The curse of political mediocrity; The informed, bold, courageous policies that Australia needs in health are nowhere to be seen. (Part 2 of 3)

Feb 22, 2018

This “fair go mate” country of ours is wealthy but in reality ever less egalitarian. Increasing Inequity is palpable and most notable in the problems we have with housing, education and health. Health outcomes for Individuals are increasingly dependent on personal financial wellbeing. Australians are spending about 30 billion dollars a year to supplement the care available from our universal health care system. Many, of course, do not have the resources to cover “out of pocket” expenses. Many of these problems have become chronic as political intransigence inhibits the development of bold, informed and even courageous policies. Policy development, such as it is, is often insular, ignoring the successful tactics of other countries in addressing similar problems. The Commonwealth Fund, which compares the world’s health systems for quality, is critical of our efforts to swing our health system around to focus on the prevention of disease. Eleven other OECD countries are currently doing a better job than we are. How can we change this unsatisfactory situation? PART 2 of 3.

 Well for significant structural reforms to happen we need a clear vision for what it is we want from reforms, a detailed plan for the journey and an instrument to take us to our destination. Let’s start with a vision of what Primary care might look like in ten years time.

February 2028.

To: COAG Health Council Ministers

From: Australian Healthcare Reform Commission.

The Commission is pleased to report on the improvements to the Australian health care system over the last decade. Arguably the enthusiastic uptake of the “My Medical Home” initiative by the public and health professionals has made the biggest difference. 73% of Australians are now enrolled in a “Medical Home” practice. Whereas in 2018 only 2% of the health budget was spent on prevention and an acute or established problem generated a visit to one’s GP, enrolled patients of a Medical Home are encouraged to use the skills available to help them and their families stay well.

The advantages of “team medicine” are now well established and accepted and it has been very cost effective  for Medicare dollars to fund the nursing and allied health professionals necessary for Integrated Primary Care teams. Expensive hospital admissions have, as predicted, decreased significantly (see below).The average Medical Home team is now composed of 8-10 doctors, a dietician/nutritionist, a nurse educator, and nurse specialists appropriate for the local demographics. At last we are giving dental health appropriate prominence and a dental hygienist is available to the those enrolled.  Importantly, Medical Homes, which cater for about 12000 patients, employ a social worker/case manager and the allied health professionals needed to provide “in-house” care for patients with chronic and complicated diseases.  Outreach nurses offer monitoring and care in the community for the practice’s elderly and fragile.

In 2018 we knew that an effective intervention in a community/home setting in the three weeks before many patients presented to emergency rooms, so sick that they needed admission, could avoid that necessity. There was however no structured care program to provide that outcome. Now continuity of care, better case management and the provision of outreach services from a Medical Home into the community/home setting has changed that dynamic. In 2018, 600,000 admissions to our public hospitals were deemed “avoidable” today we estimate that figure to be 50,000.The Commission notes with satisfaction the popular uptake of nursing courses providing the expertise needed for a career in Primary care.

Ministers, evaluation of this primary care strategy reveals a significant increase over the decade in the health literacy of those enrolled, a related drop in the incidence of childhood obesity and an increased understanding of what constitutes a healthy lifestyle.  Education and improved health literacy is providing many with the confidence and desire to better manage their own health problems. Already the continuity of care available has resulted in the earlier detection of mental health issue in teenagers so vital if early intervention is to minimise the progression to more serious mental Illness.

You will remember that in 2018 we knew how Important it was to integrate the care plans for people with chronic diseases but also how we struggled to deliver the “one stop shop” approach so desired by patients and now available. The ill conceived “Primary Health Networks” of 2018 were not able to provide that integrated care.

As you know the opportunity for General Practitioners to move from “fee for service” payments to contractural payments was never forced on the profession. Over the decade however, as was the case in New Zealand, GPs have, with increasing enthusiasm, embraced contractural  payments while maintaining their clinical independence. However for these payments they are required to document the  health outcomes for their patients, with financial bonuses available for outstanding results. We discuss below in this report, the assistance we are providing to doctors to help with measuring outcomes. So now 84% of GPs have moved away from “fee for service” payments. Most importantly for both job satisfaction and patient satisfaction our GPs are better using their skills with time now to care for many they would previously have referred to specialists.

In 2027 we spent 10.9% of our GDP on health. The percentage is only slightly increased compared to the 2018 rate but the dollar figure has increased substantially as has our GDP. We are pleased that with all the improvements we can report we are holding at our target level of less than 11% of GDP. In 2018 we spend 20 billion dollars on Medicare expenditures. Seven billion was spent on paying for GP care. Last year we spent 14 billion dollars on Primary Care with a total Medicare expenditure of 28 billion dollars but this did not increase the percentage of GDP required.

Included in this expenditure was the completion of the transition of the ineffectual Primary Healthcare Networks to Primary Healthcare “Hubs” (PHH’s). These hubs have two main functions. They provide services to affiliated satellite medical practices/Medical Homes and they offer “secondary” services to area patients who previously would have sought help from a hospital. Many provide a “23 hour ward” service wherein patients can spend some hours to determine if a hospital admission is necessary. For the affiliated practices, hubs offer IT help for the documentation of  health outcomes, financial expertise, opportunities for continuing professional development, in-house evaluation of new drugs and their use ( no more pharmaceutical “reps” visiting practices) and the coordination of visiting health professionals who can be shared among practices.

The Commission is confident that the above strategies are largely responsible for the fact that, compared to 2018, 20% fewer public hospital admissions are required today

We can present evidence for the improvement of health services to rural based Australians though there is still much to be done. Larger towns have established Medical Homes. Even smaller towns are using their available work force in a more integrated fashion and are receiving more help via web links to supporting rural based universities and PHH’s. Three rural based universities are now graduating students with rural backgrounds who seek a rural based career and who have completed a rural specific curriculum. The programs include“Inter-professional learning” modules  to prepare young doctors for “team medicine”. All of the post graduate  training needed is now available in rural centres, important as so many doctors who went to big cities for further training stayed there.

The Commission can report that the devolution for the responsibility for contracting hospital, community and primary care services to “Regional Authorities” is now complete. It became obvious over the last decade that a resource distribution formula should be based on regional need not just population statistics and that traditional boundaries that defined state and territories geographically should be ignored in providing cost effective services in a National Health scheme. We now have a classic Funder/Provider split model wherein a Regional Authority will seek and fund providers of excellence in delivering Hospital and Primary Care services. It is noteworthy that in a role delineation exercise, Private and Public hospitals  are cooperating  in seeking funds to provide the hospital services required in an area utilising their different capacities productively.

Ministers we are finalising a supplementary report which details the current issues associated with the delivery of hospital services, changes in the Private Health Insurance landscape, and the Commissions partnership with other agencies to better address the social determinants of health which play such an Important role in the overall health of our Australian community.

We look forward to discussing this report at our next meeting

Professor John Dwyer is an Emeritus Professor of Medicine at UNSW and has been involved in the promotion of structural  reforms to Australia’s health system for many years. He was the Founder of  the Australian Health Care Reform Alliance.

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