TIM WOODRUFF. Health Services or a Health System?: We Have a Choice

Apr 30, 2020

How do we keep our population healthy? From a patient perspective we don’t have a health system. From a provider’s perspective we don’t have a health system.

The nightmare for patients consists of multiple poorly connected pieces: the public hospital system, the publicly subsidised private hospital system, the GP system, the publicly subsidised private specialist system, the community care system, the publicly funded private allied health system, the private mental health system, the public mental health system, the private dental system, the publicly funded private dental system, the public dental system, the Aged Care system, and a myriad of other pieces.

From a provider’s perspective, let me describe how it is. Equity and efficiency are not part of the plan. There is no ‘system’.

As a rheumatologist I see patients with muscle and joint aches and pains. I want them to see a physiotherapist or a podiatrist. If on a good income they can afford to go privately. If not, they have to return to their general practitioner to get a ‘care plan’ which gives them up to 5 subsidised visits. Then it’s full price. They can try the local community health centre if there is one, and hope they are seen within 3 months. Or they can suffer.

I see patients for whom stress and/or past traumatic events make an important contribution to their ongoing pain. I want them to see a counsellor or psychologist. The situation is the same as for the physiotherapist. I suggest Tai Chi. But it’s unaffordable or unavailable. Their preventable pain and distress continues.

I see patients with multiple issues managed by 3 different specialists and a different GP at almost every visit to their large corporate general practice. Communication between the specialists is often good but not always. Good GPs can hold the picture together, but if the specialists are poor communicators the GP is up against it.

I see patients discharged from hospital where the drugs I have prescribed have been stopped, sometimes with good reason, other times without. I am rung often by the hospital doctors, but not always and usually by the most junior doctor who frequently doesn’t understand the issues. Sometimes I receive a discharge summary. Often I do not. When I do, it is frequently a 6 page proforma screed prepared by the junior doctor which, if summarised by a competent senior doctor on the team, would fit on 1 page and be so more informative. The same happens when my patients are seen in hospital clinics. Nothing, or 6 pages of repetitive waffle which could be summarised in 2 paragraphs.

My patient needs a hip replacement. “Should I go privately?” is the question put to me for those who may be able to afford it. There is no correct answer. It’s not even a question for many.

Recently an elderly regular patient of mine attended and I consulted My Health Record (MHR) to see if she was still getting her prescription drugs as she wasn’t sure what she was on. Her record was empty but it was there. MHR was set up to facilitate communication. Less than 10% of doctors are reported to be using it. Most specialists have not even registered for it.

Primary Health Networks were set up in 2015 to improve efficiency, effectiveness, and co-ordination of health care. Most GPs have had their first interaction with them only since the COVID pandemic because they were supposedly the source for Protective Personal Equipment.

I treat thin weak bones i.e. osteoporosis. It’s recommended a patient have a dental assessment before I start specific drugs for the condition. Should I withhold treatment for the 3 years it will take to get a public dental appointment. The mouth is part of the body, but governments ignore this fact.

My patient needs a nursing home. The nightmare begins. Potluck if you are on a low income or sadly if you can pay but are not sufficiently financially literate to understand the financial details.

The health ‘system’ appears to be currently structured so as to centre on providers rather than patients and to advantage the well resourced, health literate, independently capable patients. We health providers work in silos. We are funded to work in silos. Whether it is the individual GP, specialist, dentist, allied health worker, or the bigger silos of private hospitals, public hospitals, nursing homes, community health workers, mental health workers, social workers, and psychologists.

For the patient it is a disaster waiting to happen. With sufficient money and support from family, they do often manage to negotiate the maze and connect the silos themselves. Examples of first class co-ordinated care abound, particularly for example in cancer care. But there are so many exceptions.

Who and/or what is responsible for this maze of poorly connected health services which often barely manage to work together to provide health care of extremely variable quality depending on many competing variables such as income, geography, ethnicity, culture, and type of illness?

Funding is paramount. Siloed funding does not facilitate co-operation, co-ordination and integration. Divided funding (Federal/State) ensures divided responsibilities and denial of accountability. State run hospitals live in a different world from Federally funded GP care with notable exceptions. It has always been thus. It does not need to be.

It is not that we necessarily need more funding. We need to direct it to efficient and effective services on an equitable basis. The existing Australian Commission on Quality and Safety in Health Care can provide the information regarding such services, but the question of equity is different, and needs to be addressed separately. To address the problems of responsibility and accountability the funding needs to be in the hands of an independent single funder of all health services. This would set the scene for new models of care which could have patients rather than providers as the central focus. It would quickly highlight those areas of chronic underfunding like mental health and dental health. It would recognise and be able to expose and have addressed the amazing variability in costs of identical procedures in different hospitals (Duckett). It would see an end to the duplication of services. It could result in savings estimated in the billions. Data and evidence would be central to its capacity to fulfil its task.

Politicians would decide the size of the health budget. Priority setting however, would be decided independently on the basis of evidence. Lobby groups would be successful only with evidence. Marginal electorates may well miss out. Health providers would have the opportunity to work together in an environment where the central focus is total care of the patient, rather than just fixing a single isolated problem. We do work as teams often. We do not do it enough. Our patients want and deserve more.

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.(WHO) We need a health system, not a maze of poorly connected health services.

Tim Woodruff is President of the Doctors Reform Society, an organisation of doctors and medical students promoting measures to improve health for all, in a socially just and equitable way. On Twitter: @drsreform

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