Introduction by Croakey: You might not guess it from our national health debate that is tiredly rehashing outworn arguments about hospital financing, but the pandemic could open the door for transformative changes for health.
That’s according to emergency physician Dr Clare Skinner, who below offers five recommendations for health reform, to follow on from her previous suggestions.
Clare Skinner writes:
At the start of 2020, during a brief summer break from clinical work in the emergency department, I crafted a wish list of 11 recommendations for health system reform. Following much conversation, and in collaboration with colleagues from the Australasian College for Emergency Medicine, the list turned into an article for Croakey.
“Emergency departments are doing it tough,” begins the article, which was titled, ‘At a time of looming crisis, a vision for health system transformation’.
At the time of writing, the pandemic was still a blip on the horizon for Australia. We were watching and waiting, yet to experience toilet paper shortages and curves flattened by extensive lockdowns.
In emergency departments (EDs), we were alert but not alarmed, with no real idea of the challenges – including health workforce shortages, social fragmentation, politicisation of public health measures, and severe ED overcrowding and hospital access block – that lay ahead.
More than a year and a half later I am still getting feedback about that article, which had reach beyond my wildest dreams. The 11 suggestions to improve emergency care have held up well. They stay on the wish list, for now – with only a few pandemic-proofing tweaks.
But, the world is changed. COVID-19 has swept through our health system and our society, like a blast of icy wind, finding the cracks, exposing them, and – in many cases – blowing them wide open.
In the middle of a global pandemic, even acknowledging the relatively successful public health response in Australia to-date, I find myself wanting more.
The pandemic has made it clear that health is about far more than healthcare. Our health, as individuals, as communities, and as a population, depends on everything about and around us: who we are, how and where we live, our work, our leisure, our culture, our race, and the extent of our financial and political agency.
With this in mind, and in no particular order, I offer a few extra big picture items to add to my list of suggestions for health reform.
12. A truly integrated Australian health system
The pandemic has made it clear that Australia has many separate health systems, with agendas that often conflict or compete. This is perhaps best illustrated by vastly different approaches to contact tracing, lockdowns and border control implemented by the Australian states and territories in response to COVID outbreaks, despite the formation of the National Cabinet to support coordination early in the pandemic.
The health system also has structural barriers that impede cooperation, flexibility and sharing of critical resources between regions and sectors. The federal-state funding divide is a well-described, longstanding barrier to integration between community and hospital-based care. During the pandemic, these sectors relied on different stockpiles (National vs State) and procurement systems for personal protective equipment (PPE), resulting in shortages that impacted on clinical service provision.
Even basic infection control terminology differs between jurisdictions, for example Tier 1 and Tier 2 COVID exposure sites in Victoria, versus close or casual COVID contacts in New South Wales. Tier 3 PPE in Victoria, versus standard, contact, droplet and airborne precautions in New South Wales.
This has resulted in confused public messaging (for example, no coordinated vaccination promotion campaign), inconsistent clinical and operational advice (for example, health service infection prevention and control guidance), a staggering amount of duplication (for example, commonwealth and state run COVID testing clinics with different protocols) and overt politicisation of the public health response to the pandemic (for example, the current stoush over public hospital funding arrangements vs early loosening of state imposed public health restrictions).
Just imagine how differently the pandemic might have played out with central coordination and clear, nationally focused leadership and communication.
Australia has desperate need of strong national health agencies – the equivalents of the Centers for Disease Control and Prevention in the USA, or the National Institute for Clinical Excellence in the UK. Critical gaps in health professional recruitment in 2020 and 2021 demonstrate that Health Workforce Australia, with its nationwide focus and longitudinal, multidisciplinary approach to workforce planning, is sorely missed. A new national agency dedicated to health promotion and communication would be a welcome addition.
Many excellent agencies are hosted by commonwealth, state and territory governments – for example, the NSW Agency for Clinical Innovation, Safer Care Victoria, The Queensland Clinical Senate, and The Australian Commission on Quality and Safety in Health Care. Many other bodies, including universities, specialist colleges and NGOs, also contribute to health policy and planning. The Royal Children’s Hospital Melbourne and the Therapeutic Guidelines publish comprehensive, peer-reviewed clinical guidelines which are widely used by health professionals, but, when similar locally developed resources exist, it is unclear which guideline should apply.
