would appear that even prior to the dismal showing of the NSW Labor government in March they had been advised to revert back to the super Area Health Services. Hence, the Southern Highlands will likely come under a re-formed SSWAHS but, hopefully, without the Executive misfits who always found it hard to look beyond Campbelltown.

Socrates, ever the optimist, is hoping that the new coalition government, and their new Director-General for Health, will not only accept the advice of the Commonwealth but also ensure that any new NSW health structure will take into consideration the possibility of local members having a greater say in their local hospitals, and that funding be commensurate to ensure that the hospital and community health services can provide the services required by the local people, locally.

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 24

100 days to become a Medicare Local

• By Gemma Collins on 6 April 2011
• 6Minutes
  

"It will take 100 days for Divisions of General Practice to transform into “high performing” Medicare Locals, according to business experts who are offering their help with the transition.

The consultancy firm Ernst and Young has come up with a “transition framework” to help individual organisations competing to become part of the government’s $417 million plan for Medicare Locals.

And it will only take 100 days for the Divisions of General Practice to become Medicare Locals, according to their advert on the AGPN website.

The company may be too late in helping organisations submit their bids for the first round of 15 Medicare Locals, due to start in June.

But there is still time for the second round due to start next year, with the deadline on July 19.

And Ernst and Young which says it has done work for the UK’s Department of Health, insists the transition can be covered over four phases.

The phases range from developing a bid and a 100 day plan to assessing the health needs of the population, creating a workforce and finally “executing” the plan.

“You have a unique opportunity to transform the delivery of primary healthcare as part of the overall reform program and transition to a system of high performing Medicare Local organisations that are capable of realising the benefits envisaged,” the company says."

It would seem to Socrates that even Blind Freddy can see where a large chunk of the Federal Government's funding will go if the so-called "not-for-profit" corporate organisations such as the Macarthur-Southern Highlands Divisions consortium gets the nod for setting up a Medicare Local up in Macarthur.

SSWAHS = SWSLHN + SLHN + Medicare Locals and Rural Health in the Southern Highlands

Some searing critique of the health system from John Menadue and others at the national rural health conference

March 17, 2011 – 7:09 pm, by Melissa Sweet

Two particularly searing critiques of the health sector were given yesterday on the final day of the national rural health conference in Perth.

John Menadue, of the Centre for Policy Development, titled his paper, “Beating the hospital obsession; the key to rural health reform is in primary care”. (Update: you can now watch his presentation here).

His themes were very much reinforced by a subsequent presentation by the University of South Australia’s Professor Robyn McDermott, who coined the memorable line that we are poisoning our old folks (with harmful polypharmacy) and fattening the young (via our failure to take effective policy action on obesity).

Below is an edited extract of Menadue’s speaking notes, as well as a selection of my conference tweets of some of his key points, and a short summary of McDermott’s presentation, and related tweets.

***

Edited version of John Menadue’s speaking notes

The summary:

There are systemic problems in our health sector – a lack of guiding values and principles, governance confusion, exclusion of the community from health decisions, rapidly rising costs and the obsession with hospitals. We are bedevilled by powerful special interests.

But what are the particular issues which advocates of rural health reform should promote?

First, the driver of rural health reform must be primary healthcare with particular attention to the Medicare Locals and the roll out of the GP super clinics. The MBS schedule should be amended and contracts written with corporate and non-corporate general practices to promote integrated care.

Second, there are many health determinants and services outside the health portfolio that are vital – NBN, prevention and transport. Paper records are problematic enough in the cities. They slow down information transfers even more severely in the bush.

Third, unless there is an informed and open discussion about how the health dollar is spent, the media-savvy and the special interests in the city will squeeze out the major health priority needs in this country – rural health, Indigenous health and mental health.

Fourth, we need an upgrading and re-skilling of tens of thousands of people in the health sector who could help fill the gaps in the delivery of health services for country people. Particular attention must be given to expanding the roles of nurse practitioners, other allied health, pharmacists and ambulance officers. We don’t so much need more doctors; we need an up-skilling of tens of thousands of other clinicians. We need also to make sure we make best use of the skills they already have.

