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A healthier future for all Australians: speech to the National Press Club for the launch of NHHRC interim report.



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SPEECH TO THE NATIONAL PRESS CLUB LAUNCH OF NHHRC INTERIM REPORT MONDAY 16 FEBRUARY 2009 - CHAIR OF THE NATIONAL HEALTH AND HOSPITALS REFORM COMMISSION (NHHRC) DR CHRISTINE BENNETT

**Check Against Delivery

A Healthier Future for all Australians

Minister Roxon, fellow Commissioners, members of the National Press Club, working press, colleagues in health care, ladies and gentlemen …

I wish to first acknowledge the traditional owners of the land we are meeting on - the Ngunnawal people.

This is a very proud and exciting day for the National Health and Hospitals Reform Commission as we release our Interim Report, titled ‘A Healthier Future for all Australians’.

Over the last year, we have been listening, reading and researching the many issues, views and challenges relating to our health and to our health care system.

We heard great ideas from health workers at the frontline, and from managers and policy makers right around the country.

The community is also calling for change.

It is this readiness for change that makes this such an historic and important opportunity to ‘get it right’.

The Prime Minister established our Commission to develop a long-term health reform plan for the future of health care in Australia.

The themes and the policy directions we are putting forward are based on the realities of today.

But they are designed to serve the health needs of the nation five, ten, twenty years into the future.

To quote the Prime Minister: “We are getting ahead of the curve”.

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Our brief was broad, and our horizon long. So, by necessity, our Interim Report covers many issues.

It is not possible today to cover all of the 116 reform directions presented in our report.

I will highlight some of our major - and perhaps bolder - reform proposals to generate further debate.

We have organised our ideas, proposals and reform directions under four themes which are action-oriented messages of reform.

The first of our four themes is Taking responsibility.

This is about individual and collective action to build good health and wellbeing.

This theme emphasises that health isn’t just about health care.

As parents and families, as communities, as health professionals, businesses and governments - health is everyone’s business.

The second theme is Connecting care.

This is about comprehensive care for people over their lifetime.

Connecting care is about the need to complete and rebalance the continuum of health and aged care services with a greater emphasis on prevention and primary health care.

Connecting care is also about gluing health care together for an individual person - through a particular illness, through care of a long term condition, or through meeting the different health needs of people over their lifetime.

The third theme is Facing inequities.

We have to recognise and tackle the causes and impacts of health inequities.

We focus on Indigenous health, remote and rural health, mental health, and dental health.

This theme is about a fair health system where we make universal entitlement real.

Our fourth theme is Driving quality performance

This involves making the best use of the people, resources, and evolving knowledge in health.

Here we cover the tough questions around governance, financing and funding, our health workforce, safety and quality, research and innovation, and continuous learning.

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Taking responsibility

Healthy Australia 2020 Goals

Under our first theme of ‘taking responsibility’, we are proposing that, as a nation, we develop a set of shared health goals to which we can all actively contribute.

We call these goals ‘Healthy Australia 2020 Goals’.

They could target turning the tide on the obesity epidemic; reducing teenage binge drinking rates; or perhaps reducing trauma and injury in our community.

These goals should be developed with broad community ownership and commitment.

This leads us to our next proposal, which is the establishment of an independent National Health Promotion and Prevention Agency.

National Health Promotion and Prevention Agency

This Agency would be responsible for national leadership of the Healthy Australia 2020 Goals.

It would develop the targets with the community, make them happen, and provide feedback on progress.

The Agency would work with health care providers and funders to ensure that prevention is integrated into all aspects of our health care system.

With growing momentum in the community for healthier lifestyles and an increasing focus on wellness, we believe the time is right for this agency.

Greater personal responsibility and health literacy

A third proposal is around how we help people to take greater personal responsibility for their health.

According to the Australian Institute of Health and Welfare, a third of the burden of disease in Australia is contributed to by our personal behaviour and lifestyle choices.

