After its first year was dominated by ministerial resignations and scandals, and large-scale spending and staff cuts, Campbell Newman’s government has now revealed its hand. The findings of the Commission of Audit have set the direction for public policy, public management and service delivery.
The radical changes to the delivery of healthcare proposed by Health Minister Lawrence Springborg’s “Blueprint for Better Healthcare” make a lot more sense now we know the government looks favourably on the recommendations its audit commission made.
The commission, headed by former Liberal treasurer Peter Costello, has not released its full report. Only the executive summary was released to the press; it’s unclear whether even government backbenchers have access. In a strange approach to consultation, the government has simultaneously called for a debate and indicated it would publish the report and its response in six weeks. The interim report attracted heavy criticism from independent economists such as Professor John Quiggin — not just directed at the report’s ideology but at its financial and statistical assumptions and accuracy.
We know enough to say the report is a sweeping blueprint not just for privatisation of state assets but also for outsourcing (“contestability”) of government services. Page 11 of the executive summary effectively protects only the courts, police and emergency services from the outsourcing drive.
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And now health. The “contestability” of services is spun in the blueprint as agnosticism towards the ownership of service providers, but its implications are both more far-reaching and also not subject to the mandate the government says it will seek for privatisations of assets.
Like the cuts to public health, no clue was given prior to last March’s state election that this approach would dominate health. Yet the straws have been blowing in the wind. And politically, this time the Minister has the Australian Medical Association on his side, but unions are promising “the mother of all campaigns”.
Federal Treasurer Wayne Swan has vowed to fight, claiming that the moves amount to a dismantling of Medicare. There has already been controversy over payments not made to Queensland because of a failure to meet agreed Council of Australian Governments targets. In a classic exemplar of the “blame game” over funding, the state calls this money a “cut” while Canberra decries the state for breaking its promises.
In this game, the Commonwealth probably has the best of the argument, but — as with the Gonski education forms — a co-ordinated national approach to policy now lies in tatters. Springborg’s document gestures to the role of Medicare Locals, but his own federal counterparts promise to abolish them if elected in September.
The report reads as if bureaucrats have tried to harmonise the government’s direction with national objectives. But it’s far from clear how successful they’ve been, owing to the unfortunate rhetorical sludge that characterises the writing.
Those who advocate a national approach to health reform must see this blueprint as a setback.
We don’t know much — as yet — about how the proposals will translate into practice. The paper is heavy on rhetoric and also trumpets the government’s achievements in several areas it did foreshadow in the campaign: a ban on “ambulance bypass”, for instance. And a lot of small operational initiatives are interspersed with vague generalities about how the promised land will be reached.
One worthy aspect is the emphasis on transparency. It will indeed be necessary to judge the strategy by patient outcomes and other meaningful indicators.
But there are at least two red flags that should be flying. Firstly, the call for streamlined awards and agreements. It’s true the award and classification structures in Queensland Health are complex and unwieldy; this was one of the causes of the payroll debacle. Work has been done in the past on a more logical structure, including workforce reform, which many would welcome. But there’s little indication that a competency-based approach to the scope of practice has really been thought through.
There certainly is reason to believe reducing pay rates and conditions might be part of the picture, particularly when considering remuneration is normally lower in the private sector for nurses, allied health professionals and other health workers. The government has also weakened employee protections in legislation rushed through Parliament last year. Whether a further drift of doctors to private practice will be a result is a legitimate question.
Secondly, the paper emphasises — rightly — accountability and results. But overseas experience shows outsourcing often cuts standards, and contract and performance management eats up resources that might more optimally be directed to service provision. Problems of co-ordination are also rife, with contractualism replacing co-operative management. Add contracts for service delivery to the mix of local hospital boards’ responsibility for purchasing services and you have a recipe for the sorts of bureaucratic confusion and empire building the blueprint rejects.
Something might have been learnt from outsourcing the design of the payroll system.
Costello is now trumpeting the audit report as a template for other states and a federal Liberal-National Coalition government to follow. Even if that’s blowing in the wind (and it probably isn’t), we deserve better than to be told by Springborg to “get on the train or get under it”. Change of this magnitude ought not to be done by fiat. But the train seems to have left the station.
*Dr Mark Bahnisch is a fellow of the Centre for Policy Development and a postdoctoral research fellow in the Centre Medical Education Research and Scholarship, School of Medicine at the University of Queensland