Disappointment of health reform

I was sceptical about the claims of Kevin Rudd last June that the health reforms were ‘the greatest since Medicare’. I have seen little since then, including the Commonwealth Government announcement in association with the premiers last month that would change my mind. It is more muddling through.

What a disappointment it has been since the federal government came to power in 2007 with what I hoped were well considered strategies for healthcare reform and the means to implement them.

But before I become too pessimistic, let me acknowledge some incremental improvements that have been announced in recent months. They will be valuable – activity-based hospital funding, some local governance of hospital networks, primary healthcare organizations to aid primary healthcare integration and broader health service planning, including I expect, full Commonwealth responsibility for aged care.

At last there is some progress on e-health, although only this week the Victorian Government and the Liberal Opposition in NSW expressed reservations about the new systems being introduced in those states. There is clearly more money, but I believe that we are not getting value for the money we already spend. A survey of Canadians over 45, who were experienced healthcare users, showed that 58% did not believe that healthcare would improve if the government spent more money in health. I believe the same is true in Australia. We should be spending existing money much more effectively. We waste about $10 b pa or 10% of our total health expenditure.

Major problems and omissions remain

• It is not at all clear that the government has any clear values and principles which guide its health policies, e.g. universality, equity, efficiency – both technical and allocative – subsidiarity and single-funder. Without such guiding principles health policy will continue to be subject to managerial fads, responses to hot-button issues and the placating of noisy and selfish special interests.

• Governance problems between the Commonwealth and the States remain. A 60/40, 40/60 or a 50/50 split doesn’t make any difference to divided responsibility. It seems that the Australian public are better prepared for reform than the Government with a strong majority in most states favouring a Commonwealth takeover of state hospitals. In addition to the unresolved Commonwealth/state issue, I have also come to the view that the traditional minister/departmental model in health is no longer viable given the size of the health sector, its complexity, its inertia and the power of vested interests. (Professor Garnaut refers to these interests in carbon pollution and mining as ‘diabolical’. They are more subtle, but just as diabolical in health.) For these reasons I have proposed a statutory Commonwealth Health Commission composed of professional and independent people, but subject to government guidelines to administer health programs in Australia. This would be similar to the way the Australian Reserve Bank acts in the monetary policy field. The health sector has broadly agreed for a decade about the general shape of necessary reform, but it has not happened because of the political power of health lobbyists to preserve corporate welfare, high prices and work practices, particularly by specialists who exploit their market power.

• The community is still largely excluded from health discussions and decisions. The Prime Minister and the Minister deal overwhelmingly with special interests and ignore the community except for some token photo opportunities, mainly in hospitals.

• Costs are continuing to rise at 5% real per annum. It is not, as often suggested, that it is ageing that is driving up healthcare costs. We all see our doctor or specialist far too much, across all age groups. In 1984/85, Medicare services per person per annum were 7.1 services. By 2007/08 it had increased to 13.1 services and this increase was across all age groups. This is a doubling over 13 years of the number of times we see our doctor. The cosy deal between the government and the Australian Pharmacy Guild, results in Australian taxpayers and consumers paying $300 m more each year for statins compared with England and Canada. This is only for statin drugs which represent only about 16% of the costs of the PBS. We can’t afford these exploitive high prices.

• Fee for service is quite inappropriate for chronic care. It has perverse incentives. It encourages doctor shops and ‘turnstile’ medicine. It discourages integrated care. Present payment methods are underwriting the rapid growth of corporatisation of general practice in Australia, up to 30% in some metropolitan areas.

• The health workforce is still mired in 19^th Century work practices.

• 70% of health expenditure in Australia is for treating chronic disease – heart, cancer, neurological, mental and diabetes. But the public campaign, particularly in the media, focuses on waiting lists and emergency departments in hospitals.

• Dental health is still a Cinderella as is mental health, although we may hear more about the latter in the near future.

• But probably the most serious problem is the continuing obsession with hospitals, an obsession shared, I must say, by the media, many health professionals and the community. According to OECD data, we have for example more acute beds per 1000 of population than in the UK, Canada or Sweden. But the continual drum-beat in Australia is for more hospital beds to accommodate particular medical fashions. In the last decade caesarean sections have increased by about 50% and joint replacement by almost 70%. We all know that about 10% of people in hospitals would not be there if there were proper alternatives available, and that it costs about ten times as much to treat a patient in hospital compared with treatment in the community. The Productivity Commission in 2008 said that 450,000 admissions to public hospitals could have been avoided if there was better community care in the three-week period before hospital admission.

