This piece was published in Croakey on 6 March 2017. My thanks to Marie McInerney.
On Friday, 3 March, the Australian Labor Party held a National Health Policy Summit in Canberra. Thanks to the endeavours of Croakey, and in particular to Marie McInerney, we were able to hear the views of some of the 150 experts there through Twitter, Periscope and Marie’s videoed online interviews.
This is not a piece about the relative value or effectiveness of the health policies of Government and Opposition. It concerns the difficulty health advocates seem continually to have in framing and agreeing proposals of the sort which might be adopted by the Government of the day or included by the Opposition of the day in its health policy platform for a coming election.
Everyone knows that advocacy should focus on answers, not problems. For the most part, politicians do not need to be reminded of what the issues are. But certain types of ‘answer’ are much more likely than others to be practicable and to improve health outcomes in the short term.
In meetings of health advocates, too much time is often spent on matters that are related to organisational principles, strategy, governance and (frankly) motherhood.
With the best will in the world, a Health Minister and their Department cannot operationalise generic principles. Nor are they what will really matter in an Opposition’s policy platform.
We can do much better.
Where the National Health Policy Summit was concerned, I read in Croakey that “there were benefits in having a big crowd of people committed to improving health in the same room, sharing an agenda with people outside their own ‘silos’ and reiterating key issues and messages with politicians and advisors that they often don’t get to reach”.
But how much more useful might it have been if there had been more focus on new policy proposals for this year’s and next year’s budget, and less on principles and strategic approaches!
This (untested!) observation led me to speculate about the type of initiatives on which health advocates currently spend their time, and what a more desirable mix would be.
Best use of an hour with the Health Minister
It is my belief that there are four classes of issue on which health advocates can work. They can be described as:
- grand principles;
- new national plans;
- redistribution of existing program expenditures; and
- evidence-based new policy proposals.
Such a classification could be applied to policies and programs which affect health but which are not within the health sector itself. That, then, would see it applied to the social determinants of health, including not just health risk factors but also, for example, proposals about taxation. However, for the purposes of this piece, I have restricted the analysis to matters that lie wholly or largely within the health sector and thus within the purview of Health Ministers and their Departments.
Table: Best use of an advocate’s one hour with the Minister of the day
|
Class of proposal or issue |
Proportion of time/effort (%): | Best: mins/hr. w. Health Minister of the day | ||||
| Currently | Desirably | |||||
| 1 | ‘Grand principles’ | 55 | 10 | 6 | ||
| 2 | New national plans | 30 | 25 | 15 | ||
| 3 | Re-jig existing program expenditure | 10 | 40 | 24 | ||
| 4 | New Policy Proposals | 5 | 25 | 15 | ||
‘Grand principles’
In the first class are what might be called strategic or organisational approaches to health. including such things as:
- the aspirational importance of universal and equal access to health care;
- the benefits of a primary health care approach to health and wellbeing – which includes many things outside the health sector itself;
- the desirability of (but major challenge posed by) a whole-of-government or Health in All Policies (HiAP) approach;
- the value of a strong primary care service;
- the importance of continuity of care for individual patients of the system (through better integration of services);
- the desirability of spending a significant proportion of the health budget on illness prevention and health promotion;
- “regarding expenditure on health promotion as an investment not a cost” (rhetoric; motherhood);
- “focussing on workforce retention as well as recruitment” (ditto);
- “supporting Primary Health Networks to make a real impact on rural and remote health outcomes” (ditto); and
- the desirability of consumer/patient involvement in the planning, management and evaluation of health services.
When lobbying politicians or engaging with the media, health advocates should, for two reasons, allocate very little time to such matters. For one thing, there is precious little disagreement, in Australia or anywhere else, about their importance. For another, such matters can and do inform ongoing political decisions but are not the stuff of short-term change or new policy proposals.
New national plans
The second class of issue consists of strategies or plans (probably national) which are not currently in place but which, if adopted by government, would be the frame within which specific programs would operate and on which new health budget allocations would be made.
