So far in this election campaign, the Coalition has provided dollar promises for worthy projects but no new health policy initiatives. The government has mentioned one policy of note – to remove family tax benefits from parents who don’t immunise their children.
How, then, can we possibly measure the major parties’ plans for solving the many problems that compromise the delivery of sustainable, quality health care in our country?
Health care in Australia is beset with structural inefficiencies, inappropriate models of care for the diseases we face, and cost increases that are producing major inequities in access. The latter is particularly obvious in rural communities.
Major barriers to real change remain opposition from those with vested interests in maintaining the status-quo and a lack of political leadership to take us on the necessarily long (ten years or more) reform journey that doesn’t fit with the short-term thinking that election cycles engender.
But if we do take that journey, it’s important to have a clear vision of what an appropriately reformed health-care system should look like.
An imagined future
Imagine the following. The year is 2023. The Commonwealth has become the single funder of the public health system.
An independent statutory authority has been established to fund a number of “regional health authorities” that are charged with delivering a model of care that emphasises prevention, timely treatment, and quality, cost-effective care based on need rather than financial status.
These regional authorities are funded on a per capita and local needs basis; state borders are no longer a barrier to efficient health care. The authorities contract a series of providers in their region to supply patient-focused integrated hospital, community and primary-care services.
Quality and safety data are collected and published.
There’s a new model of primary care with a strong focus on disease prevention. People are encouraged to enrol in a primary health-care practice and work in partnership with health professionals to share responsibility for their well-being.
The result is that we don’t just visit a medical practice when we’re ill, we attend to receive integrated primary care with a team of appropriate health professionals, who work collaboratively to help us stay well.
There are very good reasons for this approach. There’s no better use of health-care dollars than ensuring children get a healthy start to life; an obese four-year-old child is very likely to be an obese adult with attendant illnesses.
Continuity of care also provides us with the best chance to detect early signs of mental illness when serious problems can still be avoided.
Primary-care practices, which, significantly, are not doctor-centric, work under the umbrella of primary health-care organisations, which have evolved from poorly structured Medicare Locals.
These act as central service providers for linked, but clinically autonomous local practices and offer clinical services including acute services that don’t require hospital facilities, sparing local emergency departments from inappropriate attendances.
They also provide associated practices with business skills, bulk purchasing, continuing education, the collection of outcome data (now a mandatory requirement), and IT services (including help with further development of now-popular patient-controlled electronic health records).
Primary, community, and hospital care are all seamlessly integrated.
Nurses and allied health professionals deliver much of the prevention program. Most doctors dissatisfied with the “turnstile-medicine” approach fostered by (the current) fee-for-service payments have accepted the opportunity for payment by contract with a regional health authority.
GPs are financially much better rewarded in this system, and the attractiveness of working in the team environment is attracting more medical graduates to primary care (unlike in 2013, when very few medical graduates were interested in such careers).
There’s been a major revision of clinical training in the nation’s universities. “Inter-professional learning”, which has students of medicine, nursing, dentistry as well as allied health professions, spending time learning together, has produced a mutual appreciation of the specific skills of each group.
Combining skills has also resulted in a “team-medicine” approach, which is much more satisfying for professionals and patients alike. How different this is from the professional “silo” mentality of a decade ago when everyone worked separately.
Medical schools in rural-based universities with programs for students with a strong rural affiliation and a desire for a country-based career, are seeing significant numbers of graduates living and working outside of city centres.
Medical education has been shortened without any damage to required learning and is much less focused on hospital-based rotations, with more student time spent in community settings. The old mandatory internship program has been abandoned in favour of post-graduate entry into vocational training programs.
State governments no longer receive Commonwealth funds to run their hospitals but they continue to own and operate them. Funding comes through contracts with regional health authorities.
The services offered by a hospital is negotiated, with emphasis on the quality rather than the number of services on offer.
Role delineation among all the hospitals within a given region avoids duplication and a return to the old system where individual hospitals tended to be islands in an ocean of health-care without coherence.
Many private hospitals offer their services to regional health authorities.
A first step?
So, let’s return to the present, August 2013. Given health care is one of the top three issues of concern for Australian voters, it’s disappointing that health-system reform has so far received so little attention in this election campaign.
We should reasonably expect our politicians to be seriously challenged to provide a detailed and clear vision of the reforms they would pursue to create a more equitable and cost-effective health system that will met our future needs.
But we will almost certainly not get this. And perhaps that says as much about the demise of decent journalism in this country as it does about the state of our democracy and politicians.