What’s new is old is new again in budget

11 minute read

GPs probably shouldn’t be that upset that the funding to come next week is mostly three-card trickery.

It’s generally not a good idea to second guess what’s going to be in the budget in any big way in an editorial just a few days before the budget comes out.

So let’s give it go.

On spec, if the government already promised GPs $750m through the Strengthening Medicare taskforce, and then came out, as Prime Minister Anthony Albanese did early this week, and said they were upping it to $2.2 billion, you are going to think that’s another $1.45bn, right?

And we have a government another step more seriously committed to fixing what is very obviously an immediate and serious crisis in our GP sector?

Well, no. But maybe yes if you really think about it.

Of that new $1.45bn we can only see about $250m that might actually be new dollars.

The biggest three-card trick is the digital health announcement of $950m, which Health Minister Mark Butler let go at his Press Club appearance on Tuesday.

It seems almost certain that this is all money that was simply not in the budget forward estimates by the previous government: funding for the Australian Digital Health Agency (ADHA) and for the somewhat controversial My Health Record (MHR).

We knew more than a year ago that this money wasn’t in the forward estimates and had to be put back in some way or another.

Butler had to be dramatic about it, though, and spruik it as some sort of landmark announcement: “On July 1, My Health Record was due to be switched off. Unplugged. Gone. Time for doctors everywhere to dust off that 1980s fax machine!”

It was a nice touch, but 100% spin.

No one ever contemplated turning off the My Health Record – if anyone did, it would have been stupid, both practically and politically, even though it’d make little actual difference.

Turning off the fax machines that practices still use (most do) , on the other hand, would have had a big impact (which makes Butler’s theatrics almost perfectly ironic for what is going on).

But odds on Butler knows all this now.

He appears to be playing a long and politically sensible game (I hope he is).

He certainly wasn’t very complimentary of the poor old MHR (and indirectly the ADHA).

“What a waste of time and money. For patients and for the health system.”

OK, I’m putting this quote just a little out of context but not much and it sums a lot up (Butler’s whole speech is here if you want to check).

It’s important because if we’ve spent $2.2bn trying to make things better for patients and the health system and so far we’ve wasted most of it, he’s put himself and the government firmly on notice not to waste the next tranche.

When I first realised this $950m was just old money being repurposed as new money I was pretty annoyed and started writing an op ed which wasn’t all that flattering of Butler and Co.

But while attending our Wild Health leaders summit in Canberra this week (lots of good stuff coming out of that) I ran into a person who is probably our most important digital health mind and talent, who pulled me up immediately on my assessment of the $950m by saying: “Jeremy, $950m is a hell of a lot of money … if you spend it the right way”

Funny how much clarity a simple bit of logic like this can provide.

Having wasted a lot of the last $2.2 billion in digital health, what if a determined Butler and Co. don’t waste the next $950m?

Those people who are reading below the political waterline and who have been either complacent or complicit in any way in wasting all that money should maybe start to worry (and perhaps even start updating their CVs).

The practical politics of all this is that the government hasn’t got much money to throw around and while it had to keep funding the ADHA and the MHR it’s still a lot of money it decided to put back. They could have put back less, and not said the MHR was a mess.

If they are going to spend this $950m wisely though it can’t be business as usual for our mostly MIA ADHA, or the MHR, and that, at least in the medium term, is hugely important to the future of GPs and the entire healthcare system in this country.

Every GP is trapped on a tech desert island, isolated from the rest of the system by 1980s-style patient management technology that previous governments and the ADHA has allowed them to persist with for 30 years.

If GPs are going to be rescued individually from their desert islands to create connected care teams, work in rural and remote areas as integrated seamless parts of a regional and community care set up with local hospitals, compete with the cynical business models of groups like Pilot, Mosh, Instant Scripts and Juniper, and most importantly, work far more intimately and transparently with their patients, they need to be able to share data properly.

They are going to need a lot of help (and money) to get to this point.

Whether Butler and Co. realised that this week or not, when they re-committed the $950m to digital health, that’s what they were committing to.

If GPs aren’t moving viably on this journey within at least one or two years, the government will have failed on something fundamental to the future of the healthcare system and the GP profession.

Without any doubt, a part of this journey must be that Butler re-creates the ADHA as a functional and productive organisation with a better plan and dramatically improved performance to the new plan.

If you read this National Digital Health Strategy from the Agency, produced around 2019, every single major objective has been missed and by a very wide margin (check out the sections in orange under each major objective of “What will be delivered by 2022”).

This is very obviously not good enough for doctors and the healthcare system.

