Challenges in Health: Effectiveness

Our performance in the health field is mostly very positive. Australia ranks third amongst comparable OECD countries for life expectancy, sixth for healthy life expectancy and third in overall health system effectiveness. Relative to Canada the UK and the US, a higher proportion of Australians see a doctor promptly when they need to, and rate their care as very good or excellent. Waiting times for emergency departments are shorter than for the US, Canada and the UK. Waiting times for elective surgery are shorter than for Canada, New Zealand and the UK.

Our biggest failure is in regard to Indigenous health, where life expectancy is about 17 years lower than for other Australians, this gap being substantially bigger than the gaps between Indigenous and non-Indigenous peoples in the US, Canada and New Zealand. Apart from Indigenous health, our biggest challenge is to address the impact of our major successes, the fact that people are living a lot longer today, and are not dying so rapidly after heart disease and cancer and other previously fatal diseases.

Thanks to Bill Leak

This success story, mirrored amongst other developed countries, is quite dramatic. The increase in our life expectancy from 1900 to 1970 was dominated by our success in reducing child mortality and mortality amongst others under-fifty, so that many more people reached the age of 50. However, the increase in life expectancy since 1970 has been dominated by our success in ensuring that those who reach age 50 live a lot longer on average after that point. Our life expectancy is still increasing at around 3 or 4 months every year; though one of the impacts of this is that we have many more frail aged people who have survived the onset of heart disease or cancer or other diseases, but require some ongoing care regime to ensure they can live with reasonable independence and quality of life. Indeed, the AIHW has estimated that 80 percent of the burden of disease in Australia is now related to chronic disease.

So the issue of ‘effectiveness’ in health has shifted. The concern is not just how effective our local GP is in treating people with minor ailments and referring people to more specialist care, or our hospital is in treating episodes of acute problems, or our maternity arrangements and immunisation are in protecting our children. It is increasingly about the effectiveness of the system as a whole in providing appropriate and integrated care for those with chronic conditions and the increasing numbers of frail aged.

The facts show we are not as good at this as we think. We have a high rate of potentially avoidable hospitalisations. We don?t manage the frail elderly who need some hospital care very well, and too many of them go to hospital too often. We have cut back step-down and rehabilitative care over the last decade. There are up to 2,000 elderly people in hospitals who are awaiting residential aged care. Despite recently introduced incentives, GP?s are not coordinating care plans for a large proportion of our chronically ill people, and even when they do, there is patchy support for those needing allied health care and advice. Finally, mental health arrangements have not been adjusted properly since the de-institutionalisation measures of the 1980s and 1990s.

There are also problems within the different health programs – excessive waiting times in emergency departments, elective surgery patients not admitted within their clinically recommended times, limited access to GP?s in rural areas, and so on. But while these tend to get more attention in the media, the biggest challenge we face is making the overall system more effective.

This challenge is not due solely to the increase in numbers of chronically ill and frail aged. It is also driven by technology. Interventions once only possible in acute care hospitals can now be done in doctors? surgeries and in day-clinics, helped by new drug treatments. The former distinctions between types of care – primary, acute, subacute and so on – have become increasingly blurred.

Are these issues unique to health? I don?t think so. Improving effectiveness in many fields is increasingly a systems issue, partly because of our past successes and increasing community expectations, partly because we are now addressing more complex problems, and partly because of new technology which makes systems solutions possible.

‘Connected Government’ was the title of the Management Advisory committee report 18 months ago. The report drew in part on some IPAA research from a few years ago. It highlighted the importance of culture, of appropriate processes and systems, of flexible financial arrangements and accountability, of good information systems and of stakeholder engagement. These are all critical to further improving the effectiveness of our health system and, I suspect, quite a few other areas of government services.

In part, we are looking for a better bottom-up process: in health this means a patient-oriented system where money more closely follows the patient across the system, and the health professionals are aided not hindered by our funding arrangements and information systems. In other fields, such as Indigenous services, there is a similar challenge to have multiple programs respond to the concerns of each community, or each individual.

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