Speech by NHHRC Chair Dr Christine Bennett to AFR Health Conference

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Speech to the Australian Financial Review Health Conference - “Health Reform: Aligning Policy with Funding Reality” Melbourne Tuesday 24 June2008

Chair of the National Health and Hospitals Reform Commission (NHHRC) Dr Christine Bennett

Health Policy Reform – Getting it Right

Good morning.

It is a pleasure to speak at this influential Conference at an important and exciting time for health policy in this country. It is a time when ‘reform’ is squarely on the national agenda.

I chair what is arguably the key agent of health system reform – the National Health and Hospitals Reform Commission.

While there are a number of groups looking closely at specific aspects of the health system, the Commission is looking at the whole ‘big picture’ – the future Australian health system for the long term.

We are taking a ‘helicopter’ view of the current system before putting together a re-designed system to meet current and future health needs.

The Government has asked the Commission to provide a blueprint for design and a plan of action to tackle current and future challenges in the Australian health system.

These challenges include:

• The burden of chronic disease,
• Inequities in the health care system, including for rural and remote communities
• Unhealthy behaviours and lifestyles,
• Unacceptable waiting times to access services,
• The ageing of the population,
• Indigenous health,
• Rising health costs, and
• Inefficiencies and waste in the system made worse by cost shifting and the blame game.

We all know there are many problems and many challenges for us to consider in the reform process.

In fact, it is very easy to talk about what we think – and know - is wrong with the health system.

The Commission, however, needs to go beyond this.

We want to hear practical ideas and solutions and we want to build on what is good with our health system.

Our job is to look at structural and system solutions.

By international standards, we have a very good health system, which is the envy of many countries.

But the system is under growing pressure and we must act now – especially if we are to build a system that will serve our children and, frankly, all of us as we get older.

Reform is needed - but what type of reform and how far do we go?

That question is at the heart of the work of the Commission.

Announced on the 25th of February this year, the Commission has been working on its task for just on four months now.

And we have a year in which to prepare our major report for Government.

Our ten Commissioners have a wealth of knowledge and experience of health.

• The Honourable Dr Geoff Gallop AC is a former Premier of Western Australia. He is currently Director of the Graduate School of Government at Sydney University,
• The Honourable Rob Knowles AO is a former Victorian Health Minister who is currently Chair of the Mental Health Council of Australia,
• Dr Mukesh Haikerwal is a Melbourne GP and immediate past-President of the Federal AMA,
• Sabina Knight is a Remote Area Nurse and Senior Lecturer in Remote Health Practice and Remote Health Management at the Centre for Remote Health in Alice Springs,
• Mary Ann O’Loughlin is a Director of the Allen Consulting Group who specialises in health and social policy analysis and development,
• Professor Ronald Penny is one of Australia’s leading immunologists and is currently Emeritus Professor of Medicine at the University of New South Wales,
• Dr Sharon Willcox is Director of the independent health consulting company, Health Policy Solutions, and has more than 25 years experience working in health policy here and overseas,
• Professor Justin Beilby is the Executive Dean of Health Sciences and Professor of General Practice at the University of Adelaide,
• Dr Stephen Duckett is Executive Director of the Reform and Development Division of Queensland Health, and was formerly Professor of Health Policy and Dean of the Faculty of Health Sciences at La Trobe University, and
• I am currently Chief Medical Officer at BUPA Australia. A specialist paediatrician, I have been CEO of Research Australia, General Manager of the Royal Hospital for Women in Sydney, and Chief Executive of Westmead Hospital and Community Health Services.

From the outset, we believed as a group that in creating a vision for our future health system it is vital that we hear the views and harness the ideas of the Australian community and frontline health professionals.

One of the first things we did as a Commission was develop a set of principles to underpin our design work for a future health system.

We believe they should shape the design of the entire Australian health and aged care system - public and private, hospital and community-based.

We believe they should be evident in how the system functions for patients and their carers.

I’d like to share these principles with you before I talk further about the work of the Commission.

Principles:
People and family-centred

First, health is all about people.

The direction of our health system and the provision of health services must be shaped around the health needs of individuals, their families and communities.

The Commission firmly believes that the health system should be responsive to individual differences, cultural diversity and preferences through choice in health care.

