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

Feb 23, 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 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 worlds 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 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. Continuing with the vision.

February 2028.

To: COAG Health Council Ministers

From: Australian Healthcare Reform Commission.

Ministers, a decade ago our health system was doctor, hospital and sickness centric but the structural changes pursued by the Commission have changed that landscape. We can report that in 2027 there were 20% fewer admissions to public hospitals than there were in 2018.

A number of factors have contributed to this change. They include better care in the community for many who would otherwise need a hospital admission. The focus in the Medical Home system of helping those enrolled to generate end-of-life instructions for the care they will want and not want and the significant investment in palliative care services that provide patients and their families with the support needed for managing dying with dignity at home. In 2018 many patients had six or more hospital admissions in their last year of life.  Hospital acquired misadventure was unacceptably high for older patients in an acute care hospital. Far fewer such complications are being reported now.In 2018 the average cost of an admission to a public hospital was $5,500 the current figure is almost $10,500 so the change in utilisation provides significant financial benefits.

Perhaps more importantly, the changes achieved have resulted in a much need rebalancing of the case-mix found in our public hospitals. In 2018, 75% of the patients in public hospitals were admitted because of medical emergencies and chronic disease complications. This reality made it very difficultly to offer surgical services in a reliable and timely manner. Delays in receiving surgical help involves much suffering but also complications that increase that suffering and markedly increase the costs of subsequent health care. For example older patients with poor vision awaiting cataract surgery commonly experience falls as do patients awaiting hip surgery who are also at risk of complications from the drugs they take while awaiting surgery.

There is no doubt that in 2018 many Australians who could ill afford the exorbitant cost of Private Health Insurance (PHI) made sacrifices to obtain cover as they had lost confidence in the public hospital system being available to them when they needed it. Many surgeons once committed to offering their surgical skills to public hospitals transferred their operations to private hospitals given the problems that beset public hospitals.Today we can report that most of the reductions in admissions involve patients with medical problems and this has resulted in major hospitals now  having 50% of their beds available for surgical problems. This in turn is a major factor in the dramatic fall in the number of Australians paying for PHI as confidence in the accessibility of public hospital care increases.. Last year saw the end of the taxpayer funded rebate to support PHI. In 2018 that support cost Australians 11 billion dollars. With the graded withdrawal program over the decade the cost last year was 5 billion dollars. Clearly these dollars are far better spent on supporting the raft of health reforms instituted and being pursued.

In 2018 there were 34 insurers competing for business, their overhead costs were excessive, their product ever more expensive and the premise for government support, a reduction on the pressures faced by public hospitals, not realised. Effectively we now have a single insurer, the Australian Healthcare Commission with its Regional Health Authorities seeking care for Australians  from both public and private providers.

A number of private hospitals are offering services that are both excellent and cost effective and have won contracts to service publicly funded healthcare. They prefer to deal with the “public” insurer rather than a myriad of private insurers.Indeed Ministers, having a single funder utilising all the facilities in a region has facilitated effective integration of hospital, community and primary care.

In this construct much need role delineation for Individual hospitals is being achieved. Since 2018 it has been clear that while misadventure while hospitalised has been far too common, complication rates for Individual hospitals vary greatly. We have now had a decade of looking at what a hospital does well and does not do well. The excellence achieved by having fewer hospitals do more of the complicated procedures they do well (the “centre effect”) is already producing fewer complications due to hospitalisation itself. A Regional Health Authority assisted by advisory Boards can decide on what services it will pay for in both public and private hospitals.

Finally we wish to report on our pursuit of partnerships to tackle needed improvements to the social determinants that effect the health of the Nation. The decision by government in 2021 to have all major portfolios resourced to have them address their contributions to the mix of desired social determinants for a healthy Australia, is paying dividends.

Our partnership with the Department of Education has now resulted in government accepting that all students in all schools must be given appropriate health literacy skills; “Preparing students for life not just exams”. We are engaged in discussions and planning with housing and transport authorities. We are engaging with the food industry and the Business Council re workplace health education. In the near future we will embark on major consultations with local government. Many countries have harnessed local government skills and opportunities to add value to their health system.

Ministers, the work of the Commission involves continuous learning to provide continuous improvements but we can report with confidence that, while much still needs to be done, the structural reforms on which we are reporting have moved us far closer to achieving our goal shared by all Australians namely a Healthcare system of excellence, available to all as a right not a privilege. That system is characterised by its fairness, its availability on the basis of need not personal financial wellbeing, its emphasis on preventing illness and cost effectiveness.We thank you for your continued support.

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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