Why health care reform is vital
Why health care reform is vital
28 Jul 2009
Professor Hal Swerissen
First published in The Age on 28 July, 2009
While Australia has comparatively good health outcomes at an affordable price, we face a number of challenges over the next three decades. The population is ageing, costs are rising, there are significant gaps in service delivery - particularly for people with chronic diseases and those who need dental care - and there are significant opportunities to improve efficiency and quality.
Unfortunately, the politics of health care is driven by access to hospitals. Waiting times for elective surgery and emergency services dominate discussion, the media and elections.
In reality the problems are more deep seated. Australia effectively has nine different health care systems - one for each of the states and territories and, most importantly, one for the Commonwealth. It is the boundary issues between the Commonwealth and the States/Territory responsibilities for governance, funding, regulation and performance that produce political controversy, blame shifting and back biting. Arguably they also result in gridlock and inertia in tackling the problems.
The proposals from the National Health and Hospitals Reform Commission provide a useful framework for addressing these issues. The Commission has organised its thinking around four issues: taking responsibility for health; connecting care; facing inequalities; and driving quality performance. All are important, but the one that offers the greatest promise for health care reform is connecting care more effectively.
Notwithstanding the very real concerns about waiting times for elective surgery and emergency services and the concerns about the quality of care in hospitals, the renovators' opportunity for the Australian health care system is primary health care and prevention. It is here that much better connection of care is needed for consumers across programs, services and governments.
While there has now been the best part of 20 years of concentrated reform of the public hospital system, much less has been done in relation to a national approach to improving primary health care, community care and prevention.
The past 30 years have seen a progressive closing of large scale institutions for people with mental illness and disability, a reduced emphasis on nursing home care and reductions in length of stay in hospital. Consequently there are now far more people with complex and chronic conditions living in the community who need primary and community care. But this sector has grown layer upon layer as different funding, coordination, eligibility, regulatory and service delivery models have been developed by Commonwealth and State/Territory governments. As a result it is fragmented, uncoordinated and difficult to negotiate for both consumers and health professionals.
Population ageing and the increasing problems of risk factors - from obesity, to smoking, physical inactivity and alcohol consumption - will see a dramatic increase in chronic diseases such as heart disease, cancer, chronic respiratory disease and kidney failure. These are complex, problems, without easy solutions.
The problem for the health service is compounded by increasing rates of dementia, musculoskeletal conditions and mental illness. Often admission to hospital for these conditions occurs when we have inadequate care in the community.
People with emerging risk factors, which are likely to lead to chronic disease, need comprehensive and sustained assistance to help them to reduce their risks. Those who do develop chronic conditions want to be able to live at home and in the community. They need coordinated, integrated and continuous care to make that possible, yet too often they end up in emergency departments in distress because that care is not available.
Medicare works well for people who have relatively straightforward health care needs but it is not well-designed to address the needs of those with complex and chronic conditions. (And, of course, dental health is an exception here as it remains a major problem for people on low incomes).
In assessing the quality of health care in this country, it needs to be understood that the public hospital system should not be the first point of contact. It provides the backstop for the primary and community care system. If the first tier of the health system is not working well, then the hospital system will be put under stress.
Not only will a stronger primary care system improve people's quality of life by preventing disease, disability and distress, it should reduce pressure on the public hospital system.
The National Health and Hospital Reform Commission has provided a detailed set of proposals to address the problems of the health care system, proposals that must now be debated between the Commonwealth and the States/Territories. While it is unlikely that their proposals will be accepted in their entirety, we now have a thorough reform document for the Australian health care system for the first time in a generation. This puts all the stakeholders in the health care system under pressure to produce an agreed set of directions for the next generation. It is important not to lose this opportunity.