So, we have another “historic health reform deal” which is making loud promises while falling short on detail.

Of course we would now be moaning about the death of health reform if yesterday’s COAG meeting hadn’t achieved some sort of agreement (the details, are here). And, credit where it’s due: achieving a national handshake in such a contested area is no small effort.

But just because health reform isn’t dead doesn’t mean its vital signs are pumping. Are we really any closer to achieving a system that is fairer, more sustainable and accountable, and delivering better access to better services?

As one Croakey contributor quipped this morning: “They’re doing financial reform when they should really be doing patient care reform.”

Public sector financing expert Ian McAuley adds: “…the problem remains that this is still a hospital package, not a health package… While hospital reform is necessary, we are still no closer to achieving an integration of health services. The patient’s journey is still through different administrative systems and different funding agencies.”

After all these years of talking about the importance of primary health care reform — in order to ensure a healthier population, to keep people out of hospital, to improve chronic disease management and to ensure a fairer and better use of our health dollars — there are still so many unanswered questions about where it’s heading.

The governance arrangements of the new primary health care organisations to be known as Medicare Locals are still far from clear, never mind how they will actually work to marshall largely private providers to work together in the public interest.

As mental health policy expert Professor John Mendoza writes: “The agreement fails to address the governance weaknesses of the Medicare Locals. It seems that Medicare Locals will rely on goodwill and not much more to influence local hospital networks (set up as state statutory authorities with legal powers), individual primary care providers, the community health and social service providers and the all-powerful professional bodies to build an effective primary health system.

“The Medicare Locals also have so little money to work with it is hard to see them fulfilling their charter. One doesn’t need a degree in governance to see this is likely to lead to a diversity of outcomes and a continuation of our inadequate primary and community care services.”

Nor has the government shown any real sign of stepping up to the political battles required for substantive primary health care reform. Tackling premiers is one thing; picking a fight with the powerful provider and health industry groups is quite another matter, as we’ve already seen with the change of plans around diabetes care.

As health policy analyst Jennifer Doggett says, creating a primary care sector that is genuinely centred around consumers “will require a substantial investment of funds and political capital”.

“Powerful interest groups, such as the AMA, will strongly oppose the much-needed shake-up of doctors’ near-monopoly of Medicare funding and a move away from the fee-for-service system of health financing,” she said. “Achieving major changes in these areas will be a greater challenge than persuading the states and territories to hand over some responsibility for hospitals.”

The COAG agreement is particularly thin in the critical areas of mental health, dental health and aged care. I could find no mention of Indigenous health at all.

Associate Professor Gawaine Powell Davies, CEO of the UNSW Research Centre for Primary Health Care and Equity, said: “Little has been done to bring the orphans of health care, dental health and mental health, into the fold, and little to reduce our dependence on hospital care. If, as I understand, the Commonwealth will no longer fund 100% of primary health care, this may leave us with the current system of split funding and accountability which has hamstrung this sector for so long.”

And still, we hear not even a mention of what remote health expert, Associate Professor David Atkinson, calls the “elephant in the room”.

“Private health insurance subsidies, all completely unaccountable, are why the Commonwealth is unable to fund its share of public hospitals,” he said. “Vast subsidies to private health insurance are a major part of the cause of health inequality in Australia and without reform of the private health insurance rebate, public health care for the majority of Australians will suffer.”

At this stage of the health reform journey, the most apt metaphor I can conjure is of a blinded chauffeur who is not quite sure why she is on the road, where she is headed, or how to get there. But at least she is driving. Considering the twists and turns ahead, it would be foolish to expect a happy ending anytime soon — or that one day of political meetings will lead quickly to on-the-ground improvements in services for patients and the community.

As public health expert Professor Stephen Leeder said: “We should all be aware though that the long -erm problems in health care require decades to achieve full reform. Services can be adjusted to improve access to emergency care and elective surgery quite quickly but the big changes towards greater integration of hospital and community care and improved efficiency may take 10 to 15 years.”

This is a road-trip with no immediate end in sight.

Peter Fray

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