http://www.watoday.com.au/national/tell-me-where-it-hurts-20090220-8dqy.html?page=-1

• Nick Miller and Leo Shanahan
• February 20, 2009

NICOLA Roxon made a New Year’s resolution not to sweat the small stuff. Little annoyances like announcements on planes when they’re delayed — “we thank you for your patience” — so patronising, the federal Health Minister fumes — but, this year, she’s determined to let them pass her by.

Which is wise, as there’s plenty of big stuff to worry about. This could end up being Australia’s biggest year of health reform since Medicare. Blueprints in the pipeline cover everything from support for home births to a new relationship between patients and GPs. The reforms could change how our hospitals are run, and how food and alcohol are packaged, promoted and sold.

“It’s going to be the critical year for health reform,” Roxon says. “(Major reform) is going to take up an enormous amount of my time this year and is very exciting — it’s what all politicians want to be in government to do.”

Her chickens are coming home to roost. First to flap in, on Monday, was the interim report from the National Health and Hospitals Reform Commission, a hefty 392-page “to do” list.

Today, the Maternity Services Review arrives, tackling passionate, divisive debates over home birth, the rise in caesareans and the role of midwives.

Meanwhile, Roxon is swapping ideas with her Preventative Health Taskforce, looking at ways to force, cajole or bribe the country to eat better, drink less, exercise more and quit the ciggies.

Coming up is a review of primary health care — likely to prove very unpopular with the medical establishment. It could open up GP clinics and Medicare funds to dietitians, physios and others.

In the year the surplus vanished, this 41-year-old Victorian (who is also the mother of a three-year-old) is filling her bookshelf with a library of big ideas to fix the country’s health system — ideas that she asked for but will be expensive, or controversial, or both.

The National Health and Hospitals Reform Commission interim report arrived on Roxon’s desk on Christmas Eve, and it was unveiled on Monday. It proposes everything from the creation of a national indigenous health authority to the building of centres to monitor mental illness in young people.

But three main proposals have attracted all the attention and would mean real and substantial change: the Federal Government would take control of primary care, introducing one-stop local clinics with patient enrolment; a Medicare-style dental scheme; and the possibility of the Commonwealth wresting control of hospitals from the state governments.

Proposals for the Federal Government to control the funding and delivery of health professionals and services falling under the loose term “primary care” are not a significant departure, but it would mean an end to piecemeal funding for community health services such as alcohol and drug treatment, sexual and reproductive health, school health and maternal and child health services.

But big multi-service community health clinics in which locals are asked to enrol could mean an end to the old-style GP clinic as a sick person’s first port of call.

Roxon has been keen to highlight the similarities of this proposal with the Government’s GP super-clinics plan, and the policy to open Medicare to non-doctor health professionals.

Of all the recommendations of the NHHRC, Denticare would have the most widespread public appeal. It aims to provide Australians with universal dental care with Medicare-style bulk billing, costing Government an extra $4 billion a year and taxpayers a 0.75 per cent increase in their Medicare levy.

The Australian Dental Association has already attacked the plan, aware of the effect on the workload and incomes of GPs since bulk-billing was introduced.

But the three governance options for hospitals proposed by the commission represent the most drastic change to our health-care system, with two of them calling for a total takeover of hospitals by the Federal Government.

The first takeover proposal would have state administration of hospitals replaced by local regional bodies entirely funded by the Commonwealth who would compete for extra funding based on performance.

The second takeover option — by far the most radical — would have Medicare abolished, with all Australians enrolled in health funds, mostly likely privately run. The Government would transfer 14 per cent of income tax into the funds to pay for universal coverage.

“We wanted them to think big,” Roxon says of the commission’s work. “This directions paper will give people an opportunity to express their view as to whether some of the ideas are radical and vital, or radical and hare-brained.

“In some areas, they are proposing pretty ambitious things that are way, way ahead of where I or the Government’s thinking might be.”

For example, Denticare. “The proposal is a very ambitious one. We can’t keep doing what we’re doing now, because it’s not providing services equitably to people.

“But the type of model that they’ve proposed, and the way it’s funded, is something that’s new.”

As for the federal takeover of hospitals, Roxon hints that her department is already picking apart the commission’s three options, in order to talk turkey with the states. However, the official line remains: a takeover will happen “if the states and territories are not interested in reforming their health systems to the extent that we think they need to”.

It comes across as a threat, but judging by the Council of Australian Governments meeting late last year, there is an orgy of agreement, rather than a high-noon showdown, between the federal and state governments on health at the moment.

Anyway, sceptics in Canberra wonder whether the federal budget has any room left for real reform.

Dr Paul Gross, a health economist, doubts there will be any money left over given the amount just spent heading off economic disaster — with not a mention of health infrastructure.

“The Government has let loose five review committees on my count,” says the director of the Institute of Health Economics. “They are all over the place with timing and terms of reference and their relevance.

“While we go on writing general reports of wish lists, the really hard work is still ahead. This system is in a bit of a mess (but) it is bereft of funding at the wrong time.”