Australia is now fatter than most other nations.

With one in four children now in an unhealthy weight range, we face the horrific prospect that our children may have a shorter life expectancy than their parents.

So if we are serious about the health of our nation, and indeed the health of our children and future generations, we have to be serious about taking greater responsibility for our own health and the health of our family.

But it is important to recognise that healthy choices may not be as easy for some people for reasons such as where they live or their social circumstances.

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An important building block for taking greater responsibility for your health is your ‘health literacy’.

Health literacy is your level of knowledge about human health, your understanding of your personal health risks, and what action to take.

We propose that health literacy be included as a core element of the National Curriculum for all schools, and that it is tested in the national basic skills assessment.

Connecting care

Our second theme is Connecting care.

The health care system can be viewed as a chain of services from prevention and primary health care, to hospitals and rehabilitation services, through to aged care.

While hospitals are often the focus of public attention as the pressure point of the system, we believe that the solutions for hospitals are, in large part, about strengthening other elements of the health service continuum.

For this to occur, we need strong national leadership on the fundamental platform of health care - primary health care.

Strengthening and integrating primary health care

It is internationally acknowledged - including by the World Health Organisation - that a strong platform of primary health care is fundamental to the good health of a community.

We propose a number of changes that will help to strengthen and integrate primary health care in Australia.

Commonwealth responsible for all primary health care

First, we propose that the Commonwealth should assume responsibility for all primary health care policy and funding.

This would bring clear leadership, focus and accountability for this somewhat fractured part of the health care delivery system.

Comprehensive Primary Health Care Centres

As part of this expanded role, we believe the Commonwealth should encourage and actively foster the widespread establishment of new Comprehensive Primary Health Care Centres.

These Centres would operate over extended hours as ‘one stop shops’ with services provided by a multidisciplinary team.

We believe these comprehensive centres will play an important role in raising the visibility and accessibility of primary health care services in the community as the first point of care.

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Voluntary enrolment

Our third key reform relates to the importance of having health care provided with continuity, over time.

We want young families and people with chronic and complex conditions, including people with a disability or a long term mental illness, to have the option of enrolling with a primary health care service of their choice to be their ‘health care home’.

There would be grant funding tied to levels of enrolment for each practice.

This would support multidisciplinary clinical teams and care coordination.

The funding would complement existing fee-for-service payments.

Personal electronic health record

Next, we strongly urge that a person-controlled electronic personal health record be made a reality.

People told us they couldn’t understand why - with all the wonders of modern information and communication technology - such a record is still not available.

The Commission believes that an electronic health record for each Australian is one of the most important systemic opportunities we have.

It would improve continuity, safety, reduce waste and errors, and promote best care.

An electronic health record - that can be accessed, with the person’s agreement, by health professionals across all settings - is arguably the single most important enabler of truly person-centred care.

Healthy start to life

Investing in a healthy start to our children’s lives is one of the most powerful investments we can make in health care.

From before conception through the early years of life there are critical windows of health potential that can be realised or lost.

We propose opportunities such as universal home visits, school nurses, better targeted special care to families at risk, and more coordinated intensive care for children with disabilities and major health problems.

Ensuring timely access and safe care in hospitals

A health issue that gets everybody excited for different reasons is hospitals.

There are always headlines about waiting lists, overcrowded emergency departments, and safety concerns.

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Hospitals are undoubtedly one of the most discussed pressure points of the current health system.

Looking to the future, we believe that many of the solutions to hospital problems will require changes outside hospitals.

We need to look at strengthening primary health care, developing stronger community and home-based care, filling the ‘missing link’ of sub-acute and rehabilitation services, and providing greater choice in aged care services.

This will all help to reduce the unnecessary and avoidable demand currently placed on our hospitals.

Reshape hospital roles

But we still have to make changes to improve our hospitals.

First, the Commission sees a need to reshape hospital roles.

We suggest that the future planning of hospitals should encourage greater delineation of hospital roles.

