Putting a stethoscope to the patient

Is our current health system terminal? Do we need to significantly change the way we deliver health care? According to the Government, the answer is no.

Unfortunately we do not need to look far to see that our health system is cracking under the strains of a growing mismatch between its capacity to deliver quality healthcare and the changing needs of our communities.

It is true that by international standards the health of Australians is enviable. Overall life expectancy is high; as is the number of years we live without reduced functioning due to ill-health. And infant mortality is low.

But numerous inquiries, reports and expert commentary have long highlighted the lack of value for money, enormous waste and escalating costs which make health care inefficient and unfair.

The Federal Parliament alone has conducted three major inquiries into health funding and Medicare, while the Productivity Commission has produced many reports on health-related issues such as the health workforce and medical technology.

There’s a remarkable degree of agreement on what the problems are.

Duplication, cost shifting and buck passing between the Commonwealth and states and territories is legendary and known to be detrimental to patient care.

There is too much emphasis on hospital care and too little on prevention and primary care. There is also too much fragmentation and compartmentalisation between health programs and services.

A chronic shortage of medical staff has been aggravated by turf wars between professions, and an outdated Medical Benefits Schedule (MBS) system that is doctor oriented and rewards more expensive diagnostic procedures and interventions over cheaper preventive and early intervention activities.

Incentives for private health insurance are undermining universal access and pushing up prices for everyone.

Australia also suffers from too many health inequalities and they are growing - nowhere is this more marked than between Indigenous and non-Indigenous Australians.

It would be almost impossible to remain ignorant of the 17-year gap in life expectancy between Indigenous and non-Indigenous Australians or of the much higher rates of chronic health conditions. Infant mortality is also two to three times higher for Indigenous Australians than for non-Indigenous Australians.

Regardless of arguments about the federal government’s motivations in intervening into Aboriginal communities in the Northern Territory, there remain serious questions about whether their strategy is sufficiently coherent, well targeted and properly funded to deliver some real, ongoing health gains. Monitoring the progress of the intervention for practical results, rather than the political pontificating, will be a key task of the Senate after the federal election, assuming the Senate can be returned to being a house that is not controlled by the government of the day.

There are also geographic inequalities between rural and urban Australians and between socioeconomically disadvantaged communities and their wealthier counterparts.

In the socially and economically disadvantaged suburbs of Brisbane, people are more likely to experience ill-health, and more likely to die, than they are in the affluent suburbs.

Similarly, country Australians experience reduced access to health care, and as a result have poorer health and higher death rates than their city counterparts.

Some areas of health provision just continue to miss out completely. Despite the increasing attention that mental health has garnered in recent times, we are still not earmarking adequate resources to meet growing areas of need in mental health and disability services.

Health is a large, expensive and complex system - filled with vested interests. There are multiple competing objectives, expectations and demands and our health care needs are changing.

As Australians live longer, chronic and preventable diseases such as Type 2 diabetes are become more and more common. Older people have increasing expectations about access to operations and procedures that were previously limited. The range of conditions for which existing medicines are prescribed continues to expand, while new and expensive pharmaceuticals and surgical procedures are continually being added to the list of treatment options.

Health spending in Australia now accounts for 10 per cent of our GDP. This put us in the high spenders club internationally. And there are always calls for more money.

But good health policy is not just about throwing money around like a drunken sailor - something we will no doubt see a lot of in the election campaign.

It is not about putting out a spot fire here and there by announcing expensive, ill-thought out programs that will dampen down public concern but not actually address the real problems - such as the federal government’s recent offer to takeover the running of a single hospital in Tasmania. Good health policy is about spending money wisely and engaging with the long term issues.

The Productivity Commission has projected that over the next 40 years spending on health care will increase to between 16 and 20 per cent of GDP. If we want to rein in costs and make sure that that every dollar spent on health is spent wisely, it is time for real change and fundamental reform - not more tinkering at the edges.

The Productivity Commission estimates that a 5 per cent improvement in the productivity of health services would deliver resource savings of around $3 billion each year.

Without political leadership to usher in the reforms which are necessary to address the health care needs of Australia in the 21st century, we are at risk of ending up with an expensive skeleton of a health system that neither addresses health service provision nor meets community expectations.

