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.