This may include separating planned and emergency treatment to make hospitals more productive and efficient.

Hospital funding should reflect these roles.

We support the use of activity-based funding for both public and private hospitals using efficient casemix-based payments - including the cost of capital.

We believe that grant funding - in addition to activity-based funding - should go to hospitals with major emergency departments to address the issue of overcrowding by ensuring adequate bed availability.

National Access Guarantees and Targets

Hospital access times can be improved by the changes we have proposed within the hospital system and by strengthening services outside hospitals.

With these measures in place, we believe we should be able to guarantee timely access to services supported by public funding.

So we are proposing the development and adoption of National Access Guarantees for planned procedures.

We also propose National Access Targets for emergency care.

For example, we would like a national access target for people requiring an acute mental health intervention - measured in hours.

We would like a national access guarantee for patients requiring coronary artery surgery or cancer treatment - measured in weeks or days.

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And we would like a national access guarantee for patients requiring other planned surgery or procedures - measured in months.

We are not specifying these guarantees at this stage but, rather, floating this concept.

The actual measures should be developed incorporating clinical, economic and community perspectives, perhaps through vehicles such as citizen juries.

These guarantees would represent a level of service obligation that citizens should be able to expect from their publicly-funded health care system.

Sub-acute services

Once people receive treatment in hospital, we also need to ensure that they get access to services that help them recover.

The ‘missing link’ in the service chain is sub-acute services.

By sub-acute care services we mean rehabilitation, geriatric evaluation and management, transition care, and other ‘step-up’ or ‘step-down’ programs.

Sub-acute services can sometimes prevent admission to hospital, as well as help people recover after a hospital visit.

Many parts of Australia have limited or poorly developed sub-acute care services.

We want investment to build sub-acute care facilities to be one of the top priorities for the Health and Hospitals Infrastructure Fund.

While some people refer to sub-acute services as the ‘invisible services’, the same cannot be said about aged care.

Expand choices for care and accommodation in aged care

There is no doubt that there will be huge growth in demand for aged care services in Australia.

With the baby boomer generation advancing in years, we will see much higher consumer expectation.

In the next 20 years, the number of people aged 70 or over will double.

At the same time, smaller families and greater workforce participation will mean less family carer support will be available.

Aged care services will need to be structured in ways that are more responsive to the needs of older people and their families.

We need to expand choice for both care and accommodation in aged care.

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We need to get the best from our public funding to ensure we are protecting those who are most in need.

And, of course, we need a viable and responsive aged care industry.

To achieve these three linked objectives, the Commission believes that funding should be more directly linked to people’s needs, rather than to places.

Assessment of care and accommodation needs should be separate.

In this way, more older people may be able to be cared for in their own home, as well as in residential aged care facilities.

We propose that the limits on the number of aged care places, both residential and community, be lifted.

The number of approvals for care subsidies should be capped at the point of assessment.

This approach would encourage provider competition and put a focus on quality and service.

However, we recognise that providers will need to be able to raise revenues to invest in expanded places and offer greater choice.

We therefore suggest that accommodation bonds - and other alternative approaches for payment - be explored in this opening up of a more competitive provider market.

The final step in Connecting Care is improving care for people at the end of life.

Improved palliative care and advance care planning

In health, we are sometimes so busy struggling to preserve life that we forget that dying - and the rights, dignity and choices people make at the end of their life - deserve respect and expert care.

We propose expanding access to specialist palliative care services, including strengthening palliative care skills in primary health care services.

We support advance care planning and suggest that the Respecting Patient Choices program be implemented across all residential aged care services.

Facing inequities

Our third reform theme is Facing inequities.

Here we present reform directions that will help us recognise and tackle the causes and impacts of health inequities.

Universal entitlement doesn’t automatically translate to universal access for many Australians.

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Access can be a problem for various reasons such as where people live, a lack of doctors or hospitals, cost, or the nature of the health condition.