Private health insurance and country people

A particular issue which should concern country people is the inequity and inefficiency of the $5 billion p.a. government subsidy to high cost private health insurance companies. Put simply, this corporate welfare enables relatively wealthy people in the cities to jump the queue for elective surgery in private hospitals and it deprives public hospitals of resources. Recent data from the Australian Institute of Health and Welfare (Australian Health Expenditures by Remoteness, January 2011, page 41) shows how this subsidy short-changes country people because of the few private hospitals in country areas.

In 2006/2007, the latest year for which these figures are available, the expenditure per person in private hospitals in the country compared with major cities was 16% lower in ‘inner regional’; 34% lower in ‘outer regional’; 48% lower in ‘remote’ and 60% lower in ‘very remote’. By contrast, public hospitals served the country community much better. Compared with expenditure in public hospitals per person in major cities, public expenditure in public hospitals in ‘inner regional’ hospitals was 10% higher, 28% higher in ‘outer regional’; 68% higher in ‘remote’ and 250% higher in ‘very remote’.

Country people are being duded by the $5 b p.a. subsidy. Yet National Party MPs allow themselves to be led by the nose by the Liberals. Because there are so few country private hospitals, the $5 b p.a. subsidy inevitably operates to the disadvantage of country people. The transfer of this $5 b subsidy to rural health, mental health and indigenous health would have dramatic benefits. That would be $50 b over ten years. The new hospital package that Julia Gillard announced last month is only $16 b over ten years.

Winning the case for country health reform

On almost any measure, country people have worse health outcomes than city people. Mainly due to lack of early detection, cancer sufferers outside capital cities are 35% more likely to die within five years. Country sufferers of heart disease are more likely to die early. The story is similar across the board – stroke, birth defects and mental disorders.

Four major issues on which country health reform should focus

First, primary care. The inequity in healthcare in Australia, rural, mental and indigenous, will only be effectively addressed through primary care, not hospitals. The dignity, autonomy and good health of all citizens are best served by delivering health services in the home or as locally as possible. It is the principle of subsidiarity.

Second, health improvements are just as likely to be advanced outside the health portfolio, eg broadband.

Third, winning the debate for priority-setting and allocation of health dollars depends on an informed community. Unless this is done, the well-organised and worried-well in the cities will continue to skew resources in their favour. Unless country people can win the debate, they will continue to be unfairly serviced in health.

Fourth, workforce reform.

Primary Care

In the hospital sector, it is hard to teach old dogs new tricks. Ministers, officials and professionals with their century-old ways of doing things, are hard to change. They think institutions and providers rather than people, and the almost sacredness of existing work practices. Primary care offers the best prospect of services for country people, integrated care, the curtailment of chronic disease, reduced service fragmentation and increased efficiency, particularly through new work practices. As Jennifer Doggett has set out in ‘A new approach to primary care…’ (CPD, June 2007), primary care provides

• A greater focus on prevention
• Faster medical action
• Consolidated service delivery
• A seamless one-step approach
• Consolidated history with test results
• Better access for all.

As Jennifer Doggett summarises it, ‘Primary care reform is the single most important strategy for improving our health and making the health system sustainable. Community level prevention and primary care is essential to restoring universality and efficiency in Australian healthcare’. Health decisions and health services must be made at the most local level possible – the principle of subsidiarity.

In the long and recent statements arising from the government’s obsession with hospitals, there has been included, almost as a footnote, that ‘the Commonwealth will have full funding and policy responsibility for general practice and primary care … including community health centres … and aged care’. Those few lines if properly and fully implemented could really reform and transform healthcare in Australia. That reform won’t come through hospitals.

