Our health care system provides, at least for metropolitan based Australians, world class management of medical emergencies. A stent in a coronary artery in the middle of the night can save a heart in danger and our dedicated stroke units routinely dissolve blood vessel blockages that could have proved fatal or caused major permanent disabilities. While we can be grateful for these interventions the reality is that the management of the majority of health issues that trouble us do not meet this standard of excellence.
For the last thirty years numerous reviews of our health system have called on governments of all persuasions to introduce major structural reforms to address the system’s inadequacies. Despite the uniformity of the major initiatives called for, political intransigence, facilitated by opposition from vested interests has denied us the reforms we need. As the federal election looms the need to address structural reforms has never been more obvious and we should be looking closely at what would be governments are promising to improve the situation. Let’s look at the current health landscape to better understand the imperatives.
Australians are living longer but for many the extra years of life are blighted by chronic medical problems that rob that life of quality. Nearly 70% of all the money we spend on health is consumed by the efforts to treat these conditions most of which are avoidable as they are consequences of injudicious life styles. Despite this reality we only spend about one percent of our health budget on prevention strategies. We think of ourselves as a highly educated community but study after study finds that only 40% of Australians have even the most basic health literacy needed to understand how our bodies work, what they need and how to use our health system. Among OECD countries we score very poorly in this area. Better health literacy would protect Australians from the pervasive and fraudulent claims made for “supplements” and vitamins which have many thinking they can neutralise an unhealthy lifestyle with something from a bottle.
We have a tsunami of Australians developing avoidable problems with many suffering from more than one problem ( obesity , diabetes, arthritis, chronic lung disease, high blood pressure etc.) As a result of the vast number of people so suffering about 75 % of public hospital beds are occupied by these medical patients many of whom have repeated admissions. This in turn has progressively resulted in public hospitals having difficulty providing timely and reliable access to surgical services. Presentations to emergency departments (mainly medical cases) increase annually by about 8%. Too often planned surgery is cancelled as surgical beds are lost to overnight medical admissions. Frustratingly more than 650,000 of these admissions each year could have been avoided had a timely medical intervention occurred in a community setting. Fear that the public hospital system may not be available for surgical help when needed sees many older Australians buying private health insurance (PHI) they must struggle to afford.
Public hospitals, the responsibility of State governments in our health system, have no levers to pull to stem the tide of admissions into their hospitals. Primary care (mainly offered by our “GPs”) is funded by the Federal government. This is the arena where reforms could reduce the need for much hospitalisation. Reform reviews have consistently told governments that we are uniquely disadvantaged by the lack of seamless integration of our health care management. This jurisdictional divide must not be allowed to stay in the “too hard “ basket.
Other problems needing urgent attention include the national disgrace which is the poor dental health of so many Australians including our children, the fact that we have more “out of pocket” expenses needed to pay for our healthcare than any other country except for the US, the inadequate health care available to people living in rural and remote areas, the provision of far too many expensive but low value procedures and the lack of integrating the social determinants of health ( transport, housing, education town planning etc) into our overall health system. We can’t be complacent that in our “fair go” country increasingly health outcomes are determined by one’s personal financial well being rather than one’s need for care.
Now all of the above has been presented to our current politicians on numerous occasions. We now look for election promises that would effectively address the problems. At least 11 OECD countries are doing a better job than we are of providing health care for contemporary needs. They can teach us a lot e.g. structural reforms to health need a long term plan, one that extends beyond one election cycle, is clear about the destination and has plans for the journey. Though there are a number of issues competing for reform two are paramount.
The first step in the needed reform journey is the most important one and perhaps the most difficult. The next Federal government must create an Australian Health Care Reform Commission (AHCRC) to manage the reform process. This must be a creature of COAG, that is one supported by all our governments and reporting to the COAG Health Council. The commission should eventually morph into the Australian Health Care Commission funding and therefore integrating all aspects of our public health system. This would at last see an end to the “blame game” between the States and the Commonwealth. The Whitlam government created such a structure only to have it dismantled by the Fraser government. Its creation now is absolutely essential. Labor was exploring the idea before the last election and it is to be hoped that they remain committed to this solution.
The second essential reform is to have our Primary Care system resourced to implement evidence based prevention strategies that would improve the health of the nation and save the health budget a fortune. This will require cultural as well as structural changes. Currently we visit our GP because we have a problem. We need to embrace a system where we engage with health professionals to help us stay well. (We do this with our cars!) The concept involves the creation of “Medical Homes”, staffed by an array of health professionals, in which one (and families) enrol. The home is not doctor centric with appropriate professionals catering to one’s needs. The model has been successful in improving health literacy, thus helping people pursue healthier lifestyles, detecting early signs of illness (including mental illness) increasing the chance of successful management and avoiding chronic disability, better care of patients with chronic illness in house rather than through a series of referrals to external carers and outreach to sicker, frailer patients providing interventions that can avoid the need for hospital admission. Universities are already embracing “inter-professional” learning modules to prepare the next generation of health care professionals for “Team Medicine”.
Over the next decade such reforms would reduce medical admissions to hospitals( 20-40% reductions achieved in other countries) freeing up beds for more surgery thus reducing the need for many to pay for PHI and removing any need for taxpayers to subsidise PHI (cost currently 11 billon dollars per year) which has not reduced pressures on public hospitals, the original rationale for the subsidy. That 11 billion dollars could be better used paying for better primary care and adding dental care to Medicare.
The last election was fought around the need to “save” Medicare. This one should be about restructuring Medicare and other aspects of our health care that no longer meet contemporary needs. Over to you our politicians to show us that you understand and are committed to necessary changes and so deserve our vote.
Professor John Dwyer AO, PhD, FRACP, FRCPI, Doc Uni (Hon) ACU
Emeritus Professor of Medicine UNSW
Founder of the Australian Healthcare Reform Alliance