The great heath care awakening

Those involved in primary health care will smile wryly as they read the Final Report of the National Health and Hospitals Reform Commission of June 2009 - A Healthier Future For All Australians released yesterday and peruse the proposed elements for redesigning the health system.  The first element is ‘to embed prevention and early intervention into every aspect of our health system and our lives’. 

This is exactly what has been advocated by family physicians for over 40 years.  When the principle of prevention and early detection of illness was advanced in the seventies as the most effective approach to improving health and lightening the burden on hospitals, it was not taken seriously until a minister in the Whitlam Government accepted that thesis and continued the funding of the Royal Australian College of General Practitioners’ training programme for family doctors.  Despite that display of support for this principle, the pre-eminence of the specialities at the time curbed its widespread acceptance by the medical profession.  All that has now changed as even the narrowest of specialties recognizes that preventing illness and detecting it early is not only better for the patient, but far less costly than having to undertake complex management of advanced disease undetected until in its late stages. [more]

The Report also emphasizes that the primary care sector is where prevention and early detection is mainly carried out.

This is the great health care awakening.

The second element is ‘to connect and integrate health and aged care services for people over the course of their lives’.  Again, that is a principle that has been accepted by family doctors for many decades.

The Government’s commitment to embrace primary care and extend its services is laudable.  There have been countless studies that have shown that what patients want of their doctors, or for that matter all health care providers, is that they give them time and a listening ear, that they really understand their problems, that they explain to them their nature and their cause, and that they then discuss with them the options for management and counsel them about the most appropriate way to proceed.  They also want to be properly examined and assessed, and to receive advice about lifestyle, healthy living and the avoidance of illness.  All this requires a supportive and understanding relationship between doctor and patient over an extended period.  All this takes time. 

Barbara Starfield of The John Hopkins Bloomberg School of Public Health in Boston, a preeminent researcher in health care delivery, has shown, as have many other researchers, that “There is lots of evidence that a good relationship with a freely chosen primary-care doctor, preferably over several years, is associated with better care, more appropriate care, better health, and much lower health costs.”

So if primary care is to be the mainstay of the new health care system, whereby much health care is transferred from hospital to community settings, there will need to be augmentation of that workforce so that there are enough to give the time and expertise that the system will require.  There will need to be more family doctors, community nurses, and all the other support personnel to sustain the system.  The training that is needed has been established long ago, the facilities needed for training are well known; what is needed is more of these key health care players to provide the services.  There is a chronic shortage of doctors, nurses and ancillary personnel, especially in rural, remote and indigenous regions that needs to be corrected.  That’s where funds will be most cost-effectively expended.

Yet there are still those who place the emphasis on the need for more hospital beds, pointing out that most hospitals are running at 100% occupancy, which inevitably results in delays in admission, especially from emergency rooms simply because there are no vacant beds.  A Centre for Independent Studies report advocates 85% occupancy as a solution, and sees more hospital beds as a priority.  No doubt more beds are needed, but that need should be tempered by a more important consideration, how to keep people out of expensive high-care hospital beds.  There’s an old saying – care should be provided at the level in the health care system that is appropriate to the patient’s needs.  It is wasteful to have an elderly person who needs only supportive care in a high-tech tertiary hospital bed that should be occupied by someone who needs that advanced care.  That is a logistic problem. 

The other way to keep people out of hospital beds is to avoid the conditions that drive them there.  If there were fewer heart attacks because of healthier lifestyles, there would not be the same need for intensive care wards.  If there was less obesity and type 2 diabetes because of improvements in community care, there would be less need for hospital beds to manage out-of-control blood glucose and its many and serious complications.

Before the election, Kevin Rudd made the commitment "that if elected to Government, the Commonwealth would take responsibility for major reforms of Australia's health and hospitals system and that if the States and Territories were not willing to implement cooperatively a comprehensive health and hospitals reform plan to end the blame game, the Commonwealth would take the matter to the Australian people for a mandate to take full funding responsibility for the system.’"

Since election, the Government has undertaken the most comprehensive review of Australia’s health care services in two decades.  Major problems have been indentified by the ten-person National Health and Hospitals Reform Commission and 123 recommendations have been made.  A period of community consultation about the recommendations is now in place, and will followed by a COAG meeting later this year where the Commonwealth will put to the States and Territories a reform plan that they would either agree or disagree with as a future direction for health and hospitals reform, and that should they disagree, a proposal for a Commonwealth takeover of Australia’s hospitals would be put to the people at the next election.  Kevin Rudd’s full announcement is here.