How Medicare Locals develop will be an important key. The first thing that government should do is change their name to make it clear that these entities will not be delivering care. This is not just a cosmetic issue. They must be seen to be, and in fact become, regional planners and co-ordinators with adequate funds based on population and socioeconomic needs and for the purchasing of some services. They must be proactive in prevention. They must develop so that they can influence all hospital and non-hospital services in their region. These newly named entities must have resources and government support to drive regional planning and the delivery of services by others, e.g. early childhood, schools, welfare, housing and transport both for patients and families. Dialysis is a major problem. These new entities must be judged by their health outcomes and not their health inputs. They must get away from the medical model based on sickness that determines so much of what we do in health. If they in fact become a new name for the Divisions of General Practice, they will fail. I suggest that the rural health alliance should be focusing its activities on the development of these new entities, mistakenly called ‘Medicare locals’.

We also need to improve General Practice. I spoke earlier about fee-for-service dramatically putting up costs and discouraging integrated care. The government should consider two possible changes. The first is that the MBS schedule be amended to permit private practices to remunerate a supervising general practitioner in their practices. That supervising GP would be remunerated for over-sighting the treatment and referral of patients and their records. The second is that the government should offer to negotiate contracts with practices, both corporate and non-corporate, that will commit to the delivery of integrated care. I expect that the government would be agreeably surprised at the number of GP practices that would respond because of their concern about the ‘turnstile’ nature of a lot of general practice in Australia today.

What of the GP super clinics that the Commonwealth is rolling out? Including this year the Government will be spending $650 m over two years on 64 clinics. It is not yet clear that these clinics are on the right track. I hope we don’t have another insulation mess.

• I can’t see that the roll out of these clinics is part of a universal program. Only six of the planned 64 are operating. Why call them ‘super’? I should have thought they should be ordinary and common-place. They do appear to be part of a marginal-seat strategy rather than a health strategy.
• ‘GP’ suggests that it is doctor-centric, when the emphasis should be on multi-disciplinary teams with enrolled patients/families. Often the need is not even for a clinician, particularly for people who face lifestyle and social problems. Often a case-manager is necessary to access other agencies, e.g. education, housing and justice.
• Are the clinics the right size to enable the team to be made up of a wide range of health professionals, or will they be GP clinics with a few and limited professional add-ons?
• Emphasis seems to be on bricks and mortar and co-location, rather than the provision of integrated care. Accommodation under one roof does not necessarily lead to integration.
• How can the MBS be amended to promote more team treatment and payments to all professionals in the clinic?
• Two vitally interested organisations, the Australian Nurses’ Federation and the Australian Practice Nurses’ Association have heard very little about the program.
• The Australian Pharmacy Guild has refused to allow professional pharmacists to join the clinics unless they do so as shop-keepers. That clearly tells me that the APG is more concerned about shop-keeping than the professionalism of its members.
• There is a ‘deafening’ silence about the superclinics and how they are performing. The fact that the AMA is saying little, suggests to me that the program is not going well.

Improving health outside the health portfolio

The mis-named Medicare Locals must also drive improved health services outside the health portfolio.

Ministers for Health in Australia are seen very largely as ministers in charge of health services rather than health. The fact is that some major issues causing poor health or which could be the means to improve health are outside the normal health portfolio.

• Medicare has become a payments vehicle, and an efficient one, rather than a health insurance commission as its name suggests was intended. How can we have integrated health funding, even at the Commonwealth level, when the Minister for Human Services, not the Minister for Health, has administrative responsibility for Medicare.
• The major health problems caused by junk food, alcohol and tobacco are best addressed through taxation and restrictions on advertising, particularly for children. (Health improvement is made very difficult when the major sponsors of sport in Australia are interests associated with alcohol and junk food. They are complicit in promoting bad health habits and undo a lot of the good work on prevention. How can our sporting codes discipline players for excessive alcohol consumption, when the main sponsors of the codes are liquor companies?)
• We know that because of social and economic disadvantage, the death rate for those with the lowest socio-economic status is 13% higher than the Australian average, and for those living outside capital cities it is 8%. Poverty is the principal cause of poor health in Australia.
• Education, childcare, including pre-natal, spacial planning, housing, trade (particularly relating to intellectual property in pharmaceuticals), population, transport, taxation and social security, employment, justice and the environment, all have direct impacts on the health of Australians.
• We are coming to appreciate how electronic health and the national broadband network offer great opportunities for improved health services, particularly for people in remote areas. They offer a new model of care particularly for remote and chronically ill patients. It will hopefully be possible to bill Medicare for online treatments. But the NBN is not within the health portfolio. NBN can transmit data-rich information such as scans and close-up real-time high definition videos, say, of a burn or a cancerous skin mark.

