Health is a big ticket item for the Federal Government. It has made fixing funding and operational problems with the nation's public hospitals one of its top priorities. But is this enough? ANU Reporter spoke with two experts about what's really needed for Australia to get a good diagnosis for its health system. Associate Professor Kirsty Douglas is the Acting Director of the Australian Primary Health Care Research Institute and an educator in general practice at the ANU Medical School. Professor Bob Wells is the Director of the Menzies Centre for Health Policy and Executive Director of the ANU College of Medicine and Health Sciences.

ANU Reporter: The Rudd Government came to office promising to radically overhaul the nation’s health system. It seems to be a big ask – where should they start?

Kirsty Douglas: I don’t think you can reform the hospital system without really taking into account the primary health care system. They are very much interdependent. Unless you look at them together, any reform you try in isolation will ultimately fail.

Bob Wells: I think you’re right. Nevertheless, I think the Government might not appreciate that point. It seems to me that politically their commitment is to overhaul the hospital system, because the public discontent is around the performance of public hospitals. You rarely see people getting excited about the performance of general practice or primary care. Yet far more people use primary care than ever use hospitals – something like 110 million visits each year to GPs in Australia, which is about five per head of population, versus about six or seven million visits to a hospital. Even if you count in emergency department attendance it only comes to about 40 million visits. Despite this, the Government’s immediate focus will have to be on hospitals as they’ve committed to sort out the so-called ‘blame game’ between the Commonwealth and the states.

KD: Hopefully they’ll look at both at the same time. But the public eye will be on the reform of hospitals. Rudd seems to be very dogmatic in his approach to fulfil those promises as a first step. But if the Government is canny, and they’re looking at international experience, then of course they’re going to review the primary health care sector as well, and how that interfaces with the hospitals.

BW: Australia has the highest hospital admission rates for its size and population profile in the world. Sooner or later the question will be: Why? Why are so many people going to hospital instead of being looked after in the ways they would be in other similar countries? Sooner or later you have to say, ‘Why are we putting all these people into hospitals when maybe we could deal with it in better ways?’ That’s when you come to the whole-of-system questions.

KD: It keeps feeding out. Once you look at why some problems aren’t being treated in general practice, why they’re ending up in the hospital system, then you start coming up against workforce distribution and workforce numbers. Why can’t we attract people to general practice? That feeds out into training and education issues. It ripples on and out – it’s not a small problem to tackle.

ANU Reporter: The issue of shortages in the number of doctors and other health professionals in Australia crops up again and again. Should we be recruiting more people from overseas? Or training more people here?

KD: I think there are problems with both. If you just increase the numbers of university places here, do we have enough trained people to actually give them the high-quality education we want? And when we’re training them, how do we direct graduates into the areas we need them in? At the moment there is evidence that many of our graduates are selecting the higher-paid specialties – even though the really critical shortages are in general practices, psychiatry – some of the lower-paying, community-based specialties. I’m not sure that the systems are in place for those increased numbers of students to move into those areas of need. Getting people from overseas raises issues like: are we stealing from other nations when they’ve invested huge amounts in training people? How can we ensure quality and appropriate care when we’re taking people from different cultural contexts?

BW: The Productivity Commission looked at the Australian health care workforce a couple of years ago. It said there were shortages, but also that we don’t use the workforce we have effectively – we’re too demarcated across professions but also within professions. The Productivity Commission made some suggestions about how we could improve on that, but so far governments have not really taken them up. As for bringing in more doctors from overseas, that’s also problematic. West of the Great Dividing Range, a high proportion of our doctors come from the Indian subcontinent. I’m receiving reports that interest in coming to Australia from those parts of the world have dried up markedly in the last six months. Even if you take a more cynical view that we can always bring in more doctors – maybe we can’t. We’re vulnerable to those shocks in the system.

KD: We’re not the only ones experiencing the shortage. People from the Indian sub-continent can go anywhere in the world.

BW: And the Medicare funding doesn’t help. Proportionally, procedural specialists are rewarded better than non-procedural specialists. If you’re an ophthalmologist, because of changes in technology, you can get through the same amount of procedures in a number of days that once would have taken weeks. But the rebates haven’t changed, so you’re earning much more. If you’re a young ambitious person, where would you go?