Roxon, of course, disagrees. “I think the timing is right to talk about big-picture reform when you’ve got a government that’s got the political will to make some difficult decisions,” she says. “It would be long-term … Health is such a fast-growing component of the budget, if we don’t plan for the future, we are going to have large extra costs in any case.”

Sometimes, relatively small investments can have big consequences. That’s the reasoning behind Roxon’s push to head off chronic disease such as diabetes and cancer — the nation’s biggest and costliest health problems. The logic is fired by personal experience — her father, a smoker, died of lung cancer.

Further evidence of prevention’s potential came a few weeks ago. Roxon and husband Michael were “gobsmacked” when their daughter, Rebecca, got in the car and started singing a song to the tune of Twinkle, Twinkle, Little Star about the importance of doing up your seatbelt and scolding your parents about it.

Roxon says she was impressed by the power of education to instil a public health message. She sees preventative health as an “obvious thing” to focus on, and somewhere she can lead the debate.

“As a mother with a young child, you hope that you are going to help your children grow up with good habits, you’re very conscious of it,” she says.

“And I had a parent who died at a very young age from smoking. That is classically preventable and that does form your view as to how strongly you try to pursue these issues.”

But it can be a sticky area. Evidence for what kind of action really makes a difference varies from very strong (smoking), to fairly weak (obesity). The Government’s first steps are likely to be “suck it and see” pilots rather than wholesale change.

In preventative health, too, you often get suggestions that are political cyanide.

VicHealth chief Todd Harper says government must swallow the poison pill: taxing unhealthy options. In other words, make beer, cigarettes — maybe even Big Macs — more expensive.

“Price is one of the best ways to influence people’s choices,” he says.

“We need to start to reassess the tax system as not just a mechanism to raise money, but an opportunity to encourage healthy behaviour.”

Harper predicts the Preventative Health Taskforce will recommend bans on junk-food advertising, alongside money to promote healthy alternatives.

This will help head off the health challenges of tough economic times, when people turn to cheap and filling junk food, or worse.

“In times of economic recession, the stocks you traditionally want to buy are tobacco and alcohol,” Harper says.

“We need to get ahead of the situation. The taskforce is the best chance we have had in decades, and a health minister with a passion for prevention is something to be treasured.”

A tax rise is unlikely to be hailed as political genius — Exhibit A, the ruckus over alcopops. But it is primary health care and workforce reform that has so far stirred up the most anger against Roxon.

In her “light on the hill” speech last September, Roxon threw down the gauntlet to doctors, lumping them with the Liberals as the enemies of essential health reform.

She blames conservative resistance similar to the opposition faced by Chifley and Whitlam in building the foundations of the Pharmaceutical Benefits Scheme and Medicare for a modern health system that is the “notorious ambulance at the bottom of the cliff, not the fence at the top”.

The problem is that the system “is organised almost entirely around doctors, despite the fact that many services are now safely and ably provided by other health professionals — nurses, psychologists, physiotherapists, dietitians and others.”

The national secretary of the Australian Nursing Federation, Ged Kearney, goes further. “At the moment, all funding follows the doctor. So, really, the only person who has access to the primary health care system are GPs.

“Now that inherently has caused, in my opinion, all the problems with the health care system.”

This kind of talk will infuriate the Australian Medical Association. Its federal president, Rosanna Capolingua, insists she’s not just protecting doctor’s hip pockets, it’s about what is best for patients.

“GPs are the most effective gatekeeper in primary health care,” she told the National Press Club last year.

“Only doctors can take a history, examine and put together the whole person when making a diagnosis … Without GPs in the clinical co-ordination role, patients run the risk of being tossed back and forth without any co-ordination of their care.”

Roxon also wants a bigger role for nurses in maternity services — an argument that the review’s report, released today, supports. The review ignited angry debate between independent-minded midwives, and doctors who fear mothers could be put at greater risk. It sparked a torrent of submissions, not just from the usual lobbyists, but from mothers telling personal stories. “People who have a bad experience feel very passionately about making sure that others don’t, and people who have had a good experience are passionate that everybody have that experience,” Roxon says.

“We should … make sure health professionals work together to give women as many options as possible, and make sure they are safe.”

As the year of reform unfolds, and all Roxon’s committees report, any failure to deliver will be eagerly highlighted by Opposition health spokesman Peter Dutton, the tough-talking ex-policeman from Queensland.

“Clearly the biggest problem for Nicola Roxon at the moment is that she has ramped up expectation with the amount of inquiries she has undertaken,” he says.

“When the Government first made the referrals to these inquires, they were still in a strong surplus situation. Now whatever the Government does has to be seen as a compromise.”

Dutton says the inquiries and taskforces are a shameless three-year stalling tactic — “a media strategy and a holding pattern so they could time the Government response to these inquiries around the next election”.

But Roxon insists that action will follow reflection. “It’s always politically safer to do nothing, but the community suffers,” she says.

“I am going to look at all these ideas and say, ‘Will this improve health outcomes in the community?’ If it does, I won’t be afraid to prosecute that case.”

So what does Roxon see as her biggest challenge this year?

“The hardest thing will be seeing my family enough.”

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Categories : Homebirth Australia