Again, you have to suspect that Butler knows this now, and is playing his political cards close to his chest.

If he had gone the path of switching off the MHR and closing down the Australian Digital Health Agency, can you imagine the mess he would have been immediately mired in?

No, it’s much smarter putting that money back, working with what you have, and creating the change from within as you go. No public drama to deal with and low visibility as far as parliament goes.

The more sophisticated followers of the My Health Record may still wonder how a technology that had its day more than 10 years ago should still be persisted with, not withstanding?

After all, if we look around to countries that are well down the path to cracking the idea of “data liquidity” (effective seamless sharing of data between providers and patients) in their healthcare systems, none of them use a centralised database model, where you have to get everything in (taking time away from healthcare professionals) and then get it out somehow.

It’s a very good question.

Almost certainly the future of health system data liquidity, and rescuing GPs from their digital desert islands, is going to be not a centralised model but a distributed one, like what the US, Denmark, Israel and a few other advanced healthcare economies have. They’ve forced their software platform vendors to build standard modern data sharing protocols around or into their platforms so all providers can share data in real time from anywhere properly.

Very different to the MHR.

When and if we get to this state (it will take us a long time because we are starting more than 10 years behind) our healthcare system will be enabled to be radically transformed:

  • data will be available to effectively fund value-based and outcomes-based care where that makes sense,
  • GPs will be able to connect and work in teams with allied care and local regional hospitals, and
  • patients will have access to what data they want when they want it so their relationship with our healthcare system (and their GPs) will be transformed.

Even in the brave new world I’ve described above, the MHR will be a very useful data source, albeit it will be one of thousands connected to providers and patients all over the country.

Maybe we should be thinking of the MHR as brand now not as an actual thing. That brand could be say: “a patient centric healthcare platform powered by data liquidity”

In that brand both a modern distributed model can be built and the old MHR can still live.

As much as I’d love this idea to be mine, it isn’t.

It was an idea put to the interoperability panel of the Wild Health leaders summit by that same digital health genius who told me (over a late-night beer) that I needed to reframe how I saw the $950m of digital health money that was put back into the budget.

The idea goes like this.

The objective of the MHR was always good. It was in essence patient empowerment over their health data through creating data liquidity – the ability of meaningful data to move seamlessly across the system in real time.

The product and the execution was just never right.

So stick with the objective, and the “political brand”, but change the execution and the product over time.

It’s a bit, don’t rock the boat just make your way to the wheelhouse and quietly start steering it in a completely new direction.

So that’s $950m of the $2.2 billion.

Not new money, but it’s a lot of money and if applied in the right way it’s going to be good for GPs and their patients.

There’s still quite a bit left after the $950m which is new after the initial $750m: if my math is right here, $500m.

I have a funny feeling that $250m is just extending the $750m originally promised for Strengthening Medicare, so it’s all in the forward estimates: that is, the initial $750m was for three years, so let’s get the paperwork right and make it go the full four years of the forward estimates.

That’s a pretty loose guess, but if I’m right that still leaves a cool new $250m, which is a pretty good chunk of new money (albeit, it’s not $2.2 billion).

MyMedicare (isn’t that a much better brand-aligned name than voluntary patient enrolment?) is a complete unknown because no one is enrolled yet. But I guess we will find out this coming week how many patients the government feels will get enrolled in the next four years, and how much more money that is going to provide to a typical GP practice.

The total value is likely to be something well under $250m though because surely the government has to give some nod to the immediate crisis and the fact that rebates rises since 2010 amount to a 20% pay cut for GPs (can you imagine cutting your staff’s pay by 2% each year for more than 10 years and having a business left?).

They need to leave some for the other two initiatives they have announced: getting more practices nurses into practices and funding some more after-hours activity.

The more you get, the more you suddenly realise you need and the more you want, is one way GPs might look at next week’s budget, if they are indeed even looking.

Net, GPs don’t look they are going to get much more than the $750m originally promised to them in the election on a per annum basis.

But they are going to get some, and if you believe Butler’s rhetoric on digital health, and the analysis presented here of what might actually be going on beneath the political fun and games, then the government is thinking a lot about primary care and the future of the system.

I think we all would agree that the $11bn to be spent on pay increases for aged care workers is a good thing.

But it sort of gives you a pecking order perspective for where the government’s head is really at in terms of the GP crisis, which is probably still not where it should be.

Lower your expectations and you might be pleasantly surprised.

You aren’t getting $2.2bn in rebate increases for sure, but you aren’t getting nothing either.

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