A health care system for the 21st century

Rebecca de Boer and Dr Rhonda Jolly, Social Policy Section

Despite frequent media reports to the contrary, Australia has a good health care system. But it could be better. Politicians, policy makers and the public are often captured by the health ‘problem of the day’ as presented by its advocates. Recently, mental health and dental care have featured prominently. Not long ago similar attention was directed to hospitals. As arguments could be made for more funding to improve access to services in all these areas, how can the limited budget be prioritised to meet not only the needs of these sectors, but to improve health outcomes overall?

Under current arrangements improvements in some of these areas can, and have been made. However on average, Australians are less healthy than they were ten years ago. The challenge of how best to address rising health expenditure and the growing burden of chronic disease persists.

Some have argued that decision makers need to engage in visionary thinking that looks beyond addressing individual sectoral needs. Reorienting the health care system towards prevention and improved integration has been offered as part of the solution to addressing this challenge. A flexible workforce, enabled by technology including electronic applications (e-health) is also increasingly being seen as critical to achieving these objectives.

The Rudd Government’s National Health and Hospitals Reform Commission (NHHRC) put forward a range of proposals that would go some way to a more integrated health care system. Despite the Government’s response to the NHHRC, there are fears that any opportunity for significant, structural change may remain elusive, at least in the short term.

Early intervention, prevention and integration

Hospitals remain the primary focus of the health debate and receive significant amounts of funding. This is despite evidence which suggests that Australia is over reliant on hospitals and that there would be benefits if more were spent on preventative care than the mere two per cent of the health budget currently allocated.

There have been calls such as those from the NHHRC for government to adopt a ‘primary health care’ approach when planning the health care system. This concept of primary health care involves more than the ‘first point of contact’ with the health care system or a consultation with a general practitioner. It represents a comprehensive model of care that integrates the various health sectors and emphasises early intervention and prevention. Evidence emerging from some health care providers in the United States (US) and from Spain suggests that a primary health care approach has been successful in improving health outcomes and reducing overall expenditure on health.

However, for Australia the challenge is that implementation of such an approach would require adopting a different attitude to funding, delivery and organisation to that of the current system. It would also require re-consideration of the role of governments in the provision and funding of health care, which currently is largely the domain of the states. Arguments have been made that a single funder for the provision of all health care would help to address structural challenges and influence such change. Alternatives such as the concept of a ‘medical home’ (Kaiser Permanente in the US is an example) could also be considered. The medical home is responsible for the continuum of care for its patients, from prevention to acute care. These approaches would however, require moving beyond the traditional divide between the public/private provision of health care.

Flexible workforce

The question of what needs to be done to match the size and shape of Australia’s health workforce to the changing needs of health consumers has long been debated and is far from resolved. Any new approaches to health care and organisation of the health care system will also require changes to the health workforce.

Shortages across the health workforce are the result of complex and multifaceted interactions between demographic, social and clinical factors. A limitation of the numerous strategies and initiatives has been that solutions have not been multi-dimensional. Strategies have increased the supply of some workers to the exclusion of others, favoured one profession over others, or sought to enlist workers in some geographical areas or types of care in preference to others without consideration of the overall outcome.

Workforce reform is unlikely to be achieved through the tweaking of either supply or demand; reform involves addressing all aspects of the system from all perspectives. Integral to the challenge is likely to be the breaking down of long-standing and entrenched traditional professional boundaries.

A further challenge will be to introduce a concept of workforce flexibility which does not tie health workers to particular expectations about the care they are able, or should deliver, and which responds to health needs. This flexibility would therefore entail continuous re-assessment of skills mixes across professions and more responsive education and training programs.

E-health

A growing body of research has highlighted the role e-health may be able to play in delivering a safer, more equitable and more efficient health system. E-health cannot be considered a ‘silver bullet’. However, it is expected to achieve efficiencies by reducing medical errors associated with lack of access to patient information and adverse drug events, as well as time and costs associated with duplicated or unnecessary treatments and tests. While e-health offers great potential, it would also need to be approached in the context of re-evaluation of the overall system. Careful scrutiny by the parliament will be required to ensure that technology does indeed deliver what it promises—better outcomes for patients and health professionals at a cost that the community can afford.

Future prospects

Changing patterns of disease and improvements in medical and communications technology are contributing to the momentum for a new approach to ensure that the Australian health care system is responsive to the demands of the 21st century. Such an approach may well involve major changes across the entire health care system—from funding models, to service delivery, to workforce. A strong commitment to prevention and addressing the social determinants of health would seem to underpin such changes. The challenge for policy makers, parliament and the public would be to accommodate moves away from more traditional approaches to health policy to objectively consider alternatives that may run counter to vested interests.

Library publications and key documents

National Health and Hospital Reform Commission (NHHRC), A healthier future for all Australians – final report, NHHRC, 2009, http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/nhhrc-report

National E-Health and Information Principal Committee, National e-health strategy, Deloitte, 2008, http://www.health.gov.au/internet/main/publishing.nsf/Content/604CF066BE48789DCA25751D000C15C7/$File/National%20eHealth%20Strategy%20final.pdf

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