KD: When I went through medical school, I studied for free. I graduated at 24 with no debts and a good income earning potential. Today, medical students are graduating at an average age of 28 or 29 so more of them have got dependents, and they’re graduating with a combined HECS and personal debt of about $100,000. That gives you a lot of pressure about where you go and what you do.

ANU Reporter: Another election promise from the Federal Government was to create a raft of new GP super clinics around Australia? Are these a good idea?

KD: It is a good idea, but it’s only going to be a small part of a greater solution, and it’s got to be done thoughtfully. It’s not a solution in itself. The first issue is how will you staff them? How will you maintain that staff?

BW: Keeping the staff there will be an issue. Also, some of the staff will be on fee-for-service, while some will be on salaries. You get the professional demarcations again, what’s the hierarchy; will physiotherapists want to work alongside occupational therapists? There are models like this around, but to say that suddenly we’re going to impose them in these strategic locations by fiat – that’s optimistic.

KD: Some of the Aboriginal controlled medical services have exactly that sort of model, and the good ones work superbly well. We can take those good ideas forward. But even in these good centres it’s not easy to recruit and maintain staff. Once you start putting centres out in regional places where it’s not attractive to work for a variety of reasons, it gets harder.

BW: Also these centres will be placed in a context. There are already some GPs in place, whether in solo practice or from the local hospital. How are the super clinics going to fit in?

ANU Reporter: Do we need to break down the guild mentality in the health professions?

BW: Part of the problem is that people are trained in silos, so they don’t really have an appreciation of how people can work in teams. It probably gets back to training. You can’t impose by fiat that people will want to work together. You have to give them experience in training – and there’s a long way to go in that regard.

KD: I’m not sure that the reasons behind the ‘guild mentality’ are all that valuable, apart from the fact that it’s historical. It’s incredibly hard to break down. People have been trying to break down those barriers for a long time. It’s something that we need to work out but I don’t know if we know how to do it yet.

ANU Reporter: Much of the political discussion around hospitals centres on funding. Will everything be fixed if we moved to a 50/50 state-federal funding split?

BW: It would be silly if the Commonwealth committed to fund 50/50, because it’s an open-ended commitment. 50 per cent of what, for a start? But if the Commonwealth upped its funding to 50 per cent of what the current costs are, for example, the states would withdraw their extra funding. The hospitals might or might not benefit from that. If you want to put more money into hospitals, that’s not the best way. I’m not sure that anyone knows how much more is required. All the estimates are based around the proportion that the Commonwealth is not paying, but we know the states are stepping in to fill that void. It seems quite circular to me.

ANU Reporter: Which leads to the question of jurisdiction. Would we have a more efficient system if the hospitals were completely under federal control?

BW: Why would the Federal Government be any better at running hospitals than the states? That’s the first question. There might be funding problems that might be easier to solve, but would the Federal Government give more money to the hospitals? Why would it? How would it know how much extra to give?

KD: Would it be adaptable to local areas, or would it be a one-size-fits-all approach?

BW: Yes. How would you know what is appropriate for the Pilbara from Canberra? These are difficult questions. What you’d probably do is set up regional administrative entities. There is an attraction in regional administration of health, but if all they’re doing is running the hospital part, without incorporating the primary health care, you’re probably not better off.

KD: I agree - having the capacity for regional administration to allow adaptation to local needs is probably very important. That way you can probably better integrate local primary care and hospital services with local needs. Certainly the UK experience has been to move away from a national approach to regional Primary Care Trusts which provide primary and community care services as well as commissioning the majority of hospital care. It certainly isn’t a perfect system but does allow local adaptation. In Australia we need a system that will allow the Pilbara region to prioritise health needs and health service expenditure differently to that in the Sydney suburbs – one size fits all doesn’t work.

BW: Looking at the current situation, why would you inject a lot more money into a system that is broken? Let’s come back to the model of integrated Aboriginal medical services. They certainly have problems, because of where they are largely, but where they work they work very well. They have a comprehensive approach to care, and they fit the needs of their community. There’s nowhere else you get that in Australia. It comes down to different pipelines to different sources, and people muddle through on the ground.

KD: The demand for services is just going to keep growing. Our technology is going to keep getting better, and that’s much more costly, and we’ve got this tsunami of chronic disease that’s currently hitting us. The problem is going to get bigger and pouring money into the hospital system without standing back and looking at the health system as a whole is not the way to go.

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ANU Reporter 
Autumn 2008