Closing the health gap for Aboriginal and Torres Strait Islander peoples

First, we face up to the unacceptable and horrific fact that Australians from an Aboriginal or Torres Strait Islander background have an average life expectancy 17 years lower than the Australian community as a whole.

This is not ‘new’ news. We recognise the enormous efforts over the last year in developing a clear way forward to ‘Close the Gap.’

We also agree that closing the gap will require significant action in areas other than health care, including housing, education and employment.

But we are focusing on the 30 per cent improvement that has been suggested can be gained by improving health care delivery.

A significant increase in funding will be required to achieve the ‘Close the Gap’ goals

The question we posed is: how can that extra investment in health care most effectively make a difference?

Our reform proposal is that an expert purchasing function should be developed to lead this additional investment.

The Commission believes that this could be achieved by forming a National Aboriginal and Torres Strait Islander Health Authority as a specialised purchasing function within Health.

We see this as similar to the purchasing function within the Department of Veterans’ Affairs.

The new Authority we are proposing would purchase health services with a focus on better outcomes, timely access, and culturally appropriate care.

Aboriginal Community Controlled Health Organisations would continue to play a critical role.

Along with mainstream services, they need to be better supported to achieve quality outcomes.

We acknowledge that this proposal would change the way health services are delivered to Aboriginal and Torres Strait Islander people who choose to participate.

And that is the point. A new approach is required to drive improvement in the quality of outcomes and the responsiveness of the whole health system to Indigenous Australians.

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Delivering better health outcomes for remote and rural communities

We believe we can make a real difference to health in remote and rural communities.

Nearly one third of Australians live in remote and rural areas.

They generally have poorer health status, with shorter life expectancy, and higher rates of accident and injury and some chronic diseases and preventable cancers.

We argue that more equitable health care requires more equitable distribution of funding.

We therefore propose that where remote and rural communities are under-served by MBS providers, an ‘equivalence’ payment be made.

This would be used flexibly for local health care delivery.

Caring for people in remote and rural locations involves either bringing care to the person or bringing the person to the care.

To bring more care to people in rural and remote areas we propose expansion of specialist outreach services - covering medical specialists, midwives, allied health, pharmacy, and dental services.

We want to encourage greater use of telehealth services including funding to support referral and advice networks for remote and rural practitioners, and on-call 24-hour telephone and internet consultation and advice services.

When it is necessary to take people to the care they need, the Commission proposes that patient travel and accommodation be funded at a level that takes better account of the out-of-pocket expenses of patients and their families.

The patient travel and accommodation issue is a big issue in country Australia.

People are passionate about it, and rightly so.

Like all Australians, country people want to be able to support their loved ones when they are sick - especially when they have to leave home for treatment.

Supporting people living with mental illness

One of the most compelling and common examples of health inequity is people living with mental illness.

The scale of mental illness in our community is larger than we may think and mostly emerges in teenage or young adult years.

It is estimated that 65 per cent of people who need mental health care go untreated.

And we know that young people in particular are reluctant to seek assistance.

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We propose that a youth-friendly community-based service - which provides information and screening for mental disorders and sexual health - be rolled out nationally for all young Australians.

We imagine a model similar to the headspace program that would use internet and telephonic based approaches.

A range of social support services beyond clinical care - including employment support and assisted housing - is needed to help those suffering from mental illness.

We move now to a subject that was not surprisingly on everybody’s lips - or closely adjacent to them - during our national consultations.

Improving oral health and access to dental care

I’m talking about oral health and dental care.

Oral health is important to your general health.

It is also vital to your ability to speak, eat, smile, and even kiss without pain or embarrassment.

But many Australians suffer from poor oral health.

Around 650,000 adults are on public dental waiting lists. The average waiting time is 27 months.

Low income households spend more than eight per cent of their household income on dental services.

We need a health system ‘with teeth’.

Well, the Commission has put a lot of thinking and discussion into this hole in our health system.

