The Australian health system has evolved into a discontinuous system across the nine state and federal jurisdictions, across hospitals and the community, and across public and private settings. In the future this discontinuity and these boundaries must change.
In the 18th and early 19th centuries public hospitals were charitable institutions where the poor and indigent received health care from newly qualified doctors (‘residents’) who provided their services in return for room and board and extra training before embarking on private practice. Their training and general supervision were provided pro bono by senior doctors (‘honoraries’) who would take time from their private practices for this charity work. Doctors in the community were privately funded on a fee for service basis without government subsidy and had to run as small businesses.
Today, public hospitals are funded by state/territory revenues plus grants to the state/territory jurisdictions by the federal government (and so supported by one federal and eight state and territory bureaucracies). Private for profit and private not for profit hospitals are funded through fees received from patients from over forty insurance funds (subsidised by the federal government health insurance rebate and again all with their own different bureaucracies) and the patients themselves via various gap arrangements and self insurance. There are ‘private’ medical and other expenses in hospital and the community funded predominantly from Medicare (and so the tax payer) again with variable gap arrangements paid by the consumer (and health insurer for hospital services); as well as private non medical services paid by the consumer (sometimes with subsidy from health insurance). These ‘private’ arrangements are not really private in that they are mostly tax payer funded and regulated by the federal government without a true free market focus.
Our system is mostly fee for service and focused on illness and treatment with substantially less focus on well being and health. There is no financial premium for quality and better outcomes, nor overall population based incentive for health promotion and illness prevention. Apart from specific programs for immunisations and screening for certain groups it is actually illegal to provide health screening under Medicare subsidy.
An aim would be to have one system rather than nine; to make the ‘private’ system truly private (without any government subsidy), remove state and territory bureaucracies, provide financial incentive for quality of care, equity of access (especially in rural and remote areas and for disadvantaged groups), timeliness and outcomes and develop a population health focus.
Information management in health is equally complex. While most general practices are now computerised (mainly for the purpose of prescribing and billing) many community and hospital based specialist practices and hospitals are not. Most patient records are little changed since Victorian times with paper and pen predominant. Although diagnostic pathology reporting is electronic most providers use different systems. Nowhere is there a single system from which all of the clinicians involved in a single patient’s care can obtain the same complete and comprehensive data set to ensure mutual understanding of that patient’s conditions, investigations, treatments, progress, communications and plans. Healthconnect is going some way to address this but is optional and virtually useless in the current context, merely adding to the multitude of records already available for each patient. A vision for the future is for all clinicians involved in a patient’s care to use the same continuous information, verified and edited by the patient and properly protected for confidentiality.
Whilst computerised prescribing is wide spread in general practice and includes some decision support to help prevent errors, such systems are yet to make an impact in hospitals. Here, hand written entries are checked and corrected (or not) by pharmacists and nurses relying on the entry to be legible, their own memory for what is important, and the separate hospital paper record for important facts.
Computerised clinical decision support systems are known to be able to integrate relevant information about a person’s conditions and medications and their interactions and cross effects, can be built to operate continuously and not fatigue, can be encrypted for confidentiality and security, and most importantly are known to reduce errors. Yet they are not available in our highest risk health care areas such as hospitals. In the future an inbuilt and structural clinical decision support system integrated into a continuous electronic record should aid all clinical decision making.
Another vision is to improve the discontinuity of care among the health professionals involved in each person’s care, resulting in better team integration and changed professional boundaries. In Victorian times doctors did most things themselves including medication dispensing and surgery and the only other health professionals they worked with were nurses and midwives. Now, with specialisation, health professionals work with a multitude of other specialist doctors, nurses, nurse practitioners, midwives, lactation consultants, pharmacists, occupational therapists, psychologists, social workers, physiotherapists, speech therapists, audiologists, optometrists, radiographers and scientists amongst others.
The individuals tend to work less together and more in isolation optimising and applying their own depth of skill without overall coordination or holistic view. It is nonsensical to think that specific intellectual and technical skills are the province of one profession merely because of history. Clearly other health professionals could develop specific competencies with appropriate specific and targeted training in certain technical/procedural areas. This applies in particular to the hegemony by medical proceduralists which flows from the inappropriately high historically based remuneration. If the funding model was changed then the training and practice model would rapidly change. Cataract operations, endoscopies, angiography and angioplasty/stent insertion and many others are examples where a doctor (with a minimum of 13 years training) could be substituted by someone with shorter more focused training. This would free up doctors’ time for thinking and the overall coordination and planning of care, as well as communication with patients and their carers. Restructuring our system away from highly paid procedures toward rewarding integrated care planning and teamwork would shift focus toward prevention and potentially more balanced illness care.
Finally given the increasing costs of health care, we must more transparently address the issue of health spending and prioritisation. The Pharmaceutical Benefits Scheme already prioritises which medications will receive public subsidy but the process for prioritisation of government subsidy for other clinical services is more obscure. The community should have more involvement in taxation and spending for health. In my opinion, the Oregon model of informed community involvement in deciding health spending priorities would be a good place to start.
In conclusion I believe we need to redesign our health system to remove boundaries that obstruct care and make it more inefficient and less cost effective. We need to invest more in technology that helps achieve this. And we need to rethink the professional boundaries to ensure better integrated care that is driven by better health outcomes rather than history and professional tradition.