Pearls and Irritations

Introduction by Croakey: So much of our day-to-day attention is focused on the problems facing healthcare systems now. Lifting our gaze to envision the likely future challenges – say in 2050 – can help set a course forward.

In the first of a two-part series, Croakey editor Jennifer Doggett gazes into a health policy crystal ball, providing advice to the policymakers of today around five key themes: health financing; workforce; technology; climate and planetary health; and patient and community involvement in healthcare.

This article is published in collaboration with cohealth, a not-for-profit community health organisation, as part of their Health Equity Champion membership of the Croakey Health Media funding consortium. The series is also available in this Caring for our future e-publication.

Jennifer Doggett writes:

For three years on the frontline of a global pandemic, our health system has been focused on meeting the short-term demands of this rapidly changing crisis.

Time and energy for long-term planning have been scarce, but this is critical now in order to set our health system up to meet the demands of the future.

It is impossible to predict exactly what these will be but we certainly know enough about key trends impacting our health system to make an educated guess about our future population health needs.

As well as planning for these predictable demands, we also need to ensure we are prepared for unlikely but potentially catastrophic events. The COVID-19 pandemic has demonstrated the importance of comprehensive disaster preparedness, which also means addressing health inequities and the social determinants of health.

Thinking about the sort of health system we will need in 2050 can help us make changes now to ensure we are able to meet these future health challenges.

This article draws on the expertise of three senior cohealth leaders: Dr Richard di Natale, cohealth public health adviser, GP and former leader of the Australian Greens; Research Chair, Professor Virginia Lewis; and Dr Kim Webber, former Executive Lead – Strategy, Impact & Development.

As they gaze into the health policy crystal ball, these health leaders make some predictions for the future and provide advice to the policymakers of today about in five key areas: health financing; workforce; technology; climate and planetary health; and patient and community involvement in healthcare.

Financing

In 2050 Medicare, if it still exists, will be almost 70. This would make it an exceptionally long lived government program but this is not unprecedented in the health sector (the Pharmaceutical Benefits Scheme was established in the 1940s and is still going strong).

Compared to the PBS, however, Medicare is a complex program that will be more challenging to evolve to ensure it keeps pace with Australian’s changing healthcare needs. While it remains popular with the community and (at least in name) has bipartisan political support, there are already clear signs that Medicare’s design is not ideal for our current needs.

The structural deficits within Medicare are likely to worsen as the burden of disease continues to tip towards chronic and complex conditions, which require a coordinated, long-term and multidisciplinary approaches to care.

These deficits will be compounded if future governments fail to adequately fund Medicare to deliver on its original vision as a universal health program.

Di Natale describes ongoing under-funding of Medicare as a reflection of a shift in political thinking of healthcare as an individual responsibility rather than governments having a central role. This, he says, risks resulting in a two tier United States-style health system. One example of this approach he cites is the public subsidy of private health insurance.

A challenge for the future will be to maintain the universality and equity of Medicare, and fund it adequately, while also introducing the needed reforms to ensure it keeps pace with changing community needs.

“Future proofing” Medicare, Di Natale suggests, should involve moving towards a single funder for healthcare which would increase efficiency of health spending and avoid incentives currently built into the system that encourage cost shifting between governments and services.

“If something in the health system costs tax payers more but costs one level of government less, they will still do it,” he says.

Di Natale and Webber both argue for a move away from a strictly activity-based, fee-for-service funding system for primary care, towards alternative approaches, including blended payments to incentivise outcomes such as quality of care, patient experience, prevention and health promotion.

Webber also stresses the need to address the geographic inequities inherent in Medicare, which she describes as a system where health financing is driven by the needs of the health workforce rather than those of patients.

“We need to put the dollars where the patients are – not where clinicians are, and this is difficult to do when the bulk of funding for primary healthcare is funnelled through private general practice,” she says.

Webber cites as evidence the failure of Primary Health Networks (PHNs) to make significant changes to the equitable distribution of health services.

Di Natale and Webber both recognise that while regionalised health funding and governance would be the most effective strategy for ensuring a fair allocation of healthcare resources and driving innovation, this will be difficult to achieve due to opposition from the medical profession.

All three experts also agree on the need for reform of health financing to incentivise quality care and outcomes, rather than process and services, but Lewis warns that it can be difficult to ensure incentive payments deliver better care.

“One problem is that for any given incentive program, there is a proportion of the medical profession who will take the payment without changing the service they provide,” she says.

“This means that an incentive might allow good GPs to improve their services but also enable ‘bad’ GPs to make more money without providing any additional care.”

Lewis also describes the complexity of measuring outcomes in primary healthcare, saying that overly simplistic approaches can ignore the factors in primary healthcare that deliver the most value.

“There is a risk in making things all about outcomes,” she says. “Outcomes-based models which work in hospitals are a disaster when applied to community health.”

