Reforming our health care system: time to rip off the band‐aid?

The health reform imperative is clear; it now requires national courage and leadership to implement it

While Australia has traditionally delivered some of the best health care outcomes in the world,1 there are increasing signs that our strained health care system is pushing the stress performance curve into the red. Benchmarks of hospital activity demonstrate ongoing difficulty;2 Local Hospital Networks scramble to meet demand despite annual federal government funding increases of 6.5%; and the grey literature attests to the unfolding human impact behind the figures.3 Patients deteriorate waiting for specialist assessment,4 and junior doctors find themselves trapped in increasingly overstretched, dysfunctional work environments. The much‐reviewed experience of Yumiko Kadota is not an isolated incident, with similar experiences documented regularly by doctors‐in‐training nationwide.5

What is going wrong and what can we do?

The demography of illness has shifted and continues to change dramatically over the past few decades. No longer episodic, acute presentations but complex chronic health and social issues predominate, requiring high quality teamwork across multiple settings while maintaining continuity of care. Prevention and health literacy are critical, given the sizable input of unhealthy lifestyle to rising morbidity and cost. National inquiries into aged care, mental health, productivity, and system reform demand change and propose workable solutions,6,7 but little concrete change seems forthcoming. While the concerted message is unambiguous, implementation presents a sizable challenge to our dual‐funded, dual‐governed, crisis‐driven health care system.

Put simply, our health system is fragmented, inefficient, inflexible, and organisation‐ rather than person‐focused; locked into decline without significant structural, governance and funding reform. State governments continue to fund acute and specialised service delivery along historical activity‐based lines, with the Commonwealth taking the heavy lifting on community general practice, pathology, radiology, specialist and aged care services. Without governance alignment, this allows little opportunity to develop fully integrated models of care. Yet, this is what the main consumers of health resources — those with complex chronic conditions, the frail, and those with mental illness — depend upon to achieve optimal personal and system support. While recognised and addressed in other nations,8,9 to date, Australia has made little tangible progress.

One state’s reform experience

In the absence of a Commonwealth–state consensus on system vision and strategy, states and territories have, by necessity, gone their own way — within the constraints of Commonwealth funding agreements. One state, New South Wales, has arguably been the most consistent, exploring integrated care over 15 years from early HealthOne demonstration sites to current maturing co‐commissioning models.

HealthOne laid the conceptual groundwork via a state capital investment program enabling Area Health Services (now Local Health Districts/Networks) and Medicare Locals, working within a common framework of objectives and principles, to develop locally relevant integrated services. These brought together general practice and community health to form flexible multidisciplinary teams via co‐located, hub‐and‐spoke or virtual configurations, achieving, and learning from, varying degrees of success.

By 2011, this approach extended to the statewide Connecting Care Program that articulated NSW Health’s commitment to:

• local flexibility within a NSW framework of policy, principles and high level strategy;
• general practitioners as the continuing lynchpin of care based on patient‐centred medical home principles;
• e‐health development applied to shared care;
• collaboration and partnerships with primary care organisations; and
• specialist and acute services supporting and building primary care capacity.10

The learnings from this work informed the state’s Integrated Care Program, the Leading Better Value Care initiatives (aligned with quadruple aim outcomes), and now, Collaborative Commissioning (co‐commissioning). In western Sydney, successful Integrated Care initiatives have been progressively incorporated into today’s co‐commissioning models of care. These include:

• specialist rapid access clinics for patient stabilisation and general practitioner support, demonstrating a 32% reduction in emergency department presentations and a 34% reduction in admissions;11
• diabetes outreach to general practice via specialist case conferencing, demonstrating enhancement in general practice team capability and patient clinical outcomes;12 and
• non‐prescribing pharmacists in general practices providing measurable change or deprescribing in complex care patients.13

Co‐commissioning also incorporates key e‐health developments such as Lumos, which brings general practice and NSW Health data together to enable analysis of the entire patient journey and its outcomes,14 and in western Sydney, the award‐winning CareMonitor,15 a shared care, home monitoring and patient capacity building software platform.