In short, the health Minister and her department must have expertise beyond ‘health services’ and particularly economic expertise in a joined-up government approach.

As Ian McAuley has put it:

One problem … is a reluctance by policy makers to look on healthcare as an industry and to apply the normal evaluative mechanisms which are applied to other industries. Such a blinkered view allows the development of an idea that health should be exempt from the normal economic considerations of efficiency and equity. It’s a notion that pushes economic thinking to one side, in the erroneous belief that economics is intrinsically illiberal and dismissive of human welfare. For a country reviewing its healthcare industry, it is useful to take a broad view and consider the whole industry. Only in such a way is there likely to be policy coherence and resulting economic and equity benefits of integration of programs into one system, underpinned by principles which align with the community’s values and priorities.

Setting health priorities

Unless there is an informed community debate, rural health will continue to be squeezed out by organised city-centric interests. You just do not have the lobbying power of the AMA, private health insurance funds, the Australian Pharmacy Guild and hospital interests. But you do have Independents who hold the balance of power in the House of Representatives. The case must be won that choices have to be made and priorities set. It will be a red-letter day in Australia when we have a prime minister, premier or health minister who will publicly say that we can’t have all we want in health. We need to shift the debate away from hot-button issues of more beds, and emergency departments, to the longer-term issues of priorities in spending the health dollar. I happen to think that the major priority areas of need in Australian health are rural health, mental health and Indigenous health. But that is not reflected in informed community debate. The squeaky city wheels get the oil.

Healthcare is rationed on a vast scale. But it is done behind closed doors to the benefit of the powerful and the media savvy. Canberra has 34 full-time lobbyists for every Cabinet minister. They are very influential in determining priorities in government health spending.

Unless the debate is continuously conducted about limited resources and choices, we will always be applying bandaids rather than ensuring genuine long-term reform. The urgent will be addressed rather than the important. In speaking about community engagement – I am not speaking about opinion polling, marketing and focus groups. If that is all we do, we will only get a snap shot at a particular time on community attitudes formed by the West Australian, talk-back radio or hospital vested interests.

We must move beyond this superficial debate of community attitudes. The object must be to educate and inform the community about new ways of doing things. It is about being truthful with the community about what is possible. There are a whole range of ways of doing this where the methodology has been validated – citizens’ juries, town hall meetings and deliberative polling. Country health in Western Australia has had some success. Professor Gavin Mooney will be talking further on this subject. My experience is that when the community is informed and engaged in structured discussions it comes to good decisions about the choices that need to be made and the priorities set. This makes it easier for ministers to make hard decisions when they confront the special interests. This would greatly benefit country people and country patients.

Julia Gillard was derided in the last election campaign for her proposed citizens’ assembly on climate change. But it has the germ of an idea for an informed public discussion and informed government decisions on health spending priorities at every level in Australia – national, state and particularly, local.

Workforce

There is certainly more money in the COAG package for workforce training, although it is largely to do the same things, the same way that we have done for decades. A break-through has been made in nurse-practitioner prescribing and accessing MBS ($59.7 m over four years), and $18.7 m over four years in the budget for the evaluation of the role of nurse practitioners in aged care. Hopefully, we will see many nurse practitioner led clinics being established. In Canberra, such a clinic, established in mid-2010 had 10,000 patients in the first nine months. Other clinics are operating out of pharmacies. There is also $390 m in the budget over four years to assist in the employment of practice nurses. But there are vast areas where we need to restructure work practices. We have tens of thousands of health professionals whose skills are under utilised or undeveloped – nurses, allied health, pharmacists and ambulance officers. We need clinical assistance at almost every clinical level, e.g. a physician assistant. We don’t have so much a shortage of doctors as a misallocation. In 2007 we had 1.5 GPs per 1,000 of population. In other countries it was much lower, NZ 0.8, Canada 1.0, USA 1.0 and UK 0.7. (AIHW, Australian Health, 2010, p.461) We have problems because doctors refuse to share territory with other clinicians, in the name of ‘safety’- a notion that ignores the danger of people finding it difficult to access any services. Auctioning provider numbers by postcode may not be politically do-able, as I suggested at your Albury conference, even though 80% of doctors’ incomes come from the Commonwealth Government. Perhaps we could start by capping the number of new provider numbers in areas already in over-supply.

