Roadmap to a better health system

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Australia ‘s health system is very good by world standards. We provide a high level of access to health care for a cost that is around the OECD average. Our universal health system, spearheaded by the Medicare and the Pharmaceutical Benefits Scheme, has ensured that all Australians have access to GPs, hospital services and pharmaceuticals – at least on paper. Our efforts in public health have also been impressive: the response to threats, such as the HIV/AIDS epidemic, stands out as an example of what the Australian health system can achieve.

We need to preserve the many good qualities of our existing health system, and strengthen it so that it can meet the future challenges of providing health care to the Australian community. These challenges are likely to be considerable.

As our population ages and the burden of chronic disease increases, more and more stress will be placed on our health services and on our economy. We will also have to cope with an ongoing shortage of doctors, nurses and other health workers. This will place additional stresses on a health system that is already struggling to cope with demand.

The Australian Healthcare Association (AHA) has identified 5 major challenges to be addressed in any strategy to reform our health system.

1. Community engagement in policy options

A nation’s health policy should aim for ‘optimal’ health for its population. The term ‘optimal’ recognises that, while it is technically possible to achieve health gains for some individuals in a community, it is not always possible to deliver the required services because of resource constraint. Even with this recognition, further clarification of the idea of ‘optimal’ is required. For example, does our community wish to invest in an initiative which may result in a large net, but small individual improvement in the health of the community as a whole; or would the community prefer a smaller net, but larger individual improvement in the health of that section of the community with the worst health outcomes? This question is far from theoretical.

For several years governments have been exploring the introduction of health call centres to provide advice and recommend an appropriate point of care as required. These services provide small health gains to the entire community, mainly in terms of heath service access. The quantum of funding proposed for this initiative is approximately 1-2 per cent of national expenditure on Aboriginal and Torres Straight Islander Health, a group which has the lowest level of health in the country.

To date there have not been clear objectives for the Australian healthcare system. To the extent that objectives have been considered there has often been a lack of community consultation and transparency. The issue of engaging the community in determining what its health priorities are is necessarily the first challenge for Australia’s health policy.

2. Integrated services

The second challenge for Australian health policy is to provide services in an integrated manner. A health service model needs to consider improved integration in at least three overlapping dimensions:

  • The three tiers of government (Federal, state/territory, local) in service provision;
  • Acute, continuing and chronic, and preventative care provision, and;
  • The public and private sectors.

3. Access and outcomes

The third challenge is to maintain and improve equity of access to, and outcomes from, our healthcare system. It is known that the least well-off members of Western societies, including in Australia, have the worst health status, the worst access to health services and benefit least from population health initiatives.

Historically Australia has managed the trade-off between outcomes, efficiency and equity of access relatively well compared to other OECD countries. This is partly because the principle of equity of access was enshrined in the structure of Medicare. There is, however, room for improvement, and there is usually a tension between efficiency (often achieved through economies of scale) and access (which reflects services tailored to individual needs). This tension requires that health system reformers are mindful of the extent to which they seek equity from the healthcare system, and are careful to monitor the effect of changes they make on it.

4. Transparency on rationing

A fourth challenge to the Australian healthcare system is lack of transparency around resource constraint. Resource constraint is not simply an issue of providing more money. There will always be more things that it is possible to do to improve healthcare, no matter how large the overall health budget. It has been necessary for health service providers to make rationing decisions in response to this open-ended demand. At the same time there has been a tendency to deny that demand is constrained.

Individual health service providers get their satisfaction, professional identity and income from these services and so are unlikely to wish to acknowledge resource limitation. Equally, politicians are often reluctant to face this issue, presumably for fear of electoral backlash. These motivations inhibit the provision of information about resource utilization. Greater transparency is required about health costs and the benefits that accrue so that the community can determine whether it wants to spend more (or less) money on health compared to transport, education, tax cuts etc.

5. Evidence-based policy making

The fifth challenge is to provide services as efficiently as possible, taking into account the foregoing challenges. This can only occur in an environment which encourages innovation and demands evidence based policy making. In this context, the following priority areas require immediate research:

  • Situations in which multidisciplinary care is cost-effective, so that policies to foster this model can be developed where it is found to be beneficial;
  • Infrastructure requirements to support more community-based services involving a multi-disciplinary team-based approach so that policies can be developed to establish and fund appropriate facilities and information/communication technologies;
  • The health needs of an ageing population so that strategies to meet these needs can be developed;
  • The health access paradox whereby those with the greatest need are least able to access health services, particularly Aboriginal and Torres Straight Island populations, so that policies to redress the inequities can be developed;
  • The use information/communication technology so that policies can be developed to realize its benefits in linking all services and mitigate the apparent high risk of program failure in this area;
  • The disproportionate growth in unplanned health appliance and pharmaceutical costs at the expense of other health services so that policies can be developed to manage these expenditures;
  • Implications of changes in workforce numbers and the fact that workforce per capita may overestimate workforce availability due to increases in part-time work, changing lifestyle expectations of healthcare workers, ageing workforce, ageing population, concerns about the need for safer working hours and international working hours trends, and workforce feminisation.

Conclusion

In conclusion, if we want Australia to have the best possible health system we need to change the way in which we currently fund and deliver health services. This requires a commitment from both federal and state governments, health stakeholders, including the medical profession, and the involvement of the community.

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