Co‐commissioning has been the game changer, levelling the Local Hospital District/Primary Health Network playing field, equalising the governance model, and bringing state resources within scope for joint decision making. This is enabling true integration, with a shift in resources to community capacity‐building, gradual closure of the hospital–community and health–social care gaps, and a rethinking of general practice financing outside the Medical Benefits Schedule. The process has been vastly challenging, requiring leadership, flexibility and considerable system redesign. NSW Health and its Local Hospital Districts are essentially siloed, multilevel bureaucracies working under great pressure to juggle jurisdictional complexities, Medicare Local and Primary Health Network maturation, ever‐expanding workload, and financing pressures. Progress to date is testimony to this commitment and tenacity.

While the journey is far from complete, the critical success factors in NSW have been noted. These factors include sustained leadership from NSW Health; conceptual clarity maintained over time; wide consultation, particularly with primary care; consistent evaluation and applied learning; and a willingness to invest in cross‐sector partnerships and general practice capacity building.

The Commonwealth commitment to achieve sustainability is highlighted in the system reform flagged in the June 2020 addendum to the National Health Reform Agreement (c28):16

 The reform plan for Joint Planning and Funding at a Local Level will include, but  not be limited to, the following activities and commitments:

1. nationally agreed principles for local‐level commissioning;
2. identifying and supporting removal of barriers to joint governance, needs assessment, service integration, evaluation and funding, at a national and state and territory level;
3. progressively trialling, evaluating, refining and scaling up joint planning and funding arrangements of increasing levels of ambition.

The future

Health system governance and resourcing must now refocus. Although it is challenging, we must stop demanding band‐aid funding to prop up a fragmented, often wasteful, health care system, and declare a change in course. This will require a focus locally on the identified root causes of current dysfunction, a system‐wide approach to solutions, the use of effective evidence‐based service reform focused on the needs of patients and families, and meaningful measurement and maturation. Coronavirus disease 2019 (COVID‐19) has precipitated the rapid formation of new collaborations and major change in health system operation. From the formation of a National Cabinet, through rapid scale‐up of hospital intensive care unit capacity, virtual care, specialist outreach and hospital‐in‐the‐home innovation, to general practice and PHN establishment of respiratory clinics and widespread telehealth consultation, COVID‐19 has proven we can work across one system when the vision and challenge is shared and outcomes are important and immediate. The years 2020–2021, while confronting and painful, have enabled us to think of the simplest, most consistent way to deliver individual care and to tailor digital health and virtual support to suit. It has forced us, as a sector, to let go of the bar in the shallow end of the pool and take a few careful strokes forward, using the success of vanguards to guide us. It has proven we can take effective and person‐centric initiatives forward rapidly if we can align the governance stars.

We can provide care in partnership, recognising that some parts of the health and social care system may be better placed to deliver effective care than traditional players or settings. That means taking some of the 6.5% funding increase each year and putting it into creating something different: a model of integrated health and social care that recognises the importance of each person’s nominated general practice or Aboriginal Community Controlled Health Service and of effective articulation with it. Australia has a ready opportunity to learn from NSW’s steady progress in governance and care reform, and apply it in other populations or settings. Clinician and executive innovators should play a prominent role in this national policy and implementation reform — despite the many barriers to change, they have succeeded in delivering effective new models of care.

So it is time to rip off the band‐aid and regard our health system as it really is: bruised, bleeding, unsustainable and rightly criticised as increasingly failing both users and providers of care. The essential guideposts to repair have been consistently spelt out by dozens of commissions, reform advisory groups and consumer briefs, but courage and leadership are needed to turn our struggling health system around. We must build new regional governance structures that bring the critical organisations and service providers together, enabling joint planning, pooled funding and the codesign, delivery, and continuing evaluation of relevant new health initiatives. We must recognise that an increasing number of Australians need care that is complex and requires coordination by their ongoing community team in partnership with the broader health and social care sector — not care in siloes. We must stop toxic workplace cultures and reconfigure a health system that works for receivers and providers of care, without sacrificing the mentorship and peer support that has been a historical feature of our health workplace. And we must recognise that innovation is the lifeblood of a sustainable and evolving health care system, and should be identified, nurtured and translated effectively if we are to protect and grow a world‐class health system for the benefit all Australians.