Tuesday, March 10, 2009

AHCRA Summit March 2009: response to the NHHRC Interim Report

Last week I attended the Australian Health Care Reform Alliance (AHCRA) Summit in Melbourne.

The purpose of the Summit was to develop the AHCRA response to the Interim Report of the National Health and Hospital Reform Commission. The Summit was very well supported by the membership of the Alliance with clinicians, academics, lobby groups and consumers present. There were a range of presentations and then discussion groups based on a range of questions central to the presentations (called World Cafe conversational process).

On Day 1 Dr Christine Bennett (Chair, NHHRC) provided an overview of the Interim Report and we had the opportunity to ask questions. Dr Joanne Holt, Secretariat to the Commission participated for the two days of the Summit and was very interested to hear a range of views.

Participants were very supportive of proposals for one national health system (rather than the eight systems funded by nine governments we currently have) and the much stronger focus on primary health care.

Equity was a theme that resonated strongly through all discussions and presentations at the summit. This is hardly surprising given that AHCRA holds dear the notion of equity and has been a strong advocate that any reform must ensure equity. This principle was expressed strongly regarding the equity (and efficiency) of the private health insurance rebate.

The Summit recognised that the effect of the social determinants of health on health outcomes was crucial and should be a priority in public policy planning and would like to see the NHHRC reflect this more strongly. Professor Leonie Segal, a health economist form university of South Australia, spoke about the equity and efficiency of our health system. Professor Fran Baum, Member of the World Health Organisation Commission on the Social Determinants of Health spoke about linking health policy to the social determinants of health and health equity. She shared a quote from Dr Margaret Chan, Director General of the World Health Organisation on the need to embed the social determinants of health in all government policy:

“The Commission's main finding is straightforward. The social conditions in which people are born, live, and work are the single most important determinant of good health or ill health, of a long and productive life, or a short and miserable one. … This ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. … But, let me emphasize, it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place”.

This quote resonated strongly with participants and framed much of the discussion at the Summit.

Meaningful community engagement was another theme that emerged. We were privileged that Dr Mick Adams (Chair, NACCHO) and Paula Arnol (Danila Dilba Health Service) were able to participate and share their experience of aboriginal community controlled health services. Rom Mokak (CEO, Australian Indigenous Doctors' Association). They spoke about the need for capacity development to ensure communities are able to engagement meaningfully in identifying health needs, planning, monitoring and evaluating policies and services, developing and implementing governance structures and sustaining this level of engagement. Paula Arnold spoke about the Katherine West Health Board as an example of successful community engagement.

Comprehensive Primary Care is promoted in the Interim Report as the necessary reform in the Australian health system. There was considerable discussion about what the essential elements of comprehensive primary care. The NHRRC defines primary care quite simplistically as "the first level of care". Participants drew on their own experiences as consumers, clinicians, researchers and policy makers to flesh this out. This included universal accessible health care, community based services and the importance of continuity of care. Professor Claire Jackson (Chair of the Primary Health Care Strategy Expert Reference Group) and Professor Michael Kidd (Dean, Flinders Medical School) in their presentation on primary care drew our attention to the definition contained in the National Aboriginal Health Strategy (1989) as they considered this to include the essential elements of comprehensive primary care.

“Essential health care based on practical, scientifically sound, socially and culturally acceptable methods and technology made universally accessible to individuals and families in the communities in which they live through their full participation at every stage of development in the spirit of self-reliance and self-determination.”

Participants argued for the inclusion of oral health into primary care rather than continue the strangely entrenched separation of oral health (including dental) in the proposed establishment of Denticare. We argued for step-up Step-down facilities to be included in comprehensive primary care rather than continuing to see this as transition care and by default being attached to the acute setting.

Super clinics and comprehensive primary health care

The government is committed to 31 super clinics. The strong message was that communities need to be involved in establishing these clinics to ensure that the comprehensive primary care services will meet the needs of the community. Concerns were expressed also around safeguarding these centres from the further corporatisation of primary care. The community must be enabled to play a critical role in the selection of providers through the tender process and then the ongoing monitoring the performance of these super clinics.

Regional Health Authorities

Participants agreed that the health system should be driven by population /consumer/community needs, not by those of providers. One way this can be strengthened is acceptance of the NHHRC Option B, to establish regional health authorities. This option had strongest support from participants. The regional health authorities would have funding allocated on basis of demonstrated need of the community. A population size of approx. 100,000 to 500,000 would allow local responsiveness, but have a critical population mass to support primary and secondary services.

Funding models

There was considerable agreement bet ween participants that the most equitable and efficient way to fund health care is through a universal health system funded through taxation. Participants expressed the view that the system needs to move away from fee-for service payments and consumer payments, towards a blended system with significant payments for the total health care needs of a population, based on voluntary enrolment.

The presentations are available online at the AHCRA website.