Greg Hunt’s final act against universal healthcare

Low down in the latest budget was a decision that will fundamentally change the availability of low-cost, safe healthcare. In a single line item, the Morrison government defunded Australia’s national prescribing service, NPS MedicineWise (NPS).

The move came without announcement. There was no warning or consultation with the organisation – or with any other medical bodies. It was a fait accompli.

From the first of January next year, NPS will lose stewardship of the code that ensures prescribers, pharmacists and patients are well informed about medications and use them properly – the quality use of medicines (QUM) strategy.

Two weeks after this announcement, on the day Scott Morrison called the election, the Department of Health quietly announced that it had invited Dr Peter Boxall to chair a review into the health technology assessment (HTA) processes. Boxall is a former senior public servant renowned in policy and medical circles for his attempts to abolish the Pharmaceutical Benefits Scheme (PBS)during the Howard and Abbott governments.

An HTA decides what medications and therapies are subsidised by the PBS. The review is the result of a formal agreement between the government and Medicines Australia, the peak body representing the research-based medicines industry, which agreed to give up about $2 billion in statutory price cuts over five years in return for an audit of how Australia applies the HTA.

Taken together, these decisions may do more damage to our universal healthcare system than any changes to bulk-billing.

Both major doctors’ groups – the Australian Medical Association and the Royal Australian College of General Practitioners – say the NPS decision was “a complete surprise”. They have expressed disappointment and concern about the potential discontinuation of a “reliable, independent, evidence-based resource for doctors, clinicians, and patients”.

“We weren’t consulted,” says NPS chief executive Katherine Burchfield. “We found out on budget night with everyone else. The department indicated it was a decision of government.”

The work of the NPS, which is an independent organisation previously funded by the Department of Health, will now be subsumed by the Australian Commission on Safety and Quality in Health Care (ACSQHC). While she respects the “really great work” of the ACSQHC, Burchfield says the commission is not structured to deliver the same kind of independent, evidence-based support that NPS MedicineWise has provided for decades to frontline health professionals and consumers, actively working to improve decisions about use of medicines, and ultimately better health and economic outcomes for Australians.

“It’s not something I believe the commission can replicate,” she says. “I think the sector is going to lose a really valuable resource, primarily hitting primary and aged care.”

Medicines Australia has not formed a view on whether NPS should be retained. The group’s chief executive, Elizabeth de Somer, is calling for the reinstatement of a governance framework that includes QUM measures whose methodologies account for the broader economic benefits of particular health treatments when assessing value for money.

Prior to its defunding, NPS received about $25.9 million a year, a significant reduction from the more than $40 million it was receiving about five years ago.

In a 2018 review, the former chair of the Pharmaceutical Benefits Advisory Committee, Professor Lloyd Sansom, found NPS had inappropriately used its Quality Use of Medicines grant to fund a commercial arm, called VentureWise, which was subsequently shut down. NPS addressed a set of 37 recommendations and refreshed its board. Burchfield is the new chief executive, having replaced adjunct associate professor Steven Morris five months ago. While the review criticised potential conflicts of interest created by the now-defunct VentureWise, it also found NPS MedicineWise delivered high-quality work and should continue in its role as a national QUM steward.

“That’s one of the things we’re struggling with,” Burchfield says. “It felt like we had responded really well to the review. We implemented its recommendations, we had strong foundations, were delivering well, and were working on a new strategic plan … So it really knocked me sideways when this announcement came out.”

Dr Mike Freelander, a paediatrician and Labor member of the house of representatives standing committee on health, aged care and sport, says he and his colleagues were “taken aback” by the decision, which he says is an attempt to “downgrade its significance” and “reduce its power”.

“It would be much better to continue funding NPS as a separate entity, because it’s used by virtually all the different stakeholders I know of, myself included – doctors, dentists, pharmacists. It has widespread respect. I just hope it can maintain its prominence in the face of the clinicians who are using it actively.”

A spokesperson for outgoing Health minister Greg Hunt said that the 2022-23 budget measure includes an additional $3.9 million investment in QUM activities, and that the changes will make it easier for ACSQHC to drive quality and safety improvements related to use of medicines and diagnostics across the health system.

“The activities will be complemented by competitive grant and procurement processes to fund QUM diagnostic educational activities for both health professionals and consumers, which will receive $10 million in annual grants, to support the optimal use of therapeutics and diagnostics, as well as promote innovation and value for money.”

The decision to shut down NPS comes at the same time as the proposed appointment of Peter Boxall to chair the HTA review.

Boxall is a former head of both the departments of Finance and Employment, working under John Howard and Tony Abbott respectively. He reportedly argued for “the wholesale deconstruction of the PBS” as one of the five commissioners overseeing the 2014 National Commission of Audit.

The PBS does more than administer funded access to medicines; it provides a system of wholesale distribution to a network of 5500 community and hospital pharmacists.

“That’s why the system needs to be protected,” says Paul Cross, who was a ministerial adviser to two Australian health ministers under John Howard. The cumulative effect of defunding NPS MedicineWise and the appointment of “a PBS critic” to the HTA review means many Australians will lose access to medicines at a time when millions with complex or chronic illnesses are already paying too much, Cross says.

Raphaella Kathryn Crosby, founder of Migraines Australia, says Australia’s current system of listing medications on the PBS “doesn’t work for anyone; not for doctors, pharmacists, or patients”.

The system is so dysfunctional that health system reform advocacy body Better Access Australia says it takes an average of 820 days for a medication to be listed on the PBS after it has been registered with the Therapeutic Goods Administration. In their submission to a recent parliamentary inquiry into this system, the body detailed how it was easier to get a hip replacement than a new medication in Australia’s public health system.

“It is deeply problematic that someone with a history of opposing public health programs is chairing an HTA review that relates to the second-oldest public health program in the world,” Cross says.

Cross says he witnessed “first-hand” Boxall’s commitment to diminishing the government’s role in public health when he “took a crack” at defunding the PBS as Finance secretary in the 1990s, and again in 2014 as a commissioner on the National Commission of Audit.

“They basically said the government should remove itself from the provision of medicines by introducing a New Zealand-type model, an absolutely dreadful dog-eat-dog market-based system where it takes up to 15 years to get a new drug funded. And now he’s reappeared in this HTA review.”

Boxall did not respond to requests for comment. Medicines Australia’s Elizabeth de Somer wouldn’t be drawn on the potential captain’s pick. She says the organisation “worked hard to ensure there was an independent chair” and that “the person who fills that criteria needs to have a very strong track record of support for public health programs”.

While Labor has officially condemned the appointment, a spokesperson for Minister Hunt said the government consulted Medicines Australia on the HTA review.