System 50 years out of date for chronic illness
28 July 2009
Many people with chronic health conditions have more than one disease, which makes caring for them much more complex. Unfortunately, the way our health system is structured now, and the way it is paid for, reflects the health needs our society had about 50 years ago.
Then the average age of the population was much lower and most health activity was around episodic care, when people were treated for a health problem that would be expected to ''get better'' at some point.
This capacity remains vital in our world today, but many of us now have health problems for which there is no cure (like diabetes) and which have to be managed to enable us to continue to lead productive and satisfying lives in the community.
Extensive evidence from around the world shows that chronic conditions are better managed within the primary care sector, with hospitals providing relevant interventions for acute episodes. The better the management in primary care, the fewer acute episodes should occur.
In this way the final report of the National Health and Hospitals Reform Commission provides a good blueprint for future health reform in Australia.
The commission has placed considerable emphasis on the system's ability to deal with the increasing burden of chronic disease in the community. Its report has a shopping list of proposals that, taken on their own, would improve particular aspects of patient care. Some cover gaps - for instance, the dental scheme would start to remedy the most gaping hole in health care.
Depression and other mental illness are the grim companion of much chronic illness. There are many useful ways to improve and integrate our overstretched mental health services with the rest of health care. Those most in need of medical care often report the greatest trouble in gaining access to out-of-hours services - often adding to the strain on hospital emergency services. The report offers some practical methods, including telephone coaching services, to relieve this pressure.
More importantly, there are some structural changes that offer openings for long-term changes in the way health is delivered - away from the acute, hospital-centred model towards a system that puts more resources into prevention and care in the community.
Most of these start from changes in the way health care is financed, not in the big bang of a Commonwealth takeover, but smaller adjustments that leave a lot of scope for invention, for state, private and local initiatives.
Under the biggest change the Commonwealth would take financial responsibility for all primary and community-based health care. This covers general practitioners, community health nurses and most of the services outside hospitals, including prevention. The Federal Government would take financial responsibility in various areas of care and be able to use its financial clout to aid the linking up of services.
This would start with the organisation of the health professionals themselves.
One of the successes of the 1990s were regional organisations of general practitioners funded by the Commonwealth to work independently to improve services. These Divisionsof General Practice would be broadened to form Primary Health Care Organisations drawing in the health professionals involved in comprehensive primary care and covering a wider population base.
If implemented, the commission's plans offer the chance to fundamentally improve the way chronic care is managed - and allowing the scope for wider professional autonomy.
What would this mean for patients? Those living with chronic conditions would have a choice of registering with a practice, giving them a recognised medical home. Registration would remain voluntary in deference to medical worries about freedom of choice.
It would enable improvements in services, borrowing British and New Zealand models. At present doctors are paid for each distinct episode of care, giving some incentives to overservice and certainly none to help the patient to mange their illness more effectively and reduce their need for medical care.
Registration offers new possibilities of bundling up payments, so medical professionals are paid for a whole course of care or over an extended period. It also makes it easier for a practice to work out a comprehensive care plan by integrating many different specialities. Patients would face less of a maze when they navigate the system.
If primary care is strengthened, patients may see other improvements. Australia has struggled for years over the problems of building effective e-health systems. An e-health record attached to each patient would reduce the dangers of medication errors - every doctor would know existing prescriptions - and reduce the wearisome business of a patient having to explain themselves to every new professional. Progress has been stymied by the failures of massive bureaucratic e-health schemes. The commission supports a patient-controlled e-health record, shifting from the top-down approach that had many worried about privacy.
The commission started its work in a very different financial climate. Many hopes for sweeping reform have withered with the collapse in Commonwealth revenues. But many of these changes involve small investments, which, if made, promise large returns - some in savings, but more in improved quality of life for the growing numbers living with long-term illnesses.
Dr James Gillespie is deputy director of the Menzies Centre for Health Policy at the University of Sydney. Robert Wells is director of the Menzies Centre at the Australian National University.
Contact: Sarah Stock
Phone: 0419 278 715