About 10% of normal births in Australia are managed by midwives. In NZ it is over 90%. We have about 400 nurse practitioners when we should have thousands. The medical colleges have disproportionate influence in controlling access to the professions. Medical training is strongly focused on acute care in hospitals, whereas most of the work of future doctors will be with chronically ill patients in the community. Few are trained to work in team practices and certainly not in country areas. Primary care is not seen as an attractive option for young doctors. Only 13% of final year students have any interest in working in primary care, and only 13% would consider working in rural areas. General practice must be made more attractive and better paid, but not via fee-for-service.

Health is the largest part of the Australian workforce (825,000 in 2008). It is the fastest growing – 23% growth in five years. We are regularly told that we need to improve the productivity of the Australian workforce. Every cocky in every aviary is cackling on about it, but the largest part of the Australian workforce is not mentioned. We have seen the dramatic benefits in productivity improvements through workforce reform on the waterfront. But those gains are small beer compared with the potential gains with health workforce reform, leveraged by such means as wider access to MBS and making all Commonwealth health funding conditional on substantial workforce reform.

SSWAHS = SWSLHN + SLHN and mental health services in the Southern Highlands - 1

So you’re wondering what’s happening with mental health at a federal level?

April 1, 2011 – 6:08 pm, by Melissa Sweet

Note to readers: Please see author’s correction at bottom of the post.

At this time of year, there is always a lot of pre-budget jockeying. This year there is great expectation and also great apprehension about what the Federal Budget might hold for mental health.

Mental health advocate Professor Alan Rosen has been watching recent developments closely, and his analysis follows below (at the bottom of the post you will find an invitation to provide feedback to the Federal Government’s mental health advisors).

Professor Alan Rosen writes:

"The bookies seem to know what every election result will be. So why did we bother having Saturday’s NSW election? Couldn’t we just extrapolate from where the odds stand at midnight on election day?

"Then we could spend the Electoral Commission’s budget on our run-down mental health services. Maybe, on past disappointing form, we should not even wager our lunch on having much of a boost for mental health on budget night, despite Julia Gillard’s insistence that it is a 2^nd term priority. (Perhaps it should be called budget-smugglers’ night, to celebrate that dark art of sleight of the contents of taxpayers’ pockets?).

"But the longer the Government keeps postponing the crying need to reform Mental Health Services, the more that the growing affected community will keep raising the stakes. It is a dead-cert that it won’t just go away as an issue if ignored. In an international survey last year, foremost among all countries, the Australian public placed mental health services as one of its top 3 concerns, alongside the global financial crisis and climate change.

"Sensing the disquiet and impatience of the burgeoning Australian mental health constituency, Mark Butler, the federal Minister for Mental Health, recently put out an update letter about his deliberations with his expert committee, which said next to nothing about what they might be proposing in their advice to him, about which they were all sworn to secrecy.

"It may be that he is engaged in a delicate negotiating process to squeeze something substantial out of the tightening federal budget, but for what purpose?

"It is a bad move not to take this seasoned network into your confidence on your way. It is laudable that early in his tenure, Mr Butler did a whistle-stop tour around Australia, running brief group consultations in urban and regional centres.

"But that was before he installed his expert panel to develop these proposals. The fact is that he does not seem to have foreshadowed any wider consultation process, on any actual proposals. He has commissioned a separate kitchen committee, derived partially from his expert group, to develop a “blueprint”, published not as a draft out there for consultation, but as time is of the essence in the budget build up process, as a finished submission to be taken urgently to Treasury, hopefully for funding*.

"There is a lot to commend in its striving for a transformative approach, and its shopping list of “evidence based best buys” for different age groups. So far so good.

"However, many of its proposed structures for adults though possibly promising, are substantially untested. We need time to produce some evidence that they work, because we don’t want to repeat the blatant wastage caused under Howard’s CoAG initiatives like Better Access, perpetuated by Nicola Roxon.