Equity and universal access

Health care in Australia should be accessible to all people based on health needs, not ability to pay.

The multiple dimensions of inequality should be addressed, whether related to geographic location, socio-economic status, language, culture, or Indigenous status.

Shared responsibility

All Australians share responsibility for our own health and the success of the health system.

We each make choices about our lifestyle and personal risk behaviours.

Forty to 50 per cent of our community's health burden relates to decisions about personal behaviour.

The health system has a particularly important role in helping people of all ages become more self-reliant and better able to manage their own health care needs.

Strengthening prevention and wellness

The balance of our health system needs to be reoriented towards prevention and wellness, rather than being only about illness and treatment.

Our health system needs greater emphasis on helping people stay healthy through stronger investment in wellness, prevention and early detection, and appropriate intervention to maintain people in as optimal health as possible.

Comprehensive approach

We need a system that provides end to end continuity of care for people. People have a multiplicity of different health needs, which change over their life course.

Meeting those needs requires a system built on a foundation of strong primary health care services, with timely access to acute and emergency services in both community and hospital settings.

Value for money

The resources available to support our health care system are finite, so the system must be run as efficiently and effectively as possible to deliver the best possible health outcomes.

Providing for future generations

We live in a dynamic environment of change. Health needs are changing - with improved life expectancy, rising community expectations, advances in health technologies, an exploding information revolution, and continuous developments in clinical practice.

The health sector’s commitment to education and research, and its relationship with the education and training sector, should be planned and implemented in a logical and seamless way involving all relevant sectors – public and private, institutional, and community.

Recognise that broader environmental influences shape our health

Our environment plays an important role in affecting our health and in helping us to make sensible decisions about our health.

We recognise that there are other key contributors to our good health. It is not just the health system we need engaged.

Cross-community and cross-sectoral awareness and action are needed, including by employers, schools, food manufacturers, transport and recreational facilities, to name a few.

Taking the long term view

A critical function for effective governance of the health system is to act strategically with a long term view, not ‘short term-ism’.

A responsible forward-looking approach demands that we actively monitor and plan the health system of the future to respond to changing demographics and health needs, clinical practices and societal influences.

Safety and quality

There should be effective systems of clinical governance at all levels of the health system to ensure we learn from mistakes to ensure the safety and improve the quality of services.

The first step to effective clinical governance is a culture that embraces improvement in patient safety and quality, and a structure that promotes clinician-led quality improvement.

Open, transparent reporting and a positive culture in dealing with and learning from adverse events are key features.

Transparency and accountability

The decisions that governments, other funders and providers make in managing our health care system should become clearer and more transparent.

The responsibilities of the Commonwealth and State governments and the private and non-government sectors should all be clearly delineated so that the system can work more effectively end to end.

Australians are entitled to regular reports on the status, quality and performance of our whole health care system - both public and private.

This reporting should range across the spectrum from primary to tertiary care - and at local, state and national levels.

Public voice

Public participation is important to ensuring a viable, responsive and effective health care system that meets people's needs.

A respectful, ethical system

Our health care system must apply the highest ethical standards.

Our health system must recognise the worth and dignity of the whole person - including their biological, emotional, physical, psychological, cultural, social and spiritual needs.

Importantly the health system must respect and value the health workforce.

Responsible spending on health

There should be no waste or inefficiency with health spending.

Good management should ensure that resources flow effectively to the front line of care, with accountability requirements efficiently implemented and red tape and wastage minimised.

Funding mechanisms should reward best practice models of care, rather than models of care being inappropriately driven by funding mechanisms.

Funding systems should be designed to promote continuity of care with common eligibility and access requirements to avoid program silos or ‘cracks’ in the health system.

There should be a productive, balanced and effective use of both public and private sectors.

A culture of reflective improvement and innovation

Reform, improvement and innovation in health are continuous processes and not fixed term activities.

The Australian health system should foster innovation, research and sharing of practices shown to be effective and to improve not only the specific services it provides, but also the health of all Australians.

The continuum of basic science to applied clinical and health services research will underpin this and needs to be embedded in the system.

Beyond the Blame Game

These principles were presented in our first report – Beyond the Blame Game – which we delivered to Health Minister Roxon at the end of April.