In response to this NHHRC Report, which contains so much information, and makes so many crucial recommendations about how to remedy the problems the health care system faces, all the Opposition spokesmen, Malcolm Turnbull and Peter Dutton could manage were the tired old mantras ‘too little too late’ and ‘Rudd has broken his promise to fix the health care system by mid 2009’.  It really is pathetic that this is all they could say, even when invited to comment on the content.  Dutton protested that he had had the report for less than 24 hours and had not had time to digest it.  If he had taken the trouble to burn a little midnight oil like Government ministers do all the time, he might have had something about which he could have commented.  Was his inability to comment the result of laziness, incompetence or disinterest, or all of the above?  Is it any wonder the Coalition's and Turnbull's poll ratings are so poor?

Media commentary has generally been favourable but that did not stop the experienced Michelle Grattan, who should have known better, from saying in today's Age: “Rudd’s real problem is one of credibility — before the 2007 election he gave the impression he could ‘fix’ the hospitals and of course that’s a long, difficult challenge that won’t be met any time soon.”  Whatever ‘impression’ Grattan got, it was not what Rudd actually said.  TV and radio journalists have expressed similar sentiments.  It’s tiresome to have to deal with journalists who seem unable to separate what was actually said from the ‘impressions’ they gathered from it.  It's not Rudd's credibility that is in question.

At least Grattan seemed to grasp that ‘fixing’ something as extraordinarily complex as our health care system is not something that can be achieved with the snap of the fingers.  This system, of which we should be very proud since it is world class, is failing in parts, and needs reshaping to meet future needs.  But reshaping such a complex system will be full of twists and turns, will be beset with countless difficulties, will encounter resistance from people and sectors that do not want to change, and will be time consuming and costly.  But we must begin and persist until the job is done and then set in train a process of continual review to enable the new system to renew itself, stay up to date, and continue to give excellent health care to the people of this country.

What do you think?

There will be other items on this subject on The Political Sword in the days ahead.

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janice

29/07/2009You can bet your last dollar that the Coalition and the media will have nothing but negative criticism to offer as has happened with every other issue. The fixing of the nation's heath system is going to be a mammoth task for the Government. IMO I think the Government should focus on the public hospital system and leave the private system to those who want, and can afford, 5-star accommodation and the private health care insurance without taxpayer support. I like the idea of providing separate emergency hospitals. The government needs to made provision for top pay and conditions for doctors and nurses who work in the public system. To address the lack of doctors in rural and remote areas, I think this could be solved by changing the Provider Number system. If Provider numbers were issued to districts/towns/cities rather than to individual doctors, the doctors would have to go and practice where there are vacant provider numbers. Here, in my town, we have a fairly new $5m hospital which has something like 13 aged care beds, 5 acute-care beds and a paliative care ward. So far two doctors have come and gone because their wives and familes refused to move away from city facilities. Understandably, the doctors gave in after commuting long distances every second weekend to be with their family. This of course, left the town without a doctor every second weekend. Our shiny new hospital is nothing more than an aged-care facility which we appreciate, but it could be so much more.

Ad astra reply

29/07/2009janice, You’re probably right – negativity will be the dominant theme of the Coalition, coupled with an almost complete absence of positive comment and suggestions about how to improve the health care system. I was disappointed that on [i]AM[/i] yesterday the Shadow Health Minister Peter Dutton, pleading that he hadn’t had time to digest the NHHRC Report, performed so poorly. When he was scheduled to appear on [i]Lateline[/i] last night, with another day to study the Report, I watched hoping to hear something more constructive from him. Again, I was disappointed. He was intent on repeating the ‘broken promise’ mantra which he did to Tony Jones’ annoyance. Despite Jones’ efforts to extract from him some of the Coalition’s position on several issues, such as taking over hospitals, consolidating bureaucracies, dental care, the value of community consultation about the Report’s recommendations, he waffled, avoiding any well-defined position, presumably having been warned by his spin doctors not to commit to anything. He insisted the Government was ‘full of spin and hype’, but proceeded to display an abundance of this himself. If you missed [i]Lateline[/i], here’s the link to the transcript. http://www.abc.net.au/lateline/content/2008/s2639240.htm To provide a supply of emergency beds there could be emergency hospitals, or beds assigned specifically for emergency cases. The idea of having dedicated elective surgery hospitals (we have one in Melbourne at the old Repatriation Hospital which is attached to the Austin Hospital) means that elective surgery can proceed there as scheduled, uninterrupted by emergencies. But it also frees up acute beds at the Austin for emergencies, beds that might otherwise be occupied by elective surgery cases. I like your idea of assigning provider numbers to ‘districts/towns/cities rather than to individual doctors’. I’ve never heard that before. Servicing rural areas has been a problem for decades. In the days when doctors’ spouses were content to be a ‘partner’ in the practice rather than pursue their own agenda, it was easier to attract doctors to the country. Today most spouses have their own career and often find it difficult if not impossible to follow it in a rural setting. Then there’s the issue of the education of their children. Boarding school seems to be a much less attractive option than it was a few decades ago. Rural practice is most attractive and professionally rewarding for those who enjoy the responsibility and satisfaction of being multi-skilled, and existing programmes train graduates comprehensively for this role. But the problem that has never been solved is the long-term retention of these well-trained and proficient doctors in the country when there is so much pressure to return to the city for the sake of the family. Kevin Rudd has a blog, the current topic being [i]Australia’s hospital and health care system[/i] which is open on this topic until 31 July. It is at http://www.pm.gov.au/PM_Connect/PMs_Blog Why not make your suggestion about provider numbers there? You might get stir up interest in your novel idea.

