Australia needs an integrated health service model that is able to focus on the prevention of illness rather than just more money for hospitals, welcome though this is.
Australia has a uniquely inefficient health ‘system’ wherein the States are responsible for building and operating hospitals while the Commonwealth government funds primary/community care.
For at least the last 20 years, health professionals and informed consumers have advocated to change this system by replacing it with a single funder of a seamlessly integrated health care model of care. Without success. As a result, the healthcare system focusses on managing established illnesses rather than prevention.
We have an ageing population, at least 50 per cent of whom have developed by the age 45 to 50 one or more avoidable health problems that significantly lessen the quality of their life and necessitates frequent help from health professionals and, all too often, hospital in-patient care.
So, it’s hardly surprising that our public hospitals are finding it increasingly difficult to provide timely and excellent care. The latest review of public hospital performance shows it to be significantly worse than a decade ago. It is in our emergency departments where we see the real strain as ever-increasing numbers outstrip the resources available for timely and excellent care. Recent ED performance studies show an unacceptable number of patients have to wait for four hours or more for care and that about a third of patients triaged as ‘urgent’ wait three hours.
It’s not just emergency departments that struggle to meet demand. Waiting times for admission for planned care, for example hip surgery, regularly exceed nine months. Some patients waiting for a colonoscopy because they are at risk of developing bowel cancer actually did so during the ten or more months they had to wait for the examination.
The availability of more beds over the last decade has been outstripped by demand. The pressure to be able to meet demand is much increased by the ever increasing ‘exit block’ created by so many older patients having to occupy an acute care bed while out-of-hospital care is arranged.
Enter the Commonwealth with a new six-year National Health Reform Agreement (NHRA), wherein it will provide Australian hospitals with an extra $25 billion to improve hospital capacity and care. While the funding is welcome, deciding how to prioritise that spending is a real challenge.
In some hospitals, more and better paid staff will lead to improved patient care. More hospitals should have Aged Care Assessment Teams (ACAT) that can start planning for discharge as soon a patient is admitted to hospital. The money should see major hospitals restore in-hospital out-patient clinics run by specialists to cater for those who need specialist care but can’t afford to see a specialist in the community. Such sessions can also provide invaluable teaching opportunities. Many more day procedures, for example colonoscopies, could be paid for. Wage inequalities, the subject of industrial action of late could be addressed.
However, health professionals are frustrated that, once again, the emphasis is on sickness requiring hospitalisation, not on system changes that prevent the need for ever increasing numbers of hospital beds.
International studies of healthcare systems conclude that Australia’s emphasis on, and systems for, achieving the prevention of disease are totally inadequate when compared with most developed nations. In Australia around one in four children aged between four and 15 years are overweight or obese. This can significantly affect a child’s physical health, mental health and wellbeing. They are also more likely to live with overweight or obesity during adulthood. Also distressing is that in our wealthy country so many children have dental caries causing tooth decay.
While we spend billions of dollars on hospital care, only 0.13 per cent of our GDP is spent on prevention. Just 34 per cent of our health dollars are spent on primary care.
The dimensions of strategies that contribute to the prevention of ill health are almost infinite and involve just about every ministerial portfolio: education, urban design, school curricula, social media, sports promotion, financial security, vaccination, and soon AI. To assemble the crucial elements of primary care that promote and sustain health and reduce the need for hospital care, we need a new paradigm.
We need a maintenance philosophy. In a simplistic but relevant analogy, we all accept the need to have our cars checked at regular intervals to avoid expensive problems developing. In health care, the evidence-based model that incorporates the maintenance philosophy is the ‘Medical Home’. Here, in one venue, you would have doctors, nurse practitioners, community nurses, physiotherapist, psychologists etc., working as a team. A practice manager coordinates the integration of services required for a particular patient. Patients ‘enrol’ in the medical home. (For more, see also No amount of money will fix the current health system and other or my articles in Pearls and Irritations.)
If we had a single funder for health maintenance and care, hospitals would seamlessly interact with the medical homes for the area they serve. As John Menadue has told us, this matter was debated within the Whitlam team. In retrospect, it was clearly a mistake not to have a single funder model for hospital and community care.
Returning to the struggle hospitals are having to meet demands for inpatient care, many studies have found that, of the nearly seven million admissions to Australian hospitals each year, some three to five hundred thousand could be avoided with a community intervention in the three weeks before admission.
With or without integration of all health services, efficient and enhanced workforce planning is more important than ever. Our failure to better use the skills of the workforce we have is lamentable. Nurse practitioners, for example, are trained to provide care that currently requires access to a doctor. Many universities training the next generation of healthcare providers include inter-professional team education so that future graduates will know more about the skills acquired by a range of health providers. Team medicine would make our health system so much more efficient.
While our hospitals and those they serve will undoubtedly benefit from the $25 billion available from the new NHRA, we still urgently need ambitious evidence-based strategies that decrease the incidence of disease and so improve Australians’ quality of life.
Professor John Dwyer AO, is an Immunologist, Emeritus Professor of Medicine at UNSW and for many years heavily involved in efforts to improve the delivery of healthcare in Australia. He was the founder of the Australian Healthcare Reform Alliance.