Health care reform should top the agenda

hal-swerissen-thumb Professor Hal Swerissen

Originally published on the Crikey website on 17 February, 2010.

Health reform is a critical issue for Australia. The population is ageing and the number of people with serious chronic diseases like cancer, heart disease and diabetes will increase. Concerns about the impact of lifestyle, particularly obesity, on health are growing.  As a result, demand for health services will grow dramatically over the next 25 years.

Unfortunately so far there has been too much emphasis on trying to ‘fix hospitals’, and not enough attention on the ‘front end’ of health: prevention and primary health care.  In 2007-08, approximately 730,000 hospital admissions could have been avoided by better primary health care and prevention.

As is evident from the recent discussions around public health reform, effective prevention and care of chronic disease in the community is not easy, and the current design of our primary health services is making it that much more difficult. The evidence points to primary health services which provide sustained, integrated, team-based services focused on prevention and care for chronic disease for geographic or enrolled populations.  People need universal and affordable access to these services.  There needs to a heavy focus on assisting people to maintain their own health through preventive measures and to self manage chronic disease if it occurs.

Currently, Australia does not have a comprehensive national primary health care strategy. Primary health services are disorganised, fragmented and dominated by small scale, general practices with little capacity to provide or manage comprehensive care. Coordination and management between acute hospital, rehabilitation and primary health services is poor, particularly in metropolitan areas.

People with complex and chronic conditions are forced to navigate a confusing mix of care provided by general practice, specialists, hospitals, home-based providers and rehabilitation services. Far too often, no one has overall responsibility for coordinating these services for the patient.  All too often the patient’s GP is sidelined into a peripheral role.

As a result, patients often have poorer health outcomes than ought to be the case, including unnecessary distress, disability and death. They have time consuming, costly and inefficient experiences. In many cases they use more services than necessary, and avoidable hospital admissions increase.

There are a number of concrete, achievable reforms to the primary health care system that should be put in place to address these issues. These have been canvassed in the report of the National Health and Hospital Reform Commission, and in the Federal Government’s draft National Primary Health Strategy.

Firstly, the Commonwealth and the States should agree that someone has to be responsible for organising and managing primary health for local communities to get better health outcomes. Primary health organisations should be set up for this purpose. These organisations should have responsibility for the primary health services for a geographic population. They should have independent boards and the financial and regulatory powers to plan, organise and manage the range of state, private and community health services that make up the local primary health system.

These new organisations should plan and manage the local implementation of primary health programs, including the Medicare scheme. They should foster and oversee system reform to develop more integrated, comprehensive, timely, extended and competent primary health care services.

The States could enter into agreements with these new organisations to commission and manage primary health services on their behalf. These new organisations would also form a vital link between hospitals and community-based health services to drive better outcomes for patients.  Exactly how these arrangements are organised could vary from state to state, and across geographic regions, depending on history and need.

Secondly, the Medicare system needs to be reformed to allow people with chronic and complex conditions to voluntarily enrol in an enhanced Medicare program that provides more coordinated and comprehensive care to better meet their needs. GPs need to be placed at the heart of these reforms and given more responsibility for the performance of specialists, allied health practitioners, hospitals and rehabilitation providers. They need a much greater role in being advocates for their patients to get better outcomes.

Thirdly, there needs to be much greater support to encourage prevention and self management through the primary health system. Around 80% of the population has contact with the primary health system each year. Prevention is largely self-managed by individuals through their diet, physical activity and avoidance of health risks. Information, encouragement and advice for prevention has to be provided on a much more systematic and sustained basis by primary health practitioners.

Reform of the primary health system has great potential to make a difference to Australian health outcomes.

Prime Minister Rudd could go a fair way to ‘fixing the hospitals’ by putting in place a comprehensive, competent and coherent national primary health system.