We are proposing a new scheme - ‘Denticare Australia’.

It would give every Australian universal access to preventive and restorative dental care, and dentures, regardless of people’s ability to pay.

‘Denticare Australia’ would be funded by an increase in the Medicare levy.

It would build on access to private dental care while strengthening public dental services.

People would choose a dental health plan with a private health insurer paid for by the levy.

Or they could opt to rely on public dental services, for which increased funding would be provided.

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We estimate that under this approach many people will pay no more than they currently pay for dental care.

People on low incomes would pay considerably less and have much better access to dental health services.

Families and older Australians would generally benefit.

Driving quality performance

Not only do we need to face up to the inequities in our health system, the Commission proposes transparent national reporting on our progress in tackling these inequities.

This is all a part of driving quality performance, which is our report’s fourth and final theme.

This is about how we make best use of people, resources, and evolving knowledge in health care.

I’ll run briefly through the topics of funding, health workforce, and building a quality, learning health system - and leave governance for last. There’s nothing like suspense!

Raising and spending money for health services

We believe that incentives for improved outcomes and efficiency should be strengthened in health care funding arrangements.

This would involve a mix of activity-based funding, payments for a course of care or period of time, and payments to reward good performance in outcomes and timeliness of care.

We propose that these payments take account of the cost of capital and cover the full range of health care activities, including clinical education.

We suggest a review of safety net arrangements to make them more integrated and less complicated, and to cover a broader range of health costs.

The Commission also wants to see the overall balance of financing through taxation, private health insurance, and out-of-pocket contribution maintained over the next decade.

A sustainable health workforce for the future

The dedication, diversity and dynamism of our health workforce are major strengths of our system.

Looking to the future, a shrinking labour market, coupled with increasing care needs, is a daunting combination.

Existing professional boundaries restrict our ability to use fully the skills of the current health workforce.

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We want health professionals to work together better as a team.

This should be reflected in how we educate and train them.

To this end, the Commission recommends the adoption of a new competency-based framework for future clinical education, and better defining of clinical scopes of practice.

We will also require multidisciplinary clinical training facilities across all service settings, including in rural areas.

To link the health and education sectors - and provide overarching national leadership - we propose the establishment of a National Clinical Education and Training Agency.

This Agency would oversee development of the competency based framework, clinical education funding, and would assist in health workforce planning.

We have examined the vexed issue of the maldistribution of the medical workforce and propose some changes.

Where doctors are scarce, such as in remote and rural areas, appropriately credentialed nurse practitioners and other registered health professionals should be able to order diagnostic tests and make specialist referrals that are covered by Medicare.

The same should apply to PBS cover for prescriptions.

We also propose that specific items on the MBS should be able to be billed by a medical practitioner where the care is provided by a competent health professional credentialed to undertake this activity.

We want the health workforce of the future to be a dynamic team, comprising individuals who are qualified, adaptable, and technically competent.

The Commission anticipates some lively feedback on these workforce reform directions.

Fostering continuous learning in our health system

One of the biggest failures in health care is that we don’t implement what we already know.

If we want to encourage clinicians to focus on the quality of their clinical care and outcomes, we need to provide them with meaningful and timely data.

We propose local systems of supportive feedback to clinicians, teams and organisations in primary health care services and public and private hospitals.

To drive safety and quality across the system, we recommend the establishment of a permanent independent national body.

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Its role should include designing indicators that can be used to monitor the safety and quality of care and to underpin reporting within the health system and to the public.

We also propose that it develop a national patient experience questionnaire and patient-reported outcome measures.

Without research and innovation, health care would not improve.

Australia already has an excellent tradition and international track record in health and medical research.

But we need better means of translating research findings into clinical practice in a ‘systemic’ and timely way.

We make a number of suggestions, including development of NHMRC collaborative research centres and an increase in part-time clinical research fellows across all health care settings.

Research is a key enabler of progress. It must be better recognised, valued and integrated with the health system.