Lewis explains how in a system with both public and private providers, incentives for particular patient groups or outcomes can lead to cherry-picking by private GPs. This can leave public providers, such as community health services, to pick up the patients who have more complex needs and complicated circumstances which require more time, thus threatening the financial sustainability of services.

“It’s difficult to devise sensible ‘outcomes for core community health activities like health promotion, community development, community engagement, which then devalues them and can lead to funding being withdrawn or becoming so narrow and constrained that people can’t do their jobs,” said Lewis.

“But also it’s very hard to develop a KPI for the work associated with ‘doing’ inter-disciplinary, team-based care,” she said.

These concerns highlight the importance of developing more sophisticated mechanisms for measuring and incentivising quality care and health outcomes, particularly in primary healthcare.

In summary

If these reforms – single funder, regional funding, better ways of measuring outcomes – can be implemented between now and 2030, there is a good chance that Medicare will still exist in 2050 as an equitable and efficient funder of universal healthcare, which supports the provision of high quality, coordinated and multidisciplinary chronic disease prevention and management. Avoiding these issues and bowing to pressure from interest groups to resist reform will result in the further erosion of Medicare due to its ongoing inability to provide effective care for chronic and complex conditions. This in turn will lead to disillusionment within the community as the market provides alternative options for those with means, with Medicare remaining as a safety-net only for the most disadvantaged and ultimately one which is easy for governments to cut when budgets are tight.

Workforce and roles

As our healthcare needs change, so should our health workforce. In practice this has proved to be difficult as professional groups resist changes that they perceive will reduce their power or influence. This means that the way we educate, train and regulate our health workforce has changed little over the past 30 years, despite significant shifts in the burden of disease.

This failure to evolve is one factor contributing to current health workforce challenges, which include widespread workforce shortages, a maldistribution across geographic areas and the under-utilisation of many health professional groups, including nurses and allied health.

These problems have taken decades to develop and cannot be solved in the short-term. Therefore, we need to start planning now if we are to have a health workforce that can meet our needs in coming years.

Webber suggests that establishing a sustainable primary healthcare workforce should be the first goal for workforce reform.

Health financing changes, such as those outlined above, are important to change the current system, which allows specialists to charge increasingly higher fees while GPs remuneration lags behind. Webber says this has made general practice an unattractive career path for many medical students, leading to an overall shortage of GPs with particular impacts on rural, regional and disadvantaged urban areas.

Medicare reform to build more flexibility into primary healthcare funding would support a genuinely multidisciplinary approach and take the pressure off the general practice workforce, thus making this career choice a more attractive option for medical students.

Workforce reforms could also involve breaking down some longstanding professional divides within other health professions, such as between nurses and doctors, or between GPs and specialists.

Webber suggests that one option could be to focus on skills rather than qualifications within the health workforce, with a new approach to health and medical education that is focussed on core minimum level competencies across disciplines.

This would require a new credentialling and regulatory framework, based around competencies and experience rather than professional roles.

Lewis also sees some merit in this type of approach but both she and Webber suggest that the power of unions and professional groups is a barrier to making these changes.

One example Webber gives of changing primary healthcare teams is cohealth’s recent move towards making peer navigators a key role in healthcare teams.

“Peer navigators understand the system and speak the language of both consumers and providers. They are the key people to join up the system, a role we currently expect GPs to perform but which does not usually occur. We can learn how this works from Aboriginal Health Workers here – they are ten years ahead of the rest of the health system.”

Another bold suggestion from Di Natale is to review the way in which we allocate provider numbers, in order to increase the number of doctors in areas of need.

“Clearly, a system that allows for an oversupply of GPs in high income areas with huge gaps in other areas is not the right system,” he says.

Webber, Lewis and Di Natale all nominate the political power of the medical profession as a barrier to progressing workforce reforms like this that would provide more flexibility and better value for consumers, particularly important in rural and regional areas.

Di Natale says some health groups dress up their own self-interest in the guise of patient safety.

“We need to challenge some interest groups and allow sensible, evidence-based reforms that are in the interest of the community, for example, expanding the role of pharmacists to provide some vaccinations,” he says. “Without allowing health professionals to work to their full scope of practice, GPs will be unable meet the care needs of their community and many patients will miss out on services which could be provided safety and efficiently by other health professionals.”

Along with the power of vested interest groups, Di Natale identifies an overall lack of planning as one underlying reason for our current workforce problems, exacerbated by the abolition of Health Workforce Australia in 2014.

In summary

Australia clearly needs to establish a comprehensive health and aged care workforce planning process to set the foundation for a future health workforce that can meet our healthcare needs. Without robust planning and the political will to resist pressure from professional vested interest groups, the most likely scenario in 2030 will be a hyper-concentration of health professionals in areas of high income where they can generate supplier-induced demand. Meanwhile, many other areas, including disadvantaged communities and rural and regional areas, will have little or no access to healthcare.

 

First published by CROAKEY HEALTH MEDIA Wednesday, April 12, 2023