janice

29/07/2009I did post on Kevin's blog Ad Astra. I also sent an email putting forward this idea of mine re provider numbers to Nicola Roxton some 12 months back. To me, the only way to get an even distribution of doctors across the nation is to allocate provider numbers to districts/towns/cities rather than to individual doctors who all tend to accumulate in big towns or cities. I don't have a lot of sympathy for the exuse about educating the kids since I don't see that our rural kids are more poorly educated than those in the cities! There is, perhaps, something in the career bit for the wives. But hell, there is plenty of scope out in the sticks for anyone qualified in anything so there are fulfilling careers to be had and pursued.

janice

29/07/2009I should add that there is no reason why a doctor who took up a provider no in a rural area is doomed to remain there - However, when that doctor did decide to move back to city living, he would only do so when a city provider no became vacant or he might do a 'swap' with a city doctor. Once doctors actually get out into rural areas and settle into the community, most of them wouldn't leave. Doctors in rural communities are not only welcomed with open arms but are almost worshipped and treated with a reverance and respect not given to any other member of the community. They become the biggest, most important fish in a small bowl, and, I'm sure get a great deal of satisfaction out of their medical expertise.

Ad astra reply

29/07/2009janice, Glad to see you’ve sent your provider number idea on. I hope it is given proper consideration. I know well the joys and satisfaction of working in a rural practice and the respect that goes with it – there is no better place to work. Regarding education, when there was no secondary education available nearby, there was little option than to use boarding schools. Education is very good now in the closer regional areas, but doctors in remote areas with no ready access to secondary education still face the education dilemma.

janice

29/07/2009I take your point, Ad astra, about secondary education in remote places but most places do have secondary schools within reach and kids are bussed to and from them. It is Uni education that causes the most angst but then, by the time the kids are ready for university they are young adults and ready to fly the nest anyway. If Labor stay in office long enough, perhaps there will be education reform in rural and remote areas as well? Anyway, everyone who lives in rural and remote areas face the same problems and therefore it is not, or should not be, a bigger dilemma for doctors than for the rest of us. IMO the Rudd Labor Govt needs to re-install top class technical education in rural areas because this is where rural Australia was cheated during the Howard era. I spent my childhood years out in the remotest areas of Central Australia. I went to boarding school in Alice Springs from aged 6 - 14 years as did many other kids like me. I saw many of these kids go on to university. Although I had a yen to do vetinerary science or medicine and my parents would have scraped up the money to support me, I was stopped dead in my tracks because I couldn't pass maths which was a compulsory uni entrance pass. It wasn't until I had my first son who turned out to be dyslexic, that I discovered that I was also dyslexic and that my dyslexia involved numbers. My son differs in that his dyslexia was more profound and involved reading and letters and numbers to a lesser degree. Strangely, in helping my son learn to overcome his problem, I helped myself to a degree but maths is still my weak link. The point in the above ramblings is that despite the remoteness we kids all got a good education and the towns' three or four doctors didn't see the necessity to send their kids off to boarding school in Adelaide until they were ready to go to uni.

