Pearls and Irritations

What have we learned from the coronavirus pandemic that can inform and drive reforms to Australia’s health care system?

The sudden arrival of the coronavirus pandemic in Australia demanded an instant response from the health care system which has demonstrated its extraordinary agility, flexibility and capability. This, in combination with the new-found ability of federal and state governments to work in a partnership to deliver a coordinated response, dramatic changes in lifestyles, and the exposure of the inequality gaps in Australian society, has encouraged many who work in health policy to hope that the coronavirus pandemic will serve as the needed incentive for reforms. What should those look like?

A number of other people who work in health policy have explored this question and some common elements and themes have emerged. These include:

1. Telehealth works and it is here to stay, although it is not a solution to every problem.

2. New models of care (virtual hospitals; hospital-in-the-home; rehabilitation-in-the-home) can effectively deliver acute care and rehabilitation services in the community.

3. New funding arrangements are needed to drive reforms in primary care to include better integration of community and acute services, more community health clinics, more multidisciplinary teams and co-located services.

4. Mental health services – essential in times of crisis – must be more widely available, more affordable, and wider in scope to address the “missing middle”.

5. The roles of private hospitals and private health insurance in the provision of health care – and federal funds allocated to this – must be reconsidered and reconfigured with the acknowledgement that in times like a pandemic, the public system will always bear the burden.

6. As the Royal Commission into Aged Care Quality and Safety has already exposed and the coronavirus pandemic has starkly demonstrated, essential improvements in the quality and safety of aged care demand an increased focus on quality and safety and more staff who are better trained and appropriately paid.

7. Ongoing investments in national systems of preparedness for national disasters such as bushfires, drought and pandemics such as coronavirus always bear fruit when the emergency arrives and should not be allowed to erode when it appears they are not needed.

Others have outlined specific issues that must be addressed when implementing reforms in these areas. For example, Duckett and an article in The Medical Republic) highlight the need to ensure that the current telehealth Medicare items, introduced to help the healthcare system in emergency mode, are refined and restructured to ensure they are fit for purpose and cannot be rorted.

Additional resources, including social services, will be required for initiatives like telehealth consultations and hospital-in-the-home to be safely and effectively implemented to deliver the best outcomes. This requires much more than simply providing an MBS item, staff, equipment and funding. Outreach efforts must be made to ensure the patient, their family and carers have sufficient health literacy, reliable IT resources, an appropriate physical environment, and access to mental health and social supports.

New models for the delivery of health care will require better coordination and integration of services and communications between health care professionals and will highlight the current inadequacies of electronic health records. They will inevitably require new skills and additional personnel in health care teams, attention to workforce distribution, and scopes of practice.

The barriers to addressing these needed reforms are substantial, not the least of which are the inherent self-interests of stakeholders that must be overcome. Again, telehealth services provide an example. Doctors have mostly welcomed telehealth services until it appears that their incomes might be adversely impacted. Now there are fears (some justified) about “opportunistic” services, expressed in terms of corporate medicine, the ability to interfere with patients’ relationships with their regular GP, and continuity of care.

Here is a list of additional lessons for health care reforms drawn from the pandemic– maybe not quite so obvious as those outlined above, but equally important, especially if the aim is to improve health outcomes and not just health care systems.

· More must be done to tackle alcohol and substance abuse and to link these services into primary care.

· The disproportionate impact of COVID-19 on the elderly highlights the importance of Advance Care Directives and family conversations about these.

· As part of the preparations for the next health crisis, issues such as the reliability of Australia’s supply chains for medical equipment, personal protection equipment, essential vaccines and drugs must be considered, along with the need to invest long-term in research around monitoring health impacts of such events.

· Much more work is needed to overcome Australians’ scepticism (perhaps distrust is not too strong here) of government e-health initiatives like MyHealthRecord and the CovidSafe app, to ensure they function as intended with appropriate privacy protections.

· The admirable success of Indigenous leaders and communities in limiting coronavirus infections highlights how critical Indigenous self-determination is for addressing Indigenous issues and Closing the Gap.

· The outbreaks of coronavirus infections in Victoria indicates the extent to which many Australians, especially those from culturally and linguistically diverse (CALD) communities, miss out on important health messages. There is a need for improved health literacy and better communications.

· Coronavirus has served to highlight the divisions and inequalities in society. More must be done to address the social determinants of health as the pandemic draws attention to:

– How important education and gainful employment is to self-esteem and mental wellbeing.

– The holes in the social welfare safety net and the inadequacy of Newstart payments.

– Too many Australians, especially children, live in poverty and with food insecurity.

– Providing housing to the homeless is an effective form of assistance.

– Family violence is a national crisis that is insufficiently resourced.

– Racism is toxic, especially for its victims.

Professors Anthony Scott and Jeffrey Braithwaite have emphasised how COVID-19 has opened up fault lines in the health care system. It is imperative that we do not just “snap back to normal” and continue these impediments to modernising the nation’s health care.

The government, whose reform legacy is not great, must now show that it can do more than one thing at a time, be widely consultative and willing to invest in long-term reforms that may not return immediate benefits and – as it has done during the pandemic – follow the evidence and the expert advice.

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