Rural

By Dr David Rivett

The Rudd government has released an outline of its proposed way forward for our nation's hospitals. It is a ‘high level' document that does not provide enough clear-cut details of the support frameworks needed for rural hospitals and rural patients.

• A single funder has not arisen but a 60% or less (Federal) and 40% or more (State) split, the variance being because the States will have to pick up the tab for any spend over 40% of the determined ‘efficient fee". And, even if the Feds swear blind that their 60% is to be uncapped, it is unlikely the States, now to be even poorer from their GST sacrifice, will do likewise. Any capped system is totally unacceptable and will perpetuate rationing and denial of both access to care and patient choice as to where that care should be best provided.
• No additional funding has been announced as yet. Efficiency gains will, we are told, be the key to additional service provision. Well, pigs might fly, some might add. However, the Victorian experience is widely accepted as evidence that casemix can drive efficiency in large urban centres. As an additional benefit, it has been shown to improve record-keeping substantively.
• Regional governance bodies will be funded entirely from existing State government health department budgets. This begs the question whether or not the regional governance bodies will have the flexibility to be formulated with the best demographic modelling, which must involve straddling State and Territory boundaries. Any model that does not do so is plainly not focussed on best serving population needs. Just looking at New South Wales alone, its southern towns naturally drain to Melbourne tertiary care centres, its northern towns to Brisbane and its southeast to Canberra.
• Casemix funding with an independent umpire deciding the efficient fee will be a key component. We know that a uniform formula, if applied nationwide, would leave smaller rural hospitals worse off.

One look says that in efficient major hospitals in large urban centres such change may drive efficiencies, but in the bush it just is not going to work. Time-poor rural docs will be about as enthusiastic about swatting up their DRGs as they would be in fishing brown snakes out from under their beds with their bare hands.

Casemix funding has been tried in rural Victoria, failed and a return to block grant funding made. This is not a reason simply to dismiss the planned changes, but it is still a warning that must be heeded. Special allowances will need to be made.

Rural hospitals must have their very substantive patient transport costs quarantined from any funding agreement, casemix or block grant.

Allowances must be made for the lack of immediate access to sophisticated diagnostic facilities in regional and rural hospitals, the higher costs of attracting medical and allied health staff to rural postings and the swings of workload that go with providing care to smaller population groups.

Only if these dilemmas can be addressed robustly and with a clear concomitant commitment to address the chronic under-funding of rural care can I be swayed to enthusiasm for the changes that lie ahead.

The Prime Minister has said that the Government will ensure that rural communities are not disadvantaged by the planned changes and that new funding arrangements will take into account the needs of rural Australians. We can't afford to get these changes wrong and the Government will clearly need to work closely with rural doctors if its hospitals plan is to deliver better health care in rural areas.