Ad astra reply

29/07/2009janice, Frankly, I don’t understand why maths was considered a prerequisite for medicine. I had similar difficulties with maths, but managed to make that up via other subjects. I can assure you that apart from statistics, maths is of very little use in medicine.

janice

29/07/2009 Ad astra, I agree that maths is of little use in medicine LOL. However, back in those days, in order to gain entrance to university one had to pass the compulsory subjects of english and maths. I had no problems with english as I always managed to pass an english exam with honours but throughout my schooling I was unable to progress further than basic maths, or as it was called then, commercial arithmetic. If only I had known the reason why my brain addled numbers I would have found ways around the problem just as my son did when he understood his dyslexia and learned to cope with it.

Just Me

29/07/2009Interesting idea, Janice. I never heard it before either. Hope they give it serious consideration. But good luck getting doctors to go along with it quietly.

Bushfire Bill

30/07/2009[i]"It’s tiresome to have to deal with journalists who seem unable to separate what was actually said from the ‘impressions’ they gathered from it. It's not Rudd's credibility that is in question."[/i] I think Grattan menas that the "impressions" were "gathered" by the general public, i.e. [i]her readers[/i]. If they got the wrong impression, then whose fault is that? Clearly, hers and her colleagues'. Another one of these is the way most interviewers, especially on the cowed ABC, let Turnbull et al get away with the following: [i]"Kevin Rudd said he would take over health by July 2009. He has not. This is just another broken Rudd promise."[/i] As I understand it, the Commonwealth Constitution does not list "Health" as one of the reserve powers available to the federal government, Rudd's or anyone else's. Therefore to take over Health, there must be a [i]referendum[/i] to change the Constitution. This is what Rudd said he would do, presenting the question at the first available election, i.e. 2010, [i]after[/i] a national debate on the pros and cons of such an amendment. [i]This is exactly what is happening[/i]. There is no broken promise. In fact, Rudd is [i]keeping[/i] his promise. So, why to radio and TV interviewers let Opposition spokespeople just blather the untruth about "broken promises" out without correcting them? Welcome to the world of "Balance", where my lie is as good as your lie, and the only "fact" involved is that the lie was uttered in the first place. This, of course, is how "impressions" are "gathered". Lazy (at best, corrupt at worst) journalists letting oppositions and governments lie, and repeatedly lie, until what they are saying becomes "generally accepted". Who are the journalists, meek and humble servants of their readership, to quibble with what the public has had impressed upon them? They're just the piano players... but only when it suits them.

El Nino

30/07/2009The relatively small side issue of homebirth might be an indicator that the government may not have a lot of appetite to take on vested interests on the issue of hospital vs. community-based primary care. I certainly hope that I am wrong. The heart of the matter goes to some underlying conflict between primary health care givers and specialists. As Roxon said on the homebirth issue, "we are trying to work with midwives and obstetricians and others to see if there is a way of resolving that. But it isn't immediately apparent..." (http://www.abc.net.au/tv/qanda/txt/s2622519.htm). There are a lot of vested interests in high cost, specialised medical care and that will need to be tackled in this process.

Ad astra reply

30/07/2009BB, Your comment: [quote]“This, of course, is how ‘impressions’ are ‘gathered’.[/quote]” is germane. I saw your comment on [i]PB[/i] about the [i]SMH[/i] editorial where again ‘impressions’ are advanced as fact. It inspired me to write something for TPS which I’ve just posted [i]Living in a bubble of unreality[/i]. I hope you enjoy it. El Nino, The problem between midwives and the medical profession has always revolved around home birth. Otherwise the two groups work together well. Medicos are concerned about unsupervised home birth as obstetric tragedies can unfold so quickly. A large part of the problem arises because these midwives cannot get proper professional indemnity as insurers are reluctant. This leaves them and their patients exposed. There seems to be no easy resolution at hand.

Just Me

31/07/2009To be honest, I got little sympathy for the 'birth is a natural process and doctors should stay out of it' crowd. Birth is still one of the most danger-ridden events in the life of both mother and child, and always will be. Lot of people forget that. I do agree strongly with having separate, dedicated birth centres in hospitals where the birth can proceed under the immediate supervision of a (properly qualified) midwife of choice, in a largely non-medical setting, with family and friends around, but still have the safety of full medical care just through the doors, including surgical and neonate units, if needed. That seem to me a very reasonable and workable compromise, that clearly benefits all parties.

cosmetic dentist Northampton

3/08/2009Thank you so much for a very informative and no-nonsense blog. It is very straight to the point. I hope you could post more blogs such as this one. Good job!

Medicare Advantage Plans

8/08/2009Me and my friend were arguing about this the other day! Now I know that I was right. lol!
How many umbrellas are there if I start with two and take 2 away?