Now, before I run out of time I suppose I should say a few words about governance of the health system!

Strengthening the governance of health and health care

Governance - or who should ‘run’ the health system and ‘how’ - is without a doubt the single most controversial issue we have been asked to tackle.

Almost everyone has an opinion - and often very strongly held opposing views.

In our consultations, we regularly heard comments such as ‘fix the system’, ‘national leadership’, ‘local flexibility’ and ‘one health system’.

Some want more local control. Some want more national control. Some want the Commonwealth to take the lot. Others cannot see a system without a significant role for the States.

Our Commissioners have a variety of evolving views on this, too. And that is a good thing!

So today we offer you three governance options to generate further discussion.

I will provide a ‘word picture’ of each - but urge you to read the detail in our report in full before forming your opinion.

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Option A

Option A - we call this option ‘shared responsibility with clearer accountability’.

With this model, we would keep both Commonwealth and state and territory involvement, but re-align and clearly define responsibilities between them.

The Commonwealth would become responsible for all primary health care funding and policy, and indeed for all non-admitted care.

The Commonwealth would also pay the states and territories a significant proportion per episode of the efficient cost of inpatient and emergency treatment and the full cost of outpatient activity.

States would continue to be responsible for the delivery of public hospital services and the development and management of sub-acute services.

These arrangements would be defined in a five-year National Health Strategy covering all health policies and funding arrangements.

This would be underpinned in turn by eight bilateral agreements between the Commonwealth and each state and territory.

Option B

Under Option B, the Commonwealth would be responsible for all aspects of health care, delivering services through regional health authorities.

These authorities would be responsible for the total health needs of a defined geographic population.

This would be done in parallel with continued national programs of medical and pharmaceutical benefits and aged care subsidies.

This option would effectively resolve the blame game between governments in regard to health.

It would make the Commonwealth clearly responsible for funding and all policies relevant to shaping health services.

Option C

Under Option C, the Commonwealth would be responsible for all aspects of health and health care.

It would establish a community-wide social health insurance scheme with people choosing from competing health plans that will purchase health care from public, private and not-for-profit providers.

These health plans would be required to cover a mandatory set of services including hospital, medical, dental, pharmaceutical, allied health, and aged care.

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Social health insurance is used by many European countries.

Key strengths of social insurance are the incentives for health plans to be responsive to the needs of their members, and for the plans to purchase services in an integrated way to meet those needs across the whole continuum of care, and over time.

Accountability is strengthened by people’s capacity to change to another health plan if they are not satisfied with the one they have.

Innovation is encouraged by competition between health plans and between providers.

However, this option requires the greatest departure from existing approaches, with all the attendant risks inherent in such a fundamental change.

I’m sure these options have you thinking already.

There is much more detail about each of these options - how they would work, and the risks and benefits of each option - in our report.

Conclusion

So, now the steps from here.

Please read the report and please tell us what you think of our reform directions.

Those here today can start by staying after the speech and chatting with the Commissioners.

Or you can send us your feedback in writing. Please be brief and to the point - we have another report to write by June.

Go to our website at www.nhhrc.org.au for information and also to take part in our electronic feedback survey.

Or send an email to talkhealth@nhhrc.org.au

I’d like thank my fellow Commissioners for all their hard work and their friendship.

I’ll ask them to please stand up and be recognised.

Our thoughts are with our friend and colleague, Geoff Gallop, who is sadly absent today for personal reasons.

This is an amazing group of people who I promise you are committed to getting this as right as we can!

This report has been a real team effort.

I would also like to thank the Minister and all the governments of Australia for entrusting us with this unique opportunity, which is a true privilege.

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Finally I would also like to acknowledge the amazing support and generous contributions of so many people in the health industry and the community who have offered their ideas and views so constructively.

We are all working towards the same goal.

As one of our community forum participants put it:

Let’s stop bragging about having the best health system … it’s time to start bragging about having the best wellness system …”

Thank you for your time today.