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