This report provided advice on the framework of the next Australian Health Care Agreements, and it was generally well received by health commentators.

There is no doubt that it generated some interesting debate.

The Commission took the approach that the next generation of Health Care Agreements should go beyond hospitals and that accountability should be clear and two-way.

We suggest that the States should be accountable for public hospitals, mental health, maternal and child health and public health.

We suggest that the Commonwealth be accountable for primary care, prevention, aged care, and Indigenous health.

To improve accountability, the Report suggests major opportunities for improvement by the Commonwealth and the State governments.

Our task was to provide the Government with advice that reflected the health system of the future and the direction of reform we saw as necessary to get there.

This was our first instalment.

If you haven’t read Beyond the Blame Game, it is available on our website – www.nhhrc.org.au

The NHHRC ‘Listening Tour’

We have now moved on to our serious design work in earnest.

We will be presenting an interim report to Government at the end of this year.

Our final report is due in mid-2009.

Our reports will not be based solely on our views and aspirations.

The health system belongs to the Australian people.

They use the health system every day.

They know what is working for them and their families, and what isn’t.

So, too, do the frontline health professionals who provide the health services to the community.

We are consulting with the community to assist us in our work.

We have been working hard to harness the ideas, experience and innovations of many people to help us shape our design for the future.

We have received around 450 written submissions so far.

It’s not too late to make a submission. Send us your ideas to talkhealth@nhhrc.org.au

We have received submissions from peak groups, academics, think tanks, community groups, and ordinary Australians concerned about their health and the health of their families.

They range from substantive professional documents to stories of personal experiences with the system.

Importantly, they all provide the Commission with different perspectives and different experiences.

The Commission has been travelling the country on what we call our ‘listening tour’.

With Melbourne, we are about halfway through our journey around Australia.

We are visiting all the capital cities and several regional centres, including Shepparton later this week.

We are meeting with frontline health workers.

We are meeting with government agencies and NGOs involved in the delivery of health and related services.

We are meeting with consumer and community groups.

We are meeting with people who want to tell us about their experiences with the health system and how things could be done better.

We are also conducting forums with experts in certain fields such as:

• research,
• prevention and wellness,
• healthy start to life,
• chronic and complex disease management,
• acute care,
• aged care,
• Indigenous health,
• primary care,
• rural and remote health,
• e-health, and
• workforce.

Importantly, we are collecting ideas, opinions, suggestions and innovations to consider.

So far, we are encouraged by what we are hearing and who we are hearing it from.

There is a lot of alignment with our principles, and a surprising level of consistency of messages from around the nation – city and country.

What people are saying – what we have heard so far

While we are still in the midst of our visits, I thought I would share and reflect on some of the themes we have heard consistently.

There are some definite patterns and similarities as well as variety, ‘colour’, and particular issues that have been raised which are specific to different locations.

I’ll run through some of them now. Many of them will not be new to you.

I must make it clear that in mentioning these issues here today, I am not implying these are the findings or views of the Commission.

We have yet to complete our consultations and we will then be drawing on all these issues, and more, in our thinking on the design of our future health system.

Community-based care

By far the most talked about issue so far has been the need for more community-based and home-based care.

People are talking about health care more broadly, and not concentrating on hospitals alone.

Certainly, hospitals are high on the agenda – as a critical part of the system - but people are warning that we should not be defining our health system in terms of hospital beds.

People don’t want to be in a hospital bed if they do not need to be there.

In many areas there is no alternative supported accommodation -no respite, hospice, or step down facilities.

There is clear demand and preference for more community-based care and more home-based care options.

There is a strong call for more community-based and home-based care, transitional care, and rehabilitation programs for aged care -but also care, more generally, not just for older Australians.

Interestingly there has been very little talk about hospital waiting lists.

In fact, a lot of the talk is about avoiding hospital.

There is a growing focus on ‘wellness’ and people being treated as people, not an illness or a disease.

Health promotion and prevention

Health promotion and prevention have been raised at just about every consultation.

People want a greater focus on prevention.

They want the Government to run major education and advertising campaigns around healthy eating, exercising, not smoking, and understanding personal health risks.

There is a strong feeling in the community that people should be taking greater responsibility for their own health and, to do this, they need messages and information.

A greater emphasis on public health was suggested in many of the meetings attended by Commissioners.