"Even more concerning is that the real firmly “evidence-based best buys” for adults with severe and persistent mental illnesses, especially with forensic, drug and alcohol comorbidities, have been left out. These include (acute) 7 day and night mobile crisis and continuity of care teams, assertive community treatment (rehabilitation) teams, and 24 hour residential respite households as an alternative to many admissions.

"The Blueprint group can’t back this trifecta, we are told, because their riding instructions stated that these are viewed federally to be state responsibilities, particularly since the states wouldn’t relinquish that 30% share of GST. This could almost be construed as a washing of hands in retaliation.

"At whose expense? These proven service delivery systems will become orphans, and many severely disabled clientele will continue to be clinically abandoned.

"Most states squandered the resources allocated for them long ago, by diverting them to medical and surgical procedures, and by failing to complete the disgorging of stand-alone institutions, preventing the shift of some of their resources to community care. With few exceptions, this has resulted in stunted development or dismemberment of such evidence-based mobile community-based mental health services, and often the retraction of their rumps back onto hospital sites.

"A little under $2 billion over 5 years is required to provide firmly tied funding to the states to restore these key teams, including rural adaptations of them Australia-wide, and to monitor, this time around, their outcomes and fidelity to evidence via a national mental health commission.

"Either that or they will need a contractual arrangement with the states to meet them half way if they want the money, not just via another CoAG agreement, which is bound to be broken.

"The AMA is completely right that we need at least a commitment of $5 billion over 4 years, partly to make up for lost time and lost people. Most in the mental health community would differ with some of the AMA priorities for this funding, however. By my rough reckoning we need at least $5.5 billion over 5 years to kick-start a national mental health program with reasonable expectations of success.

"Professors McGorry and Hickie are overly modest in their estimates of what is required to deliver an effective transformation of the mental health service system, saying they will settle for around $3.5 billion over 5 years.

"This government also needs to commit resources to:

• a widely consultative process, arriving at a rough consensus inside a few months, about priorities and a framework for a national mental health reform program for the next 10 years, integrating public, non-government and private, including fee-for-service sectors. By now, this national mental health taskforce should be out there seeking a broad consensus for this national mental health program. It must overarch the superficial revamps of the national mental health policy, plan and standards, all devoid of practical goals and timelines, which have been diluted and downgraded in political compromises between state and federal bureaucracies. Gillard & Butler & co, need to hunt the money, but they also should not waste this build-up of expectation, momentum and opportunity for really consultation leading to transformative reform. If we are really into social inclusion, we need to practice what we preach.

• a National Mental Health Commission, as also proposed in “the Blueprint” like New Zealand, Canada, and now Western Australia, and soon NSW too, which promotes the resourcing and monitors the implementation of the reform agenda at arm’s length from government, while constantly consulting with all stakeholder groups, and reporting on an all-of-government scorecard basis to the Prime Minister, Health ministers and parliament.(Link to Rosen et al 2010, International Mental Health Commission review).

• Regional integrative budget-holding commissioning authorities ( as established in New Zealand, the UK and now on a statewide basis in WA, and soon to be formed in NSW ) ensuring integration of all mental health and support services, by being able to purchase flexibly from all funding streams, public, non-government communally managed, and private health organizations if need be (Link to AHHA paper on Funding Methodologies 2008).

• We need government to find new resources to bring the mental health proportion of health budget, currently sinking from 8% to 6%, up to 13%, closer to the proportion of health burden due to mental ill-health, as most other developed countries have done.

"As clinicians, we need to follow the form and play the system squarely in the interests of our clientele and their families, in every age group and phase of care.

"And we don’t need yet another policy shoot-out between the parties to entertain the political punters.

"We need a consistent tripartisan commitment to integrated collaborative mental health care for the whole Australian community.

"So while we can’t yet bet safely on the fate of mental health in the federal budget, either way, let’s hope it romps home.

"*However, the authors have placed it in the public domain, and Professor Ian Hickie of the Brain & Mind Research Institute, Sydney, has now undertaken to invite and collate comments by email. Contact: Ian Hickie

TAMHSS (Transforming Australia’s Mental Health Service System, tamhssATyahoo.com.au) will take and list comments publically on its blog from Monday 4^th April 2011.

