I have no doubt that we have over-invested in hospitals and treating sickness and under-invested in primary care and wellbeing. Primary care is the Cinderella in Australian health. There is ample evidence that we have got the cart before the horse in healthcare with our emphasis on hospitals and sickness. We have more hospital beds per capita than comparable countries – about 50% above the Canadian rate and 30% above the US rate. In some Australian states, almost 70% of state health dollars are spent in hospitals. The health debate is invariably about hospitals, not primary care and wellbeing. 30% of people in hospital needn’t be there if there were adequate other support in the home or in the community, particularly those with chronic illness, the mentally ill and the aged. Unplanned hospital admissions are often the result of poor patient management. I believe that one reason why the NHS has outlasted its critics is because it is based in primary care much more than our system.
There are many historical reasons for our hospital and illness-centric model, but that is an issue for another time.
The case for primary care in building a healthy community is incontrovertible. Our autonomy and dignity as patients is much better enhanced if we can be advised about our health or treated either in our home or as close to our home as possible. Hospitals should be our last resort and not our first resort. The greatest cause of bad health in Australia and elsewhere is poverty – poor diet, poor lifestyle, lack of exercise, stress and lack of self-esteem. These problems, which go far beyond health, can only be really addressed in the community. New drugs, orthopaedic and cardiology procedures have improved health and life expectancy but the great advances in health care around the world have come through prevention – clean water, sewerage, vaccination, improved diet and exercise.
The biggest improvements we could make in Australia today in health would be effective and aggressive campaigns to reduce smoking and obesity. It is better to erect barriers at the top of the cliff to prevent falls, than have a fleet of ambulances at the bottom of the cliff. Further, it is cheaper to treat patients in primary care rather than in an expensive tertiary hospital. Early intervention reduces the cost of care. Failures in the primary health care system cause untold and expensive repercussions in the rest of the health care system. Delays in treatment make for worsening of health conditions particularly amongst the frail and the aged.
Primary care must be multifunctional in nature and provide a range of skills – doctors, nurses and allied health such as physiotherapy and dietary support. The nature of primary health care clinics will vary enormously from community to community, depending on the age and size of the community. Employment in primary health care clinics will also vary. Some will be private, some public and some will be a combination of both. Some will have salaried staff and some will be remunerated on a fee for service basis. The key must be health workers, including many women, working together as teams to provide an appropriate range of services in the most efficient way. The days of the lone general practitioner, usually a male, and working 70 hours a week, are well and truly passing. One of the great professional satisfactions of health and community services workers is when they can work together as a team.
Too often in primary care, as well as in hospitals, we have an organisational bias towards illness rather than wellness – treating sickness rather than keeping people healthy.
I have been particularly attracted to a proposed model of care developed earlier this year by the Division of General Practice in Redcliffe – Bribie – Caboolture. They proposed that delivery of primary health care services should shift from an illness model to a wellness model. It proposed a chain of ‘wellness’ centres – multi-disciplinary primary health care facilities that address the lifestyle determinants of health. It focused on reducing the cost of chronic disease plaguing our whole health system.
Features of the wellness centres compared with the current illness model were well thought through. Whereas in the illness model (the current model) service is provided by general practitioners with support from practice nurses, in the wellness model, it would be provided by a multi-disciplinary team including GPs, wellness nurses, exercise physiologists, lifestyle coaches, fitness trainers, nutritionists, dieticians and counsellors.
Whereas in the illness model the emphasis is on curing patients and addressing symptoms, in the wellness model, emphasis would be on keeping people well and addressing lifestyle issues before they become symptomatic. In the present model there is usually just doctor patient consultation at a practice, but in the new wellness model there would be a significant role for nurses and allied health practitioners including group counselling and domiciliary care. These wellness centres would collaborate with other health, fitness and community organizations in the same locality with ongoing and regular concentration on lifestyle issues such as nutrition, exercise and substance abuse. It could include community service roles in areas such as children, aged, disabled, youth and drugs. Once again, we have too many boxes of training and work that badly need linking up. I hope you get the picture.
It is early days in developing such a wellness model within primary care and support is not strong as the Redcliffe Division found out. We are still too addicted to a hospital-centric system and an illness model. But the logic is clear: the change must be made, particularly with rising costs and major dissatisfaction at both staff and patient level with the present system.
These changes will not happen unless the government leads the reform. The Commonwealth government is supporting divisions of general practice, but it is fairly ad hoc. There is no systematic and coherent Commonwealth approach to raising the quality and the quantity of primary care. I suggest we need Commonwealth government funding through reconstructed divisions of general practice to establish wellness centres in primary care on an agreed basis. The states have failed badly in promoting primary care and I see no reason why the Commonwealth government, which controls the purse strings, shouldn’t go direct to regional groupings. Of course those regional groupings must include a wide range of skills. Clearly funding should be based on the population of a region and not provided on an institutional basis. There would need to be agreed governance and operations.
To make the shift to primary care and wellness (rather than hospitals and illness) a reality, winning the support of the community is the key. The health debate is between insiders – doctors and ministers. The media entrenches this debate to the exclusion of the community about what is important. My experience is that when there is a genuine and informed community involvement, the community is very clear about health priorities and where the health system should head.
There is ample evidence that the community wants to participate provided it feels that its views are valued and will be reasonably acted upon. There is a whole range of techniques of community engagement – deliberative polling, town meetings, and citizens’ juries. These techniques have been validated overseas and in Australia, but they have not really moved out of the academic stream into the public arena in this country. Such public involvement in our health system is essential for the sake of the health system itself. It is also essential for the health of our democracy where so often we feel that we are alienated and excluded on major decisions that affect our community and ourselves. Decisions are made by insiders.
The process of community involvement is time-consuming and frustrating but in the end rewarding. We can hardly complain that in a democratic society the community will come up with some useful but sometimes disconcerting advice. Democracy will always be work in progress, messy but the best we’ve got.
This article is based on a speech John delivered to the CS & H Industry Skills Conference on 7 June 2005. He also spoke on Health Sector Workforce Reform.