1. New Approaches, New Institutions? A National Symposium Federalism & Regionalism in Australia Reconceiving Federal-State- Regional Relations in Health Andrew Podger 8 May 2006

2. Federalism & Regionalism in Australia Subsidiarity Principle Power should be devolved to the lowest level of government where there is shared community interest Reference: Productivity Commission 1998

3. Federalism & Regionalism in Australia Pragmatic Approaches Control Influence Appreciate Reference: Smith 1992

4. Federalism & Regionalism in Australia Drivers of Horizontal cf Vertical Management Increasingly demanding citizens New information and communications technologies Continuing pressure on budgets Experimentation with new ways to deliver services Complexity of social problems Reference: Lindquist, 2000

5. Federalism & Regionalism in Australia Risks with Horizontal Approaches Costly and time consuming Competing political and community agendas can undermine objectives May not be preferred for dealing with routine, straightforward issues Reference: Management Advisory Committee, 2004

6. Federalism & Regionalism in Australia Key Aspects of ‘Connected Government’ Structures and Processes Culture and Capability Information Management and Infrastructure Budget and Accountability Framework External Engagement Managing Crises Reference: Management Advisory Committee, 2004

7. Federalism & Regionalism in Australia Matching Whole-of-Government Structures to Different Tasks Policy Devlt Program Design / Review Program Management / Service Delivery Cross Jurisdiction / Cross Sector Crisis Manage- ment IDC HMLMH-M Taskforce HHHH-MM-L Joint team H-MM-MMM-LL Agency arrangements LLHM-LL Frontier agencies HHHLL Reference: Management Advisory Committee, 2004

8. Federalism & Regionalism in Australia Community Engagement Issues Two-way exercise Need to analyse as well as canvass views Relevance to informed decision-making and effective delivery Need for ‘clout on the ground’ Balancing open consultation with need for confidentiality Balancing open consultation with the imperative to act Need for ongoing understanding (“appreciation”) to facilitate capacity to respond (“influence” and “control”) Reference: Management Advisory Committee, 2004

9. Federalism & Regionalism in Australia Possible Implications for Federal Relationships Applicability of Subsidiarity Principle to ongoing responsibilities Need nonetheless for ongoing consultative machinery to ensure “appreciation” as well as management of boundaries Relevance of whole-of-government to complex project management, particularly crisis management Political pressure for ‘joined-up’ solutions (managing media, interest groups) Importance of capacity at local/regional level

10. Federalism & Regionalism in Australia Australian Health System National interests - –equity policy –nature of many health industries –economies of scale Lower-level interests - most service delivery Current funding – two-thirds of public spending is C’wlth

11. Federalism & Regionalism in Australia Changes in Mortality Rates 1907 to 2000 5–49 50-64 65-79 80+ 0–4 0 200 400 600 800 1,000 1,200 190719702000 Year Mortality rate (deaths/100,000 people) 80+ 65-79 50-64 5–49 0–4 Many fewer people dying under age 50 Many more people living over 50 More people living until very old (80+) Fewer people dying from 50 to 79 Age at death

12. Federalism & Regionalism in Australia Key Issues for Australia Lack of patient-oriented care that crosses service boundaries with funds following patients. Allocative inefficiency with allocation between different types of care not achieving best health outcomes possible. Poor use of information technology to reduce costs, support continuity of care, better identify patients at risk, support greater safety and provide more patient control. Poor use of competition with uneven playing field in acute care, reluctance to use competition to ensure best access to medical services at reasonable cost, and resulting in less choice. Workforce supply constraints, and increasing demand.

13. Federalism & Regionalism in Australia Case for a Single Funder Would facilitate More integrated and comprehensive planning Enhanced coordination of service delivery Improved value for money Seamless, patient-oriented services An end to cost and blame shifting

14. Federalism & Regionalism in Australia Single funder options Commonwealth States Commonwealth/State pools Managed Competition (Scotton)

15. Federalism & Regionalism in Australia Case for Commonwealth as Single Funder Importance of equity in Australian health system National character of most health industries Certain economies of scale Longer-term political momentum towards national approach Administrative feasibility Essential step for those preferring Managed Competition BUT: requires regional/local involvement in purchasing and providing

16. Federalism & Regionalism in Australia What should a Commonwealth funded Public Health System look like?

17. Federalism & Regionalism in Australia Essential Attributes of a Successful Commonwealth-funded System Separation of funding, purchasing and providing National funding, and national principles for purchasing Regional purchasing arrangements (re-allocating resources across and within regions) Local involvement in service delivery Strengthened primary care, including increased funding for Indigenous health services Further investment in preventive care Continued priority for e-health Strengthened/revised cost control and competition measures