The pandemic has highlighted some important challenges in our health care system, but system reform can occur rapidly when needed
The year 2020 so far has been consumed by the coronavirus disease 2019 (COVID‐19) pandemic and its devastating effect on health care systems worldwide. The Australian health system has yet to be truly tested by the pandemic but the prudent public health response has saved lives, protected health care capacity and continues to provide care to the most vulnerable Australians. No health system is perfect and, although Australia's has some wonderful attributes that make it the envy of many countries, it faces a number of important challenges. This article explores what might be the impact of the COVID‐19 crisis on reforming our health system for the long term, and we argue that ultimately positive reforms can occur.
The first challenge is poor integration. At a macro level, federal and state funding often results in disconnected and competing health systems; for example, the arbitrary split between the funding of general practice and hospitals,1 and the lack of a coordinated response to the aged care sector. At a state level, we see in Victoria that hospital governance has been largely devolved to local health services, making centralised planning, information technology integration and bulk purchasing decisions challenging. Within the tertiary sector, we see specialties becoming more siloed, with highly subspecialised clinicians frequently working in isolation rather than with each other, leading to disjointed care.
The second challenge is the weighting of services towards treatment of acute illness rather than prevention or wellness promotion. There have been a number of attempts to prioritise prevention in Australia but the reality is that a disproportionate slice of health funding goes to acute care and favours proceduralists over non‐proceduralists. Funding often targets short term projects rather than investment in longer term structural reforms in health care delivery.2
The third challenge is the monumental wastage and inefficiency of utilising health care resources in the Australian health care system,3 although to be fair, this is a worldwide problem.
So, what have we learned when our health system is challenged by a global pandemic that has shaken our societal norms like never before? How will it impact the future of our health systems and allow reform to happen more rapidly than previously thought possible?
Necessity is the mother of invention
Health system reforms are typically arduous, frustrating processes with vested interests, risk‐averse bureaucrats and general inertia preventing rapid change, even when changes seem eminently sensible. A remarkable characteristic of the COVID‐19 response has been the sheer pace of reform, with major changes such as the expansion of telehealth, the creation of COVID‐19‐specific clinical services within hospitals,4 and unprecedented levels of cooperation between private and public hospitals, and state and federal governments. Innovation has flourished, from ventilation hoods5 to 3D‐printed medical parts to vaccine development.
We must now determine how we carry forward this “can‐do” attitude to health reform when we emerge from the acute crisis. In reality, the current paradigm of obtaining grants and ethics approval for research projects often stifles innovation. We must learn how to capitalise on the positive unintended consequences of this pandemic to reward and facilitate innovation. One promising new development is the Australian Academy of Science Rapid Research Information Forum, which facilitates rapid and policy‐relevant information sharing about COVID‐19 within the Australian research and innovation sector.6
Flexibility is a strength
Inflexibility is unfortunately baked into many of our health system structures, exacerbated by our system of devolved governance, clinical and specialist siloing and separated lines of accountability of our public and private health systems, and segregated primary care and hospital systems. This inflexibility has been evident over decades, with reform held up by vested interests and often a culture of hostility between clinicians and health bureaucracy and between clinicians of different craft groups. This has hampered governments’ capacity to coordinate an agile system‐wide response.
Indeed, as we have discovered through the current crisis, a pandemic response requires a coordinated response. Individual hospitals must play their role as part of a larger plan, as does the public, for instance, by allowing electronic contact tracing through the CovidSafe app, even with significant community reservations about privacy.
Our health system has demonstrated flexibility in the rapid transitioning of public hospital outpatient clinics to telehealth models, but much work remains in this space.7 We hope that a lasting legacy of the current crisis will be that the flexibility to use communication technology during the COVID‐19 response becomes “business as usual”.
Use resources wisely
In a crisis, resources are more precious than ever, and as health leaders, it behoves us to prioritise resource stewardship. Suddenly, a laissez‐faire approach towards using resources becomes dangerous in a pandemic when potential shortages loom in personal protective equipment, intensive care unit capacity and laboratory capability. As countries scramble to secure adequate equipment, the COVID‐19 pandemic has been a salient reminder that health resources are indeed finite, even in wealthy countries.
It is true to say that even before the pandemic, calls had been growing to reduce the environmental footprint of health care provision.8 On a day‐to‐day level, questions have been raised about the proliferation of single‐use items, given their increased cost and significant environmental footprint compared with reusable items.9 At the same time, programs such as Evolve (https://evolve.edu.au/about) and Choosing Wisely (https://www.choosingwisely.org.au) have been calling on clinicians and consumers to be more cognisant of not only the burgeoning waste in health care but also potential harms of unnecessary investigations and treatments.