Local and international evidence points to the steps that we should take to make the necessary reforms.

Currently we are too hospital-centric, endlessly focusing on hospital waiting lists and overcrowding in emergency departments.

We will always need acute hospital services but we could provide more appropriate care for many people through better access to community based multidisciplinary primary care teams which would include GPs, nurse, allied health professionals and other health workers. This should be the cornerstone of a National Health Policy - something we still do not have.

But we must also move from supporting healthcare - or more correctly sickness care - which provides episodic management of ill-health to models of health care which support preventative care and health promotion to a much larger degree.

Prevention of sickness in the first place is one obvious way to try and reduce burgeoning health care budgets. We currently spend less than 2 per cent of the health budget on preventative programs. And there are good reasons why we should increase spending on preventative care.

Take smoking for example. Although Australia has had remarkable success with reducing cigarette smoking rates, smoking still remains the greatest single preventable cause of premature death and disease in Australia, killing almost 20,000 people each year and costing the community an estimated $21 billion per annum.

Similarly, obesity which is on the increase is already estimated to cost the Australian community almost $4 billion a year - $21 billion a year if you include the burden to individuals of living with the disability and illness associated with obesity.

Health is our largest industry, with almost 600,000 employees or 7 per cent of our civilian workforce, but we have yet to seriously tackle the workforce crisis.

We need to be making better use of our existing workforce and that means reorganising the roles and responsibilities of our health professionals and in some cases creating new professions. It also means opening up MBS funding to other health professionals.

We often hear that we do not have enough doctors but many procedures carried out by doctors and specialists could be done by other health professionals. For example only 10 per cent of normal births are delivered by midwives in Australia. In the Netherlands it is 70 per cent and in the UK 50 per cent.

Nurse practitioners, who prescribe medications, initiate tests and X-rays, refer to specialists, and admit and discharge patients, now number 65,000 in the US and are entrenched in its health system. In Australia, they number 100.

We need role renewal and we need up-skilling, multi-skilling, and team work. We also need to restructure the MBS which overvalues diagnostic and surgical procedures, and encourages investment in such interventions to the detriment of lower cost primary prevention and self-care.

We have to start making these decisions based on evidence and start tackling the barriers that are put up by some health professions.

Health care still remains too dangerous. We learnt just how dangerous 10 years ago when the first hospital safety report showed that each year 10 per cent of Australian patients suffered an adverse event because of an error in their care and 18,000 died as a result. At least 50 per cent of these adverse events were deemed avoidable or preventable.

Preventing adverse outcomes would save $2-4 billion a year - not to mention lives and disability.

We also need to change the culture in health care. We only need to look at the Bundaberg Hospital scandal to see how staff who notice mistakes are victimised. We need a culture of openness and transparency so that there is continuous improvement.

A mandatory national open disclosure standard for when things go wrong could help identify problems.

E-health also has a pivotal role to play in improving healthcare. Electronic patient records that go with the individual would enable safer and more efficient health care. It would cut huge amounts of duplication - saving time on collecting basic information, cutting down on the repeating of tests as people move from doctor to doctor and results are lost or not shared in a timely fashion, and improve medication adherence.

A national system of shared electronic health records that protects patient would support better clinical decision making, avoid waste in equipment, supplies and resources and support continuity of care and self-management.

And we need to tackle the elephant in the room - private health insurance. Private health insurance pushes up health costs and doesn't deliver better health care - taking into account the 30 per cent rebate, the 1 per cent tax penalty and other measures support for the private health insurance industry is costing about $6 billion a year.

This money could be used for more important services in Indigenous health, mental health, primary care, prevention and dental care.

If the government was to fund private sector providers directly this would still provide support to the private health sector and it would save the administration costs. Private hospitals would be better off and it would also give the government some control over costs - something that the PHI sector has not been able to do.

Health care is changing, resources are limited, and not everything can be done but the only voices we tend to hear are the doctors, pharmaceutical companies and health ministers. We need to involve the public in debates on health care and what we want for the future. One thing is clear - we can’t continue to operate using the same complex, convoluted and increasingly inequitable system to meet our future needs.