Better Choices Better Health Final Report of the South Australian Generational Health Review April 2003 Select in toolbar NAVIGATION TIPS for navigation Clicking on the Table of Contents entries will take you to the relevant section Clicking on footnotes will direct you to the footnote listing ... ... then clicking on the same footnote will take you back Clicking on table and figure references will direct you to the appropriate diagram Selecting Hyperlinks will direct you to that web address Please note – links may expire over time Generational Health Review ING Building Level 4 45 Pirie Street ADELAIDE SA 5000 PO Box 347 Rundle Mall Post Office ADELAIDE SA 5000 Hotline: 1800 090 800 Facsimile: 8207 1621 The Hon Lea Stevens, MP Minister for Health GPO Box 2000 ADELAIDE SA 5001 Dear Minister It is with pleasure that I submit to you the Generational Health Review’s report on South Australia’s public health system. The report provides the framework to meet the health needs of South Australians today and into the next generation. Significant systemic reform is recommended. I am confident that implementation of the Report’s recommendations will continue to improve the health status of all South Australian and ensure a safe, efficient and effective health care system into the future. I wish you success in the report’s implementation. JOHN MENADUE AO CHAIR GENERATIONAL HEALTH REVIEW April 2003 Website: www.dhs.sa.gov.au/generational-health-review E-mail: [email protected] BetterChoices BetterHealth i FOREWORD The Government appointed this review because it correctly recognised the need for change in Health in South Australia. What I have seen and heard over the last nine months across the state has convinced me that the case for change is even stronger than I expected, or perhaps even more than the government anticipated. In chairing this review, several impressions or events stood out. The first was the scepticism we encountered that ours might be just another review that went the same way as others over the past 30 years — nowhere — because vested interests and ‘playing politics’ with health beat back necessary changes. Health is so political. That is why we have actively promoted public understanding and support for changes in this review. We have tried to make it an open and inclusive process. Change can only be achieved if there is a broad constituency of support. That constituency carries with it a moral authority. This report offers not only the potential for a long- term sustainable health service but also, perhaps even more importantly, it can enhance public confidence in open and inclusive public processes. What has to be done is pretty clear. There are really few surprises in this report. Not just in South Australia, but in other states and overseas, the importance of primary care being the foundation of a strong health service is widely accepted. Health takes 24% of the state budget. Getting efficiency and equity in health is important, not only for the health of South Australians but also for the state’s economic future, as is well set out in its Economic Plan. It is clearly unsustainable for South Australia, with 12% lower per capita incomes than the rest of Australia, to spend 4% more on health with no discernibly better health outcomes. The great strength of the South Australian health system is the dedication of thousands of very professional people. The other side of that coin, however, is that many of the people have worked in the health system all their lives and are reluctant to change. They know no other system. That is why the workforce is compartmentalised in training and operations, and why restrictive work practices, demarcation and denial of career opportunities, particularly for nurses, abound. Building in new people, new ideas, new attitudes, particularly in implementation and change management, is essential. The second striking impression I gained was the implicit view in some quarters that SA has unlimited health dollars. So we have continual pressure and demands on the system for better equipment, more drugs, more beds and more surgery. These pressures and services are all defensible and probably beneficial on their own merits, but they can be and often are at the expense of Aboriginal health, mental health and early intervention to help children who are the subject of abuse. These are the areas that the community gives priority to — if and when it is consulted. Even if the government doubled the numbers of hospital beds they would quickly be filled, with further demands for new beds. Hospitals are like the family refrigerator — they will always be full, regardless of whether the refrigerator is large or small. Priorities have to be set and choices made. So often, at present, the powerful in the health service pre-empt the dollars. ii BetterChoices BetterHealth We all have different views and values on where priorities should lie. What we need is transparency and real community participation that has all interests and views represented at the table when health dollars are allocated. We can’t have all we want in health or in education or in transport. Governments need to persuade the community to this view. It should not be hard, for we know that the health budget is like the family budget — with limited incomes, choices have to be made. If governments ignore this critical issue, they will always be on the defensive over every new demand. It is also unreasonable for hard-pressed and dedicated staff to be subject to unrelenting demands and pressures, when the real problem is a lack of frankness as to what the health system can reasonably be expected to provide. Australians are great hospital users, about 50% above Canadian rates and 30% above USA rates. South Australia is even more hospital-centric with hospital utilisation 15% above the national average. South Australia spends 67% of its health budget on hospitals. Many patients could be better treated outside hospitals — those with chronic illness, the mentally ill, and the aged — if the services were available. The autonomy and dignity of patients is best secured when they are treated in the home or as close to their home as possible. That is where our report clearly points — to primary care in the community. Thirdly, we were consistently reminded of poor ‘governance’, with over 70 statutory hospital and health unit boards in SA looking after their own territory. That is what the legislation says they should do. They are expected to manage and promote their own services, often at the expense of an integrated health service. Governance is a ‘crunch’ issue where, in my view, good public policy and sectional interests collide. It results in duplication and fragmentation of care. Many clinicians also told us that the present governance arrangements result in serious concerns about quality and standards. With good governance and funding distributed on a population basis, we will be in a strong position to remove wasteful duplication and make better decisions about the whole spectrum of health care — how much of our health dollar should go to hospitals and how much to primary care, mental health, Aboriginal health and family health. Otherwise primary care and public health will remain the poor relation. We will keep buying expensive ambulances for the bottom of the cliff when we should be building stronger handrails at the top. But good regional governance structures alone will not be sufficient. There will also need to be wise decisions about the people governments appoint to regional boards and the respective responsibilities and accountabilities not only of boards, but ministers and CEs. Fourthly, it became clear to me that present governance arrangements are a real barrier to effective community participation. Many boards represent the interests of the people within the health unit — but not necessarily the community. Yet community participation is essential so that good choices are made at state, community and personal level. Fewer boards must be associated with greater community participation. Relevant information must be shared and processes established so that the community can really participate in decisions — whether more health dollars should be spent on equipment or early intervention to protect children; or more surgery at the expense of the transport of Aborigines to a health unit; or keeping an obstetrics unit open in an area of declining population at the expense of care for the aged. We are proposing a substantial improvement in community participation in the health system. Every service or business needs to be continually called back to its main purpose — in the case of South Australia’s public health service, it is surely to serve the health needs of the whole population rather than the medicalised and institutional focus it presently has. BetterChoices BetterHealth iii Finally, the most searing part of my work in this review was meeting with Aboriginal people. An Aboriginal woman elder said to me that ‘in talking to our young people about health, they say to me, “what is the point of being healthy”’. I will never forget that. Their prospects are so bleak and their self-esteem so low. Spirits need binding as much as bodies. We have a national emergency in Aboriginal health. If all Australians had the same health status as Aboriginal people we would rank 140 in the world, alongside Bangladesh. It is a disgraceful story. I don’t think it is because most people don’t care. I think it is because we don’t know what to do. We must not lose heart and hope. It is in that spirit that we recommend the State Government review the level of investment in programs addressing the quality of life of Aboriginal people and changes in the way services are delivered, with greater emphasis on community, kinship, family and social connectedness.