No amount of money will fix the current health system

Jun 1, 2023
Health, healthcare, medicine and pharmacy in Australia concept. Pills, vials and syringe on the map of Australia isolated on white background.

It has been obvious for many years that our health system needs a radical, evidence based, redesign if it is ever to meet the oft spoken goals of equality and cost-effectiveness, with a focus on prevention and timely availability of care based on need, not financial wellbeing.

Ours is a country where, despite politicians’ pre-election efforts at differentiation, major changes post-election are mostly modest, at best. There is a lack of the boldness needed to provide us with major structural reforms.

These thoughts surfaced with the frustration associated with the May Budget’s Health Initiatives. 3.5 billion dollars over the “forward estimates” are to be spent trying to prop up the current system of Medicare funded Primary Care.

To be sure there are some good short-term initiatives here as the Government focuses on attempts to restore “bulk billing” rates, or at least slow their decline.

We have a crisis in our provision of Primary Care, with many GP’s struggling to keep their practices financially viable, and this extra income (from November 1) will help. However, these improvements are unlikely to make a career as a GP more attractive to the 85% of young doctors currently attracted to other specialities.

We are facing a situation where we will have at least 30,000 fewer GP’s than we need by the end of the decade. It’s not just a shortage of GPs that is of concern, the situation with a broad array of healthcare workers is also dire. An urgent priority for government should be the reestablishment of Health Work Force (HWA) which was abandoned, foolishly, by the last government just when it was poised to be most useful.

Now, imagine that you are a 24-25 year old doctor who has worked after graduation in our hospital system and must now make a decision re your long-term career. You think about becoming a GP. To do so means entering a training program for three years (four if you want to work in a rural area).

You will receive a salary while training that is considerably less than you received when working in a hospital and, when ready, it will cost you many thousands of dollars for the privilege of sitting for the examination that you must pass to practice. You worry about the “Just a GP” label and know that many other specialties provide far greater incomes with better working conditions.

The new budget will increase the bulk billing rate paid to doctors for seeing children and those Australians who have an illness and government provided ‘Concession Card’ from just under $40 to just over $60. While welcomed by the College of General Practitioners, it is nothing like enough to be a significant factor in luring young doctors to become ‘Primary Care Physicians’. The average GP can look forward to making about $145 per hour.

The reforms we need must result in GPs earning more than that while providing care in a redesigned model for Primary Care that is much less doctor and illness centric. This is the challenge.

As I have written about extensively in these pages, that redesigned model must focus on the “Medical Home” model wherein one enrols in a comprehensive program delivered from a physical entity (‘Home’) populated by a multidisciplinary team of health professionals paid by Medicare.

The team works with enrolled patients of the ‘Home’ to improve their health literacy with an emphasis on avoiding disease, diagnosing potential medical and psychological problems at an early stage of development, offering integrated care for patients with chronic diseases while extending its services into the community to reduce the number of patients requiring hospital care. The Medical Home is funded by Medicare.

We have very strong evidence that early intervention by community nurses with patients whose health is deteriorating can save as many as 650,000 of the six million annual admissions to hospitals in Australia.

Our current Federal government appreciates the importance of better availability of multidisciplinary care and the concept of ‘enrolment’ in a health care program but the vision is too narrow. A GP practice can seek up to $130,000 to add a nurse or allied health professional to their team. Realistically that would provide one nurse practitioner or one allied health professional. This funding would not transform a GP practice into a Medical Home as described above.

There is widespread dissatisfaction with our ‘Fee for Service” model for payment for our GPs with the potentially perverse incentive to favour volume over quality. Space does not allow for detailed discussion of the various payment models being pursued by many countries embracing the Medical Home model, but we have a lot of evidence to suggest that many of our GPs would be interested in well-paying salaried positions which embraced the importance of their clinical autonomy.

The concept is similar to that of salaried staff specialists in our hospitals. Our government should call for expressions of interest from teams of health professionals who would wish to establish “proof of concept” Medical Homes to help us explore the best format for their introduction to health care in Australia.

However! Redesigning and implementing a new health care system that is “fit for purpose” first and foremost requires a politically acceptable instrument to integrate and fund the current health programs run by States and the Commonwealth while exploring new models of care.

This imperative was appreciated by the Whitlam Government which did not survive long enough to fully implement the initiative. Many of us would be health care “reformers” are agitating for the establishment of an ‘Australian Health Care Reform Commission’ to drive the changes needed.

In recent times, Labor and Liberal State Premiers have urged their federal colleagues to embrace the idea. It is impossible to integrate patient focussed health care efficiently and economically with the current divisions. Labor promised to pursue the model before the 2019 election, but it does not appear to be on the radar now.

Health is highly profitable. Treating the unhealthy is very expensive and increasingly so. At least 50% of us, by the time we are fifty, have at least one chronic illness. We spend annually about $180 billion, directly and indirectly on the health problems of Australians. The models of care that consume these dollars are failing us. We must pursue strategies that focus on prevention to better help millions of Australians avoid developing those illnesses that ruin the quality of life and productivity of so many of us.

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