Different advocates will have different views on such potential new plans or program frameworks; some will argue that a particular plan should not be introduced.
This class includes such things as:
- a proposal to provide new money to fund actions under the National Aboriginal and Torres Strait Islander Health Plan (at the moment all actions in the Implementation Plan are to be funded from existing program allocations);
- the introduction of specific tax regimes for sugary drinks or alcohol which would be premised on their impact on population health through influencing levels of consumption;
- the regulation of the marketing of certain foods, especially to children;
- a Senate Inquiry into food security;
- an integrated strategy to Closing the Gap for Vision, which would include a subsidised spectacle scheme for rural and remote areas and Aboriginal and Torres Strait Islander communities; and/or
- development and funding of a National Child Health Action Plan (NCHAP).
Proposals for the redistribution of existing program expenditures
The third class comprises proposals relating to existing policies or programs, suggesting ways in which the effectiveness of expenditures already on budget could be improved. This would include, for example, suggestions about how existing mental health programs should be altered, extended or terminated; or revised regulations to be applied to incentives for general practitioners who work in rural and remote areas.
Such proposals would legitimise the redirection of funding or even the termination of particular health expenditures. Such changes are of great interest to governments, particularly in fiscally-challenging times when any new program expenditures must be offset by savings from within the portfolio.
This class would include things such as:
- proposals to take a particular medicine off the Pharmaceutical Benefits Scheme or to add a new one;
- a proposal to take a particular procedure off the Medicare Benefits Scheme or to change the schedule fee for it;
- a proposal to switch some investment from, say, headspace to Mental Health Services in Rural and Remote Areas (MHSRRA);
- a proposal to increase the difference in rates of payment to general practitioners who work in the major cities and rural/remote areas;
- a proposal to switch health scholarship expenditure from, say, medicine to, say, allied health; and/or
- a proposal to change the allocation of funds within the Tackling Indigenous Smoking program.
Evidence-based new policy proposals
These are potential new programs which are justified on the basis of evidence about particular aspects of health service need, and about the efficacy of particular approaches to its management and/or treatment.
Such programs are in effect ‘shovel-ready’, with the evidence collected and the case made – in all probability by one or more advocacy body with a vested interest in the plan (not necessarily to support it). With the evidence in, there will in effect be a contest of ideas between them all, with the question of which are adopted by government answered through normal political processes.
In this class might be:
- a program to fund clinical pharmacy positions in Aboriginal Community Controlled Health Organisations to oversee the delivery of the S100 Remote Area Aboriginal Health Service Program;
- a program to fund a specialist Parkinson’s nurse (or Neurological Nurse Educator) in the 40 electorates with the highest proportion of people with the condition;
- work on a national, longitudinal health workforce data set that can inform workforce planning and incentive programs;
- a program to expand access to Nurse Practitioner and allied health services under the MBS in rural and remote settings where there are demonstrated workforce shortages;
- a program to grow and support local activity related to social approaches to end of life by a Compassionate Communities Network in Australia; and
- a program for recruiting more allied health professionals to care of the elderly and , under the NDIS, to people with a disability.
There is a place for general principles and approaches in what might be regarded as the Foreword to a set of programs for improving health outcomes on the ground. But for the most part there is only furious agreement about these principles, and what really matters are specific new policy proposals.
We have to get over the situation in which, in a room of 150 health experts, each one feels a sense of duty towards their own job or profession – as if they are in attendance with a representational duty.
What this means is that it will be easy for them to agree with others about the importance of, for example, continuity of care, but much harder to agree that scarce health dollars should be spent on anything but their own interest. When advocates for each special interest area bring their Number 1 proposal to the table, a contest of specific ideas can take place. Evidence will be scrutinised, assumptions challenged.
And at the end of the day there will hopefully be sufficient collegiality in the sector as a whole for the most effective proposals to be unanimously supported.