Principles and practice: a better system of health care

About a decade ago, the Canadian Government recognised that its forty year old Medicare system was in urgent need of reform or ‘renewal’ as they termed it. The problems they faced would be familiar to Australians: doubts about sustainability, waiting times, crowded Emergency Departments, poor access to care for minorities and Indigenous people, looming workforce shortages, chronic disease and the demographic shift.

The Canadian Government’s first and seminal action was to create a Health Transition Fund (HTF) to stimulate creative thinking about how to change the culture and practice of the system to make it more responsive, effective and efficient. The premise was that building up an inventory of evidence-based innovation would smooth that transition. A joint effort of federal, provincial and territorial governments with a budget of $C150 million, the HTF supported about 140 different pilot projects or evaluation studies across Canada between 1997 and 2001. Initially, four key theme areas were studied: primary health care; pharmaceutical issues; home care and integrated service delivery. As the program developed and submissions were received, other topics were added: children’s health; seniors, mental, rural and indigenous issues.

The impact of the first HTF was out of all proportion to its moderate cost. With four fifths of the investment devoted to provincial projects, cooperation between federal and provincial authorities improved dramatically. Many projects actually altered policy and practice: a most significant outcome has been the distinction drawn between ‘primary medical care reform’ which is concerned with the way the initial contact between a patient and a medical care provider – usually a GP – is provided and ‘primary health care reform’ which is concerned with population health, preventive medicine, health education and promotion.

Almost half of the HTF projects were concerned with primary health care, focusing on broadly based community health programs that feature the best use of a region’s health providers to maximise the health of the patient population and the best use of the health resources of the system.

The importance of keeping people well as a strategy for minimizing the pressures and costs of acute care was strongly advocated. Health Canada identified three major challenges in 2001 and I suggest that these apply equally in Australia today:

First, disadvantaged groups have significantly lower life expectancy, poorer health and a higher prevalence of disability than the average Canadian

Second, various forms of preventable disease and injury continue to undermine the health and quality of life of many Canadians; and

Third, many thousands of Canadians suffer from chronic disease, disability or various forms of emotional stress and lack adequate community support and help.

In addressing these challenges, Health Canada initiated a Royal Commission on the Future of Health in Canada. The Commissioner, Dr Roy Romanow, once First Minister of Ontario, summarized his recommendations thus:

In terms of modernizing the system’s foundations, I propose establishing a Canadian Health Covenant that expresses Canadians’ collective vision for health care and that outlines the responsibilities and entitlements of individual citizens, health providers, and governments in regard to the system. We need consensus on why the system exists, what it is intended to achieve and how its component parts should fit together. This is vital to restoring the public’s confidence in the system.

I also am proposing to modernize the Canada Health Act by updating the principle of Comprehensiveness to include priority diagnostic and homecare services, by clarifying the principle of Portability to guaranteeing portability of coverage within Canada, and by adding a sixth principle of Accountability.

Finally, I am proposing the creation of a Health Council of Canada. This inter-governmental Council would serve as a meeting place and focal point for collaboration among governments, providers and citizens in establishing overall system objectives, common indicators and benchmarks, criteria for measuring, tracking health and reporting to Canadians on system performance.

It is too early to claim that these initiatives have transformed the Canadian health system. There are still delays in accessing some elective procedures and access to needed medical care is still far from universal, but there are strong signs of improvement and some constructive innovations are changing ideas about the priorities a modern twenty first century health system should adopt.

For example, there is a clear indication that equity and economic efficiency are inseparably linked. We too must find ways of keeping people well, of providing timely solutions to simple problems before they become complex and costly to fix.

We know that the burden of disease falls most heavily on the least affluent, the most disadvantaged. Do we care? Do we care if someone cannot afford to see a dentist, a podiatrist, a physio, a GP or to get a prescription filled? We wring our hands about the health of aboriginals and their appalling life expectancy but is our anxiety for their welfare or about the reflection their condition casts on international perceptions of our culture? The homeless, the mentally ill warehoused in our prisons, do we care? Population health demands proactive thinking. It is about more than the provision of primary care services even if those services are adequate – and they are not.

The example of the Association of Ontario Health Centres is explicit:

Our vision is rooted in a care model that provides comprehensive primary care services, delivered by multi-disciplinary teams of professionals practicing within a health promotion framework. This means that by working with individuals, families and groups we increase individual and group capacity in building health communities. In fact, we are a key source of community infrastructure with which to deliver a range of integrated community-based services and to respond to health-related community concerns. Our member centres are specialists in delivering primary health care that is integrated with other social and health services partners.

Our care model is highly effective for all Ontarians. At the same time, it is a resource for people who encounter a diverse range of access barriers such as language, literacy, poverty and geography. It also works for those with other social-cultural barriers and who are at high risk for developing health problems.

