JOHN DWYER The “Canterbury Model” in health

 

Australia’s health care system needs restructuring to see it meet the contemporary and future needs of its citizens. A consensus view has emerged which argues that a long term (perhaps ten year ) plan is required for the full implementation of the desired changes. The status quo is unacceptable as the system is not resourced or organised to improve the health of the nation and is not cost effective. Its also unfair as Increasingly personal financial well-being, not need, is determining health outcomes.As a Federal election is focussing our attention on the health care initiatives envisioned by our politicians do they address the need for structural reforms?

Well, billions of dollars are being promised to address a number of inadequacies in our health system. The Coalition is largely emphasising how many medicines it has added to the Pharmaceutical Benefits Scheme (PBS) and its plan to continue to add more, a related program will reduce the “out of pocket” expenses for prescription medicines for those who need a lot of medication. The Coalition plans to use the Medical Research Future Fund to provide more mental health services with an emphasis on suicide prevention. They will also provide dollars for GPs to provide, via electronic communications, a number of services to older ( presumably IT savvy) patients.

Labor’s plan has many more generous initiatives including the provision of 50% of the funding needed for our public hospitals, lots of money for new and upgraded hospitals, the restoration of out-patient services supplied by specialists in public hospitals, more than 2 billion dollars to reduce the cost of cancer services and a dental care scheme within Medicare for seniors. All of the above would be welcome but they represent the perpetuation of a “piecemeal” approach to health care rather than a restructuring of the health system itself to make it more cost effective and correct its biggest weakness; the failure to adequately address the prevention of preventable diseases.

At least eleven OECD countries are tackling health care restructuring. Many interested in structural reforms for health care in Australia have looked carefully at what other countries are doing, noting successes and failures, all providing valuable lessons. It is frustrating that health bureaucracies and their ministers, as well as some of our major health professional organisations, seem disinterested in what is happening in this space outside of our big island! In my own case a few trips across the Tasman to look at structural reforms in New Zealand have informed a number of my views and advocacy.

My recent suggestion herein (P & I, March 14) that we should be making a mighty and informed effort to reduce the number of Australians who need hospital care rather than just building more hospitals, was supported by economists in an article published recently in “The Conversation” (April 9) entitled “More hospitals will not cure Australia’s ailing health care system”. They noted the relevant success in New Zealand of efforts to do just that. They reported on “The Canterbury Model”, named after the Canterbury region on New Zealand’s South Island (which includes Christchurch). The regional health authority created a “one system, one budget” approach replacing separate budgets for GPs and hospitals, This led to new programs that weren’t possible under the old system such as Healthpathways, which brought together GPs and specialists to decide on treatment programs for individual patients. They noted that in working to make hospitals the last resort, more time and resources have gone to GPs. There are now more 24-hour clinics, for example, making it easier to get treated by a local doctor when needed.

“A study of the Canterbury system showed that between 2007 and 2014 the number of people being hospitalised declined from 6.59 to 5.83 per 1,000. While an 11% decline may not seem huge, it represents a significant financial saving, given the high cost of hospitalisation.
Canterbury shows what can be achieved by rethinking how health care funding works. Australia has the opportunity to reimagine its health care system in a similar way.
New hospitals get a lot of attention. Politicians can point to them as concrete evidence they’re doing something to help. But emphasising hospitals as the most important part of the health system comes at a cost, and will only get more so as the population ages.
It’s time to discuss alternatives. Putting more resources into prevention and people is the right medicine for our future health needs”.

The major structural changes I believe we need can be summarised but are detailed, (ad nauseam some might say) in my P & I contributions in recent years. An Australian Health Care Reform Commission, reporting to and responding to a mandate provided by the COAG Health Council drives a ten year reform plan. Eventually it morphs into the Australian Health Commission and is the single fund holder of all the health dollars provide for our public health system. It establishes a series of Regional Health Authorities (RHAs) with each being funded by a resource distribution formula based on area need as well as population numbers. RHAs in turn establish local health networks which fund integrated hospital, community and primary care through contracts with providers of these services, including private hospitals. The preferred model for primary care involves the establishment of “Medical Homes”. Australians would enrol in a Medical Home resourced with an array of different health professionals remunerated by a blend of contracted and fee for service payments. One’s Medical Home provides advice on prevention, continuity of care, early diagnosis and treatment of problems that could cause chronic illness, in house team care of chronic disease and care in the community of many currently sent to hospital. Medical Homes are serviced by Primary Health Care Organisations (PHOs). They run 24 hour services and care for many patients who would otherwise be sent to hospital (e.g., an acute asthma attack) . They also help their satellite practices with continuing education, IT services, measurement of outcome data and advice on usage of new drugs.

My enthusiasm for regional health authorities, the practical and psychological importance or patients “enrolling” in a medical home, the supportive role off Primary Health Organisations and the advantages of a single funder for health services was generated by looking at structural reform efforts in New Zealand and a number of other countries.

Back to our election climate. No major structural reforms are detailed by either Labor or the Coalition but there is reason to be enthusiastic about Labor’s promise to establish a Health Care Reform Commission with an initial challenge to improve Primary Care. The details will be all important but if successfully implemented this could be by far the most important change to emerge from the current election promises. There is a world of health care initiatives out there that we should be learning from and indeed contributing to.

Professor John Dwyer , Emeritus Professor of Medicine UNSW, was a foundation member of the Goulston Health Reform Group and Founder of the Australian Healthcare Reform Alliance (AHCRA).

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One Response to JOHN DWYER The “Canterbury Model” in health

  1. Michael D. Breen says:

    “…the failure to adequately address the prevention of preventable diseases.” Instead each political party tries to impress by saying they are spending more on this or that aspect of treatment. Well you would have to as the population grows, wouldn’t you? So following this excellent article on better health what else? How can we punters support a preventative system where more responsibility is in our hands and the superstitious dependencies of the western medical model of illness are challenged? John argues along financial lines but are there other more cogent arguments? Like people feeling better. People knowing more about how to be healthy. Like challenging the supply of products which impair health. It seems to me that there is huge wastage in the current system. Internecine arguments between various disciplines and casts, pecking order layers in the system will not necessarily be fixed by increasing funds.
    What incentive is there for groups which have to work together to work in more preventative ways? Doctors, whether they like to admit it or not are clerics. Are they likely to give up their power lightly? Administrators seem to have increased in numbers across all areas of the health system? Are all their positions necessary? Sure the system needs a big rethink and this article is great, but does even this article go far enough?

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