Wednesday, March 3, 2010

The Golden Rule

After a growing sense that the Federal Government has been all talk and no action, culminating in the insulation fiasco prompting questions about whether the Government even has the competence to successfully deliver an outcome when it actually does take action, it seems that all of a sudden somebody has lit a fire under the Prime Minister. After months of criticisms over the failure to act on the insulation scheme, failure to live up to the promise of an “Education Revolution”, and most importantly, failure to deliver health and hospital reform according to their own schedule. Now, in the space of less than a week, the Prime Minister has sidelined Peter Garrett from anything to do with insulation, spent the weekend on television apologizing for not meeting expectations, watched on as Julia Gillard launched the new National Curriculum for schools, and today unveiled his big plan for health and hospital reform.

And not before time. Leaving aside the political considerations of losing ground in the opinion polls, and the realization that an election is looming later this year, time is running out in a very real sense for genuine health reform. With the combined effect of the growing and aging population along with the cost of increasingly sophisticated and high tech medicine, the current health system will collapse in around twenty to thirty years, or possibly even less. Even leaving aside the shortcomings of current administrative practices and structures, the states will simply run out of money. No matter how much any state government might reform its own system, the failure of revenue growth to keep pace with growth in both demand and costs in health will get them in the end.

For that reason, much of what the Prime Minister said today is absolutely correct. The time to act is now. The funding of health care must be the starting point for broader healthcare reform. The management of local hospital and health services must be entrusted to local people at the local level who have an intimate understanding of local needs. Even the finer detail of the Prime Minister’s proposal is not all that different from the concepts put forward by the opposition. Whether you call them Local Hospital Boards or Local Health and Hospital Networks, both sides of politics are talking about giving greater decision making power to administrators and clinicians at the local level. But the real question is just how much autonomy will such local bodies actually have?

Generally speaking, whoever controls the money also controls the decisions. The idea here is to create a structure which will provide the money without imposing a centralized management system. But there can never be a complete disconnect, and there will be a regime of accountability and performance benchmarks imposed from the top. While the promise to increase the Federal Government’s contribution to health funding from around 35% up to 60% means a welcome boost to real dollars, it also means that the Commonwealth holds the whip hand. The real risk is that for all the talk about local decision making, we could actually end up with an even more centralized health system with an even more remote bureaucracy that is even less responsive to the needs of the people they are supposed to serve.

That may not be the immediate outcome, but we should never forget the so called golden rule: “He who has the gold, makes the rules”.

No comments: