No vision for the health system we need. Guest blogger Prof. John Dwyer

Sep 4, 2013

In this election the Coalition has provided dollar promises for worthy projects but no new health policy initiatives while only two of note have been forthcoming from the government; a long-term investment in stem cell research and the threat to remove family tax benefits from parents who put their children and the community at risk by not immunising them. Both are laudable but of greater interest to Australians would be our politician’s plans for solving the many problems that compromise the delivery of sustainable quality health care in our country. In a   recent survey “Research Australia” found that funding for health and medical research is a higher priority for Australians than immigration policy and border control.

The current government has not focused on health system reform but rather reform of hospital financial arrangements with the States reinforcing the inappropriate hospital centric priorities of our health system. In reality financially sustainable quality hospital services are dependent on policies that will reduce the demand for those services. This will require real system reform. The National Press Club debate with Tanya Plibersek and Peter Dutton found them in furious agreement on most issues such as hospital funding, the importance of medical research and the need to emphasise prevention.  One was left with the impression that whoever wins the election it will be “business as usual” for our health system. That’s disappointing.

Healthcare in Australia is beset with structural inefficiencies, inappropriate models of care for our times and cost increases that are producing major inequities that deny many the care they need and are promised by Medicare. This is particularly obvious in rural communities. Their problems did not get a mention in the debate. The major barriers to real change remain the opposition from those with vested interests in maintaining the status quo and the lack of political leadership to take us on a necessarily long (ten years or more) reform journey that doesn’t sit comfortably within current short election cycles.  If we take that journey its important to have a clear vision of what an appropriately reformed healthcare system should look like?

Australia 2023. The Commonwealth has become the single funder of our public health system. An independent statutory authority has been established to fund a number of “Regional Health Authorities” (RHAs) charged with delivering the model of care the Commonwealth (Australian people) have embraced. It is described thus; Our health care system should be characterised by its resourcing of strategies to prevent avoidable illness and provide in a timely manner to those who are ill, cost effective quality care based on an individuals need not personal financial well being.

These RHAs are funded on a per capita and local needs basis. No longer are state boarders a barrier to efficient health care. RHAs contract with a series of providers in their region to supply patient focused integrated hospital, community and primary care services. Quality and safety data are collected and published.

A new model of primary care has been established with a strong focus on disease prevention. Australians are encouraged to enrol in a primary health care practice. Enrolment is significant in that it signals the creation of a partnership and shared responsibilities between patient and the practice’s health professionals.

In the new model, primary care practices work under the umbrella of Primary Health Care Organisations (PHO). These support local GP led services wherein teams of RHA funded health professionals from a variety of disciplines work collaboratively to deliver a range of services to enrolled patients. (“Integrated Primary Care”) No longer do people only visit a medical practice when they are ill, they attend to work with appropriate health professionals to help themselves and their families stay well.  There is no more efficient use of health care dollars that ensuring that children get a healthy start to life. An obese 4-year-old child is very likely to be an obese adult. Continuity of care provides us with the best chance to detect early signs of mental illness when serious problems can still be avoided. Such team-based practices are not doctor centric. Nurses and allied health professionals deliver much of the prevention program. Most doctors dissatisfied with the “turnstile medicine” approach fostered by “fee for service” payments have accepted the opportunity for payment by contract with an RHA. GPs who, after all, are highly trained specialists but were not previously paid as such, are financially much better rewarded in this system. This, plus the attractiveness of working in the team environment, is attracting more medical graduates to primary care, in 2013 very few medical graduates were interested in such careers.

Unlike the “old fashioned” Medicare Locals of 2013, PHO’s act as central service providers for linked, local and clinically autonomous practices. They themselves offer clinical services including acute services that do not require the facilities of a hospital sparing local emergency departments from inappropriate attendances and provide associated practices with business skills, bulk purchasing, continuing education, the collection of outcome data (now a mandatory requirement), and IT services including help with the further development of now popular patient controlled electronic health records. Primary, community and hospital care provided to an individual is seamlessly integrated.

Also important has been the major revision of clinical training in the nation’s universities. “Inter-professional learning” wherein students of Medicine, Nursing, Dentistry and the Allied Health professions spend time learning together has produced a mutual appreciation of the specific skills of each group and how combining these skills in the “Team Medicine” approach can be so much more satisfying for professionals and patients alike. How different from the professional “silo” mentality of a decade ago. Medical schools in rural based universities with programs focussed on educating students with a strong rural affiliation and a desire for a rural based career are seeing significant numbers of graduates helping rural Australians. We are, at last, becoming less dependent on overseas trained doctors, many of whom are badly needed “back home”. Medical education has been shortened without any damage to required learning and is much less focussed on hospital-based rotations with more student time spent in community settings. The old mandatory Internship program has been abandoned in favour of immediate post graduation entry into vocational training programs.

State governments are no longer receiving Commonwealth funds to run their hospitals but they do continue to own and operate them.  Funding required is supplied through a contract with a Regional Health Authority. The services to be offered by a particular hospital will be negotiated with emphasis on the quality rather than the number of services on offer. “Role delineation” for all hospitals within a given region will avoid duplication and avoid the old system where individual hospitals tended to be islands in an ocean of health care doing there own thing. Many private hospitals offer services to RHAs

Back to August 2013.

Given health care is one of the top three issues of concern for Australian voters, it’s disappointing that health system reform has so far received so little attention in the election campaign.

We could reasonably expect our politicians in the last week of the election campaign to be seriously challenged to provide a detailed and clear vision of the health reforms they would pursue to create a more equitable and cost-effective health system that will met our future needs.

But we will almost certainly not get this. And perhaps that says as much about the demise of decent journalism as it does about our politicians.

This article was first published in The Conversation on August 30, 2013.


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