Linked to this, there was strong support for more resources to be put into health education for young people to help them take care of their own health from an early age.

Primary care

Many people want access to their own GP in their own local neighbourhood whenever they need them – and they want a relationship throughout life with that GP for themselves and their family.

For others, access to other health professionals such as nurses, physios, occupational therapists, speech pathologists, and chiropractors is important. Cost is a barrier for some.

Multidisciplinary care teams have been mentioned often, as have local level primary care centres involving GPs working with nurses, physios, speech pathologists, and other health professionals.

A one-stop-shop has been a popular concept.

Better integration between acute care and aged care

The health professionals we have met with see stronger alignment between public hospitals and the aged care sector as all-important.

It would go a long way towards addressing the significant waste of resources and poor care outcomes currently in the system.

They want to see integrated care planning for elderly patients to ensure an effective transition from the hospital to more appropriate care in an aged care facility or at home.

Better end of life care and a national approach to advance care plans has been suggested in a number of locations.

Many frontline health professionals are trying to have elderly patients cared for in the most appropriate environment for their health condition, social circumstances and preference – and that environment is often not an acute hospital bed.

There has also been much discussion about dignity and respect of people’s views and decisions.

Chronic and complex disease management

People are aware that we have an ageing population and an emerging chronic disease epidemic.

They are starting to focus on the fact that we are going to have more and more people with multiple health needs.

The current health system does not provide well for people with chronic and complex conditions.

There is little or no continuity of care.

This is an area identified by the Commission as a priority, so it is encouraging that there is widespread support for improvements in caring for those with complex and chronic conditions.

Even more encouraging is that a range of innovations and local solutions, which may have broader application, has been drawn to the Commission’s attention.

End of life care

One perhaps unexpected issue that has been frequently raised with the Commission is the need for better end of life care and a consistent approach to advance care plans and decisions.

As people grow older and their health deteriorates, it is clear that their views on the type of care they want and need should be acknowledged and respected.

What a well-meaning health professional or even family member thinks is right for them may not be what they think or choose as right for them.

The ‘value’ of health

Another controversial subject being aired is the ‘value’ of health – that it is not a ‘free good’ and that a constructive debate engaging the community is needed around the ‘rationing’ of care.

Some communities are openly telling us that they don’t expect ‘everything of everything’ in health care, but they definitely want ‘something of everything’.

Indigenous Health

Everybody agrees that more needs to be done in Indigenous health.

Closing the life expectancy gap is a shared objective across the community.

We are looking forward to the first of our Indigenous Health workshops in Melbourne this week. The second will be in Darwin next week.

Mental health

People want a ‘whole of person’ approach to health, with their mental health equally important as their physical health.

It has also been mentioned that mental health requires a cross-sectoral approach including housing, employment and the justice system, among other things.

Dental health

There are strong views that dental and oral health should be considered an integral part of a person’s health, and not seen as an add-on to the health system.

Delivery of rural oral health services is seen as a real challenge, with a severe shortage of dentists and dental therapists in rural and remote areas.

An integrated personal health record system

There is broad support for an integrated national electronic health record that can be accessed and contributed to by the health professionals who provide care for a person across all settings.

Many feel access should be controlled by the individual.

People see this as a priority. They link better and timelier information with better patient care and better outcomes.

This concept has been commonly supported by consumers, doctors, nurses, other health workers, including paramedics, and pharmacists.

They don’t understand why this has not happened sooner.

Health workforce

The health workforce is a major topic of discussion wherever we go.

The shortage of doctors and nurses in many communities is hitting hard, especially in rural and remote Australia.

There are also concerns about an ageing workforce and poor morale across many disciplines.

There are concerns about attracting and retaining young health professionals in many disciplines, especially nursing.

And there are issues around remuneration.

But perhaps the biggest call is for workforce redesign.

Communities want to see clever solutions around how to best use the workforce they have.

Some want to increase the scope of practice for some health disciplines to free up more doctors’ time and provide a better patient experience.

There is strong support for multidisciplinary teams and ‘one-stop-shop’ style centres.

Others want more training and incentives made available in rural areas to try to keep medical and nursing graduates in country areas.

A common theme is a desire for more generalist health professionals to provide comprehensive care, rather than fragmented specialist services.