Quality of life
The pandemic has prompted a difficult but overdue community dialogue on how choices in health care should be directed towards improving quality of life, not merely extending life. The pandemic has necessitated great reflection by the profession about what constitutes quality of life and how we can sensibly allocate finite health resources. We hope these meaningful conversations will continue between clinicians, patients, families and the broader society about our values and what should be the goals of our health system.
Prevention is better than cure
A defining lesson of the COVID‐19 pandemic is that there are great rewards for implementing strong measures early, and for detecting, isolating and contact tracing infected people as rapidly as possible. Although less dramatic, this same lesson also applies to countries around the world tackling non‐communicable chronic diseases such as diabetes, heart disease, smoking‐related illnesses and cancers. Getting in early on these conditions through primary and secondary prevention is highly cost‐effective and increases the duration and quality of life at a population level. COVID‐19 reminds us that the greatest impact on public health is the prevention of disease through population health measures, and we should be focusing more on spending on this, rather than just on more tertiary facilities. Moreover, the ancient, humble and cheap public health recommendation about hand washing is having its time in the sun, as promotion of hand hygiene throughout the global community is a key strategy in reducing COVID‐19 spread.
Social determinants of health
The pandemic has highlighted the fragility of health care provision, and the importance of social determinants of health has never been more evident. COVID‐19 has reminded us of the vulnerabilities of our ageing populations, not only in terms of the biological impacts of the virus, but also the risks of social isolation, socio‐economic vulnerability and concurrent chronic diseases.
We see vulnerable populations in Australia — the homeless, people with disability, those residing in residential facilities, and Indigenous Australians10 — again in the spotlight as we recognise the impacts COVID‐19 will have if it runs though these communities. Further, in the United States, data show the impact of race as a determinant of outcome, with African‐American11 and Hispanic12 populations disproportionately affected. COVID‐19 plays out through the lens of socio‐economic determinants.
Thinking in terms of systems
COVID‐19 has emphasised the value of systems thinking to achieve the best outcomes in public health. Key lessons of a systems thinking approach13 include that small changes can have disproportionate impacts, and we have seen this play out, for example, with inadequate quarantine of cruise ship arrivals, and utilisation of security staff without personal protective equipment training. Systems thinking also reminds us that a purely linear approach to understanding our health system will fall short and that we need to recognise the complex (not just complicated) nature and unpredictable behaviour of health systems when planning for future crises.
An area where we could better apply systems thinking is the way in which we fund health services, and the balance between public and private funding. The ongoing concerns about the viability of private health insurance, the roles of profiteering by multinational health insurance providers, and the reliance of payee contributions and government subsidies to prop up a model which is ultimately answerable to its shareholders are ultimately complex system questions.14 The temporary successful merging of public and private systems that occurred during the pandemic opens the possibility of more symbiotic cooperation between the systems in the future.
Mental health care of our health workforce is essential
As the weight of providing health care during the pandemic fell upon the shoulders of our medical workforce, Australian policy makers responded proactively by providing support for the mental health of frontline health professionals. The 2013 National Mental Health Survey of Doctors and Medical Students highlighted that rates of psychological distress and suicidal thoughts are higher among the medical profession than the general public,15 and stigma and concerns about being reported remain barriers to doctors seeking care. Another lesson from this pandemic is therefore to support doctors’ mental health proactively as an integral part of supporting workforce capacity.
This global health care crisis, which has spread across 188 countries and regions, is not over; in fact, the Victorian experience tells us we are only at the beginning. We are far from seeing all the impacts this will have on the future of Australian and international health systems. Despite medical advances, the fragile pyramid of health care provision is at risk if we do not get the fundamentals right. The pandemic period reminds us that our health systems have evolved over time not so much as a coherent “system”, rather as sequential improvisations with mixed models of funding, poor integration, inconsistent governance, environmentally unsustainable practices and ultimately inequities in access and care. COVID‐19 has laid bare these inadequacies.
If positives result from the pandemic, it will be a change in how we, as health care providers at all levels from policy makers to individual practitioners, view our roles in care delivery. Similar crises will recur, with an increasingly crowded and interconnected planet and with increasing divisions between those who can afford care and those who cannot. The lesson to learn is that health care is a human right; we need to agree that this is the fundamental principle for the Australian health care system and use this common focus to reform our systems as we emerge from the current COVID‐19 crisis.
Provenance: Not commissioned; externally peer reviewed.
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