It is unlikely that these bodies will want to close, or that hosting organisations will give them up, so instead they should come together. Government agencies could work in federation – with national oversight and collaborative, strategic commissioning of shared, living resources. The National COVID-19 Clinical Evidence Taskforce shows how this might be achieved through a consortium model.
13. Inclusive, collaborative models for decision-making
The pandemic has presented some truly wicked problems, which has demonstrated the need for collaborative, rapid decision-making strategies. Too often we have seen a group of experts miss critical information because they failed to recognise, include or genuinely consult key stakeholders.
We have seen significant opportunities missed because standard decision-making strategies were too narrow, too risk averse, too dogmatic or too slow.
Health service planning has relied heavily on a medical model – where one specialty group ‘owns’ a problem, then consults other specialty groups in series as required – usually independently of each other.
Perhaps the best example of this is resistance to incorporating measures to prevent aerosol transmission of COVID in infection control guidance. Infection prevention guidelines have traditionally been ‘owned’ by medical and nursing specialists with expertise in infectious diseases and infection control.
Early in the pandemic, PPE guidelines were developed by infection control experts with only superficial input from clinical end-users, who possess deep knowledge of the practical, pragmatic contexts in which guidelines would be applied, and with insufficient regard for occupational health and safety considerations, or environmental factors, such as ventilation. Through the pandemic, as expert and stakeholder engagement broadened, the guidelines, and their implementation, have significantly improved.
Government department planning, which usually relies on vertical, template-driven methodologies for collecting and sharing information, has also been too slow to respond to rapidly changing health service pressures. At times, it has failed to capture critical information from all levels of the hierarchy.
Pandemic workforce planning, where the same staff members were initially included in surge plan spreadsheets for two or more clinical teams, demonstrated the need for a more comprehensive and collaborative approach.
Political decision-making has been adversarial, inflexible and secretive, when compassion, empathy and transparency were required to build and to maintain trust.
Health, economic and political priorities have been pitched against each other, especially by the media, but the truth is that they are interdependent and complex. At times, short term political priorities have trumped the longer-term health and social needs of the community.
The narrow focus on mental health impacts of lockdowns, without consideration of the impacts of entrenched social disadvantage on mental and physical health, is one example. Rapid alteration of the New South Wales pandemic ‘roadmap’ following the recent change of Premier is another.
We need better ways to make decisions about healthcare – strategies which are multidisciplinary, multi-professional and genuinely inclusive, yet agile enough to respond to new information as it arises. We particularly need to make sure that all the right people, including representatives of priority populations and communities, are at the table from the outset.
The COVID Clinical Council and Communities of Practice, which were established to manage the pandemic in New South Wales, show some promise as a way to bring frontline clinicians and system managers together.
The pandemic response has shown that health systems can rapidly adapt in flexible and creative ways when under pressure. We need to implement decision-making models that allow this to continue after outbreaks settle.
We also need effective ways to engage with consumers, carers, and the broader community – honestly and openly – especially around questions of resource allocation, values, and setting health system priorities. We need to do much better at engaging with, and empowering, people who are culturally and linguistically diverse.
Maybe we just need better politics.
14. Smarter telehealth
Telehealth has been around for decades, but the early pandemic saw rapid uptake of remote and virtual care models in mainstream clinical practice.
In most cases, the quick switch to telehealth was motivated by infection control, and models were not sophisticated – clinicians ran appointments over the phone, or by videoconference, using structures directly translated from in-person clinical care. The governance proved more challenging – especially rapid implementation of Medicare billing items to reimburse care not provided in-person.
Telehealth has evolved during the pandemic. We now have virtual hospitals providing COVID care in the community, remote ‘secondary triage’ of ambulance calls, and ward rounds in rural hospitals being run by videoconference, as well as other highly innovative practices.