There is general support for a more streamlined national registration system for health professionals.

Carers

Some people have described the health workforce as the whole community as there are more and more family members providing long-term care for their loved ones.

People want to see better information, practical support and greater recognition of the important role provided by carers in health care.

Technology

People want to see better use of technology in health – again, especially in rural areas where it is thought that technology can address some of the gaps in health workforce and the problems of distance to specialist services and technology.

Better use of things like telemedicine, teleconferencing and videoconferencing is needed.

Rural doctors want telephone and internet professional advice systems so they can share knowledge across great distances.

A 24-hour regional clinical advice hotline was mooted by specialists who have to cover a number of regional centres.

Rural and regional issues

Country people also want ‘health navigators’ to help them through the many stages of the health system, especially when they have to travel for episodes of care.

In regional Australia, the PATS Scheme – the Patient Assisted Travel Scheme and its equivalents – is seen as vital, but inadequate.

It is considered crucial in Indigenous Health as well, but does not reflect the real costs of travel and accommodation and family support.

State and local government people – and patients – also saw merit in multi-agency collaboration in rural and regional Australia.

They see too much waste and inefficiency in the current system.

There is a lot of angst in regional Australia about the loss of hospitals in smaller towns.

While they acknowledge that the loss is inevitable, they do not see enough effort going into providing alternative access to quality health services at the local level.

Commonwealth-State Issues

A theme familiar to all of us in health is the vexed issue of the Commonwealth-State divide.

A single national health system is much talked about.

But this can mean different things to different people – a single funder, a single government being responsible, or a single governance structure coordinated end to end.

There is pretty much universal support for greater efficiency in the dual Commonwealth-State roles in health service delivery.

Some want a single Government system, others just want the system to work better.

Many want greater responsibility and accountability built into the system.

It’s not about knowing who to blame, it’s about the different parts of the system working better together.

The public-private mix

While Australia’s joint public-private health system is generally supported, many country people say they do not get to enjoy the benefits of the private system.

There are concerns that there are inequities of access and affordability in some specialties between public and private hospitals.

Health professionals saw disparity in remuneration and pay scales between the public and private systems.

Some people have said they want private health insurance more affordable so more people can have it.

Consumer voice in the system

People want to have a greater say in decisions about their own health.

They want to be more involved in decisions made locally about health services.

They don’t know how they can have a say about how the health system works in their area.

Health literacy

Both frontline health workers and members of the community expressed views that people and their families need better information when making health decisions such as:

• when to go to the doctor,
• when to go to the hospital,
• who to call for urgent help, and
• how to find the right way through the system.

Some people do not have the confidence or knowledge to make important health decisions, especially for their children and their elderly parents.

Funding and governance

The governance and funding issues – the architecture of the health system – are what people want the Commission to resolve.

But that is an entire speech on its own for another day – a day when the Commission is in reporting mode.

Conclusion

As you can see from these examples, there is a lot of thinking about health going on out there in the community.

Some of it is familiar thinking. Some of it is new thinking.

But the extraordinary thing is that there is a lot of similar thinking across the spectrum of people we have been consulting.

You may be surprised at the collaborative approaches across the health professions.

We have doctors, nurses, physios, pharmacists, dentists, psychologists, carers and others coming up with similar ideas and shared visions of a future health system.

It has been refreshing to hear the stories of frontline health workers developing innovative ways to work effectively as a team.

Don’t forget – these are the views of the people we have been consulting.

They are not the findings of the Commission – our work is very much ‘work in progress’.

We want our vision for the health system to be relevant and meaningful to the Australian people – and our principles will help us get there.

We want our proposals for reform to reflect the needs and aspirations of the people and families who use the system.

We want our doctors and nurses and other health professionals to provide high quality care and feel rewarded and valued working in the health system.

What do we mean by reform? Change for the better. Simple.

What sort of system are we aiming for?

A people-centred and family-centred health system that provides all Australians with quality health services and excellent health outcomes in a fair, equitable and affordable way.

This has been a great opportunity to provide a progress report on our work.

We’re in Victoria this week in Melbourne and Shepparton and then we’re back on the road again.

Thank you for your interest.

Stay tuned.

Thank you.

Page currency, Latest update: 24 June, 2008