Our Association engages in research, develops policy and advocates in support of this community centred primary health care model. Our member centres are located throughout the province and we work directly with communities who want community primary health care.

The need to staff their multi-disciplinary primary health care teams has obliged the Canadian Provinces to devote very significant resources to recruiting and training Nurse Practitioners and other health therapists, educators and allied health professionals. As more patients experience their care, Nurse Practitioners are proving increasingly popular wherever they have been employed. And graduate RNs are beginning to appreciate the new career paths and the much increased job satisfaction that post-graduate Nurse Practitioner qualifications provide.

Election year directions for Australia

We have not yet seen the pre-election health care proposals of the major parties but we can hope that they will include some of what Canada has done. For example,

  • An Australian Health Covenant through which the Australian people express ‘their collective vision for health care’ and ‘outline the responsibilities and entitlements of individual citizens, health providers and governments in regards to the system’ is surely overdue.
Our health systems have grown like topsy, responsive to the loudest headlines, the latest technology, the most miraculous drug. Before they become even more fractured, more inefficient, more bureaucratized and more costly we must formally ask Australians what they want their health systems to deliver and their priorities for the allocation of finite resources.
  • An Australian Health Council should monitor and report to the people on the health of the health system, encouraging cooperation between the states and the Commonwealth, fostering innovation and communicating best practice. The Australian Institute of Health and Welfare (AIHW) does a wonderful job in collecting and publishing the health system data, but it is not independent and does not report to the people.
  • A broad ranging committee of enquiry similar to Romanow is needed to address medium to longer term health issues that need public discussion and expertise. The State based Enquiries, the Australian HealthCare Alliance, the Productivity Commission and the Blame Game reports have identified significant shortcomings in the arrangements now in place in Australia but all of these lack the authority of a Royal Commission.
  • The regions of Australia are not homogeneous and one size does not fit all. Social, economic, climatic, demographic variables should dictate a need for an effective, routine public consultation process. An Innovation Fund to support and pilot test new approaches in the delivery of primary health care would, as in Canada, deliver major benefits.
  • First things first. The basis of an effective health system must be primary health care, the service provided to the patient when they first recognise that they have a problem. The ‘one-stop-shop’ neighbourhood health centre, always open, is increasingly seen as the most efficient and effective use of resources, where a multi-disciplinary team is able to provide most non-acute care, including diagnostic procedures and maintenance procedures such as renal dialysis for which most patients must now visit a public hospital. The need for such centres can be seen in the crowded Emergency Departments of public hospitals, crowded because the people have nowhere else to go for often trivial problems.
  • General Practice is changing, the traditional family doctor now rare with doctors ageing as fast as the rest of the population. Increasing numbers of female GPs work a two or three day week; perhaps no more than one in five urban GPs works a five day week. Many practices have been acquired by commercial interests and now employ considerable numbers of salaried and part-time GPs and Practice Nurses. As in New Zealand and Canada, some practices now employ effective teams of allied health professionals. For this trend to have a major impact on population health, there must be a reconsideration of the Medical Benefit Schedules to ensure that the least affluent in society – who have the heaviest burden of disease and the most destructive lifestyles – have access to the full range of these services.
  • The restrictions placed on medical school places for doctors and nurses a couple of decades ago – a knee jerk reaction to rising health care costs – is responsible for serious and growing shortages of doctors and health professionals. The recommendations of the Productivity Council’s exhaustive Report on Australia’s Health WorkForce must be implemented. The costs of medical education also need examination. If HECS fees are so high that specialisation attracts too many graduates away from general practice, that effect should be recognised and countered.
  • The funds invested by Commonwealth and State authorities in prevention, health promotion and health education are totally inadequate. It seems extraordinary that, when the positive returns from preventive programs exceed four times their cost, there is so little interest in them. For example, current debate about national curricula ignores the need to provide all children with a knowledge of health theory and practice; and very many schools now fail to provide students with regular participation in compulsory team games and physical activity. It is not enough for people, young and old, to have a theoretical awareness of their personal responsibility to maintain a healthy lifestyle: they need easy, affordable access to the providers of interesting, challenging community based recreational activities.

Finally, the involvement of the people, locally and nationally, in decisions about priorities for their health system and the delivery of their health services – envisaged by Romanow as a Covenant, and mooted in Australia as citizen juries – would introduce a most important element of realism into decision making. John Menadue has spoken about ‘the hospital tail wagging the health system dog’ and glamorous, exciting acute techniques and drugs will always attract headlines. But the things that matter most are the basic necessities involved in keeping people well. And Government seems reluctant to establish effective, affordable, accessible strategies for keeping Australians well.

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