We have moved beyond a limited view of clinician-to-patient telehealth, to models which facilitate clinician-to-clinician telehealth, providing opportunities for collaborative care and early senior decision-making, without the patient having to travel long distances or wait for months. Designed right, these models could help smooth the interface between community and hospital care.
However, just because we can do something, doesn’t mean that we should.
We need to make sure that virtual care models have appropriate governance, technical support, resourcing and an equity focus. Practitioners must be adequately trained and supported to provide remote care.
We must take care to ensure that financial constraints and structural challenges do not create barriers for people who have limited access to digital resources, especially in rural and remote communities, where the challenge of geography is augmented by poor telecommunications infrastructure.
We also need to make sure that telehealth models are implemented with the goal to improve the patient and clinician experience, in order to complement, rather than substitute for, in-person care. Research is urgently required to guide development of best-practice models for quality and safety, clinical efficacy and patient acceptability.
15. Address socioeconomic determinants of health inequity
Dr Laksmi Govindasamy, recipient of the 2020 AFPHM Sue Morey Medal and dual advanced trainee in Emergency Medicine and Public Health, tweeted that emergency departments are “the intersection of the end points of unaddressed inequities in social determinants of health”.
Unsurprisingly, the pandemic has exacerbated the health gaps between society’s ‘haves’ and ‘have-nots’. COVID has had the harshest impacts on the most marginalised members of the Australian population.
The most critical errors of the Australian pandemic response have represented failures to recognise and address entrenched vulnerability and disadvantage.
It has been encouraging to see governments providing income, housing, and employment support, under the guise of the pandemic. Australia is a wealthy country – we can afford to be more generous. Given the profound impacts of social inequities on the health of our community, we cannot afford not to address widening disparities of wealth that were a challenge pre-COVID.
Now is the time to review the social welfare system, tax system, and industrial relations structures, with a view to addressing socioeconomic inequity and providing long-term social supports that persist well beyond pandemic outbreaks. While we are at it, we should implement fairer immigration and refugee policy too.
The pandemic has also highlighted inequity in the Australian education system. Education is fundamental to health, not only because of the social and economic opportunities it facilitates, but because scientific literacy and the ability to critically appraise information are necessary skills for modern life.
Australia can and must do better – from early childhood through to the tertiary sector – to ensure that all Australian have equitable access to high quality education.
We have important work to do on identity and inclusion – to strive for genuine diversity of representation in leadership and to prevent ongoing trauma and harm from racism, misogyny and other forms of discrimination and bias. We should celebrate difference, not just tolerate it.
We need to create institutions that are inclusive and culturally safe, to enable full social participation by all Australians. We should adopt the Uluru Statement from the Heart to ensure a First Nations voice is enshrined in the Constitution. We have much to learn from Indigenous ways of doing and being, especially in regard to connection to Country and community.
16. Urgent, meaningful climate action
Climate change poses the greatest threat to human health. The effects of global warming will only exacerbate inequities in health experiences and outcomes – in Australia, and across the globe. Urgent measures to limit and reduce carbon dioxide emissions are required through a whole-of-government response.
The Black Summer bushfires of 2019-20, which preceded the COVID pandemic, highlight the potential for multiple sequential or simultaneous climate-related emergencies, with significant impacts on acute and chronic health.
As temperatures rise, natural disasters will become more frequent and more severe. Ongoing health system coordination and collaboration, developed during the COVID pandemic, will be vital to support emergency responses to the evolving demands of the climate crisis.
Health can also learn from the environmental movement. Most government policy impacts on physical and mental health. It would be useful to see this deliberately interrogated, through commissioning of health impact statements on a wide range of measures, such as urban design, food and nutrition, sports and gaming, industrial relations and taxation.
It may seem that this wish list is far removed from the emergency department, but the reality is that the healthcare system makes only a tiny contribution to human health.
As an emergency physician working during a global pandemic, I encourage all of us who care about health, to think, to dream, and to advocate, much bigger.
Dr Clare Skinner is an Emergency Physician in Sydney and President Elect of the Australasian College for Emergency Medicine.
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