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Thursday, December 03, 2009

At Last Some Serious Truths are Told About the Australian Health System!

For those who have wondered why it is that we have a health system that seems to be stuck in the past, is self congratulatory and utterly resistant to positive change I think I have found a man who has a few answers.

Dr Jeff RJ Richardson (from Monash) has published a wonderful commentary on the issues here:

Steering without navigation equipment: the lamentable state of Australian health policy reform

Jeff RJ Richardson

Australia and New Zealand Health Policy 2009, 6:27doi:10.1186/1743-8462-6-27

Published: 30 November 2009

Abstract:

Background

Commentary on health policy reform in Australia often commences with an unstated logical error: Australians' health is good, therefore the Australian Health System is good. This possibly explains the disconnect between the options discussed, the areas needing reform and the generally self-congratulatory tone of the discussion: a good system needs (relatively) minor improvement.

Results

This paper comments on some issues of particular concern to Australian health policy makers and some areas needing urgent reform. The two sets of issues do not overlap. It is suggested that there are two fundamental reasons for this. The first is the failure to develop governance structures which promote the identification and resolution of problems according to their importance. The second and related failure is the failure to equip the health services industry with satisfactory navigation equipment - independent research capacity, independent reporting and evaluation - on a scale commensurate with the needs of the country's largest industry. These two failures together deprive the health system - as a system - of the chief driver of progress in every successful industry in the 20th Century.

Conclusion

Concluding comment is made on the National Health and Hospitals Reform Commission (NHHRC) . This continued the tradition of largely evidence free argument and decision making. It failed to identify and properly analyse major system failures, the reasons for them and the form of governance which would maximise the likelihood of future error leaning. The NHHRC itself failed to error learn from past policy failures, a key lesson from which is that a major - and possibly the major - obstacle to reform, is government itself. The Commission virtually ignored the issue of governance. The endorsement of a monopolised system, driven by benevolent managers will miss the major lesson of history which is illustrated by Australia's own failures.

Also making powerful points is the background to the paper:

Background

Concerns which have dominated national debate and government attention have commonly reflected vested interests and ideologies rather than the evidence-based magnitude of problems. The different interest groups include, as they have always done, the medical profession, private health insurance (PHI), private hospitals, increasingly, the pharmaceutical industry, the public health lobby and ‘government economic rationalists’.

One ideology concerns the unsubstantiated superiority of varying levels of private ownership, control and financing in the health sector. Another ideological belief is that health spending should be dedicated only to health maximisation (ignoring some notions of freedom and fairness). Then there is the ideology of many government departments – especially those heavily influenced by economists – that small government is an end in itself and that minimum resource cost per unit of measured output is always desirable. In the health sector this latter ideology does not reflect population values [1].

In contrast with these views, there is a strong argument for public spending to be based upon evidence, including evidence relating to public values. This, of course, requires information, but currently much of the information needed to achieve this apparently obvious goal does not exist, that is, the health system is being steered without satisfactory navigation equipment.

In the present paper I initially comment upon three of the prominent issues in the health debate, each of which is associated with a powerful constituency namely, private health insurance (PHI), ageing and hospital queues. Privatisation could be added as a fourth. The theme of this brief discussion is that the quality of the analysis has been poor to the extent that it borders, at times, upon disinformation.

This raises the question of how this could occur. In the following sections I outline evidence of more significant system failure – the regulation and diffusion of technology, the fairness of the system and the quality of care. Relative to their importance these issues have been largely ignored in the health debate and attracted, at best, a lethargic policy response. This again raises the question of how this could occur.

In the remainder of the article it is argued that the answer to these questions is, in large part, that the health system has poor governance and has failed to invest adequately in research and experimentation. This is symptomatic of a more fundamental problem, namely the near monopolisation of each part of the system by conservative and defensive government agencies and the belief that deficiencies may be corrected by (occasional) one-off tinkering with the system rather than by the creation of a system based upon the production an diffusion of evidence, health services research commensurate with size and importance of the health sector and upon error learning rather than error suppression. Some principles for achieving this are discussed.

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One comment only – note the central need for and the clear absence of information of the type needed to do better! Also not just how bad patient safety is in Australia and how little attention the NHHRC (or anyone else) really seems to give it. (Safety is of course and are where e-health can make a real contribution – and that is evidence based!)

Mandatory reading in my humble view:

Download the full article from here:

http://www.anzhealthpolicy.com/content/6/1/27

Thanks Jeff for this!

Note this is just in time to remind us of a COAG meeting on Monday which is to sort out our health system using the lamentable approaches highlighted in this article!

Heaven help us all!

David.

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