• Professor Alan Rosen holds positions with the Brain & Mind Research Institute, University of Sydney, and School of Public Health, University of Wollongong.

2 Comments

1. achimova1
   Posted April 1, 2011 at 7:35 pm

   Interesting that the RANZCP was not asked to field a delegate.

2. Melissa Sweet
   Posted April 1, 2011 at 9:59 pm

   Correction from Alan Rosen:

   Note: It has been drawn to my attention that there is an error of fact
   in the 2nd part of the 7th paragraph. It should read:

   “The fact is that he does not seem to have foreshadowed any wider consultation process, on any actual proposals. Meanwhile, a separate little committee, derived partially from the minister’s expert group, and including his designated deputy, Monsignor David Cappo, convened to develop a “blueprint”.

SSWAHS = SWSLHN + SLHN and the NSW State Election - 2

What has the NSW Coalition promised for health?

March 27, 2011 – 2:31 pm, by Melissa Sweet - Croakey on Crikey

"What will the change of Government mean for health in NSW?

"These are the headlines of what has been promised, according to the incoming Health Minister Jillian Skinner’s website.

• An extra 1,390 beds and 2,475 more nurses for the NSW health system. This includes 550 more beds and 275 more nurses over-and-above those currently promised by Labor at an additional cost of $340 million

• Increased funding for chronic disease management by $57 million to improve sufferers’ quality of life and drive down unnecessary hospital admissions.

• Establishment of a NSW Mental Health Commission, based on best practice models around the world, including the Western Australian Mental Health Commission. It will also provide quarantined and accountable funding for mental health expenditure; and establish three specialist units within the Mental Health Commission to better manage the experience of mental health patients and carers, divert mental health patients away from the prison system, and help ensure a smooth operation of the Mental Health Review Tribunal.

• Development of a state-wide NSW Pain Management Plan to ease the burden of suffers of chronic pain, improve their quality of life and help them re-enter the workforce. They will also maintain existing pain management and research programs across NSW.

• Establishment of an Office of Preventative Health. Located in South West Sydney, the office will have a state-wide focus and be established in partnership with the University of Western Sydney.

• A NSW Liberals & Nationals Government will fix hospitals (a promise that will no doubt come back to bite!) by investing over $3 billion in health infrastructure over the next term of government. The $3 billion investment includes an injection of an additional $885 million to fast track hospital upgrades, redevelopments and other health infrastructure priorities over the next four years, as well as the existing health infrastructure projects in the State Budget.

• A NSW Liberals & Nationals Government will appoint Peter Wills AC to help develop a 10-Year Medical Research Strategic Plan for NSW. They will also boost medical research in NSW by $20 million to drive innovation aimed at providing better patient care.

• A NSW Liberals & Nationals Government will commit $10 million to provide local health checks and improved management of chronic diseases is expected to dramatically improve the health of those at risk of, or who suffer from conditions such as diabetes, asthma, obesity and cardiovascular disease.

• A new Telehealth Technology Centre – devised and driven by doctors and their patients will be set up at Nepean Hospital under a Libnerals & Nationals Government in NSW.

• The NSW Liberals & Nationals have announced plans to increase funding for drug and alchol treatment – the first new money for respected bodies successfully treating addictions since the 1999 drug summit.

• The NSW Liberals & Nationals have released a policy outlining its intention to increase funding for the IPTAAS scheme by 50% – an extra $28million over four years.

• NSW Liberals & Nationals will deliver change to close the gap, an article Jillian wrote for the AMA’s medical journal. It was published in NSW Doctor in May 2010.

• A speech Jillian gave to the Australian Industry Information Association in April on e-health

• The Coalition’s plans to reform the management of the public health system are outlined in a document called ‘Making it Work’ released in March 2009.

***

"Meanwhile, we shall wait to see the implications for national health reform. No doubt some senior health bureaucrats are also wondering about their jobs…"

These promises seem very promising but, as far as the Southern Highlands community is concerned, they are short on detail as how these promises will result in improved health services and provide a more substantial, new and enhanced public hospital to meet the needs of our expanding and ageing population. Unfortunately, we may have to wait another four years to find out.