In the wake of floods and other disasters, debate about the flood levy, looming budget cuts, and questions about the future of national health reform, there are concerns that a vital but often neglected part of the health system – community-based services – is in grave danger.

In the first of a two-part series, a psychiatrist with long experience in community-based services, Professor Alan Rosen, suggests that such services face a very real risk of being the losers on the stormy seas of health reform and budget cuts. Governments should have the courage to tackle the open-ended expenditure on acute clinical care, and redirect funds to where they can have a greater impact, he argues.

Now is the time for a refocus on community-based care

Professor Alan Rosen writes

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The Commonwealth  Government is intent on a one-off hike in income tax to offset the public infrastructure costs of our recent great floods, to which we should add the federal bail-outs needed to fix the devastating aftermaths of Cyclone Yasi and now the Perth hills bushfires too.

It won’t pay for much of the job required. It would probably need to be recurrent  for up to 5 years and to more squarely target the well off.

Maybe our governments should take a closer look at more robust proposals that they should establish a permanent Climate Disaster Fund. Possibly this could be paid for by increased levies on profits on unhealthy products, or withdrawing the billions in subsidies for the use of fossil fuels, “most of which ends up in the pockets of Australia’s biggest polluters”, according to Get-Up. But they probably won’t.

Ironically, instead they are looking for huge savings from mainly environmental portfolios, to pay for the infrastructure replacement in the aftermath of these catastrophic events. Many of these cuts have adverse public health implications.

Worse still, they may be tempted to use these circumstances to postpone indefinitely promises of  urgently needed enhancements which have not yet been fulfilled.  This is unfortunate timing for clientele of community health, Aboriginal, dental and mental health services, who have been very much the losers so far from the so-called federal health reforms. They are  still hanging out for their turn, as the government led them to expect would come soon.

Realistically, could health savings be made, and could they help?

Health savings can be made over time by reducing the duplication of health bureaucracies, by having only one level of government running particular aspects of health services, and by setting firm limits on the perverse incentives to spend ever more on medical and surgical procedures and acute inpatient care, and on heroics in the last year of life, in both the public and private sectors. Insured people who live in well-off areas believe they have privileged access to such interventions, as they do according to the stats. But in truth, as private hospitals with expansive operating suites proliferate in these areas, these citizens should consider hanging on tighter to their purportedly disposable organs.

It is hard to see any government biting the bullet, facing the wrath of the procedural clinicians, the private hospital industry and the media beat-ups, to oblige the health industry to more accurately target the need for  such clinical activities and to make real savings.

We need government to heed the National Health & Hospital Reform Commission recommendation to cap this almost open-ended gusher of acute expenditure. Meanwhile the balance must be shifted towards community-based prevention and continuity of care in the community.

To attain these very substantial savings will take time and political courage, and requires our federal government to make a greater investment upfront in these evidence-based community initiatives.  To gain momentum and to limit growth in health expenditure with population ageing, these savings would need to be ploughed back into further improving community-based health services.

Community health services, where and when adequately funded,  have provided preventive and early detection and intervention services for many disorders, and ongoing community care for  “chronic” disorders,  to claw back better function, wellbeing and longevity from longterm disability.

There is strong evidence of these clinical, quality of life and cost saving effects, from the public and NGO sectors, and now also from some fee-for-service pilot studies in Australia and internationally. At their best, they have also provided seamless integrated care between hospital and community care, and have been the continuity of care bridge between specialty hospital based services and community based general practices and ancillary services.

They are sometimes confused with primary health care facilities, which are either run by or dominated by medical interests, who wish to maximise throughput of short GP appointments. Community health facilities could be fruitfully co-located with primary care centres, but should not have their budgets run by doctors, or the social-determinants-of-disease management and social  support aspects of their work may be undervalued and curtailed. GPs do not have either the time or skills to coordinate all these needs.

Following in the Howard Government’s footsteps,  Health Minister Nicola Roxon and the Rudd-Gillard Hospital so-called “Reforms” seem to have purposely blurred the difference between community health services, and primary health care.

Nicola Roxon often seems not to understand the difference. It may be more wilfulness than ignorance. To some, it appears as if Roxon and her key federal health bureaucrats are  determined to kill off salaried community health services during her watch. In the process, they have effectively de-funded community health services, which have  been plummetting through the  gaps in the new federal health reform funding package. This only provides 60/40 funding for hospital-based services and resourcing of primary health care centres set up under the banner  of “Medicare Locals”.

The Commonwealth wants the states to transfer policy and funding responsibility for community health to them (as well as community health funding via the GST claw back).  But there is no sign at all that the feds want to fund salaried services.  It’s all policy by Medicare Item expansion via Medicare Locals and private providers. Understandably, most of the states have baulked at this, and are now inclined to transfer little or nothing.

If the states call their community health services ‘outpatients’ they can get 60% funding from the feds (versus 100% funding for anything they transfer).  If they don’t transfer services and continue to call them community health services, there is no provision for any federal funding.

In the meantime, community health services are being tossed about in stormy seas, torn between the Scylla and Charybdis of murderous intent by the feds, and chronic neglect and exploitation by the states.

• Professor Alan Rosen holds positions with the Brain & Mind Research Institute, University of Sydney, and School of Public Health, University of Wollongong.

• Part 2 in this series will be posted shortly.

As a Crikey subscriber and someone who began working as a journalist in 1957, I am passionate about the importance of independent media like Crikey. I met a lot of Australians from many walks of life during my career and did my best to share their stories honestly and fairly with their fellow citizens.

And I never forgot how important it is to hold politicians to account. Crikey does that – something that is more important now than ever before in Australia.

North Stradbroke Island, QLD

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