Introduction by Croakey: In the second and final article in a series examining the future of healthcare, Croakey editor Jennifer Doggett investigates key issues around technology, climate and planetary health, and patient and community involvement.
She warns that if policymakers fail to implement meaningful reform, the health and wellbeing of Australians and our social fabric is at risk.
This article is published in collaboration with cohealth, a not-for-profit community health organisation, as part of their Health Equity Champion membership of the Croakey Health Media funding consortium. The series is also available in this Caring for our future e-publication.
Jennifer Doggett writes:
Technology has already transformed many areas of healthcare and promises to be an even more disruptive force over the next 30 years. Advances in digital and information technology are likely to change almost every aspect of healthcare, including how and where we access services, processes for the diagnosis and treatment of illness and the ability to personalise medicine based on individual genetic profiles.
Improving the use of technology offers opportunities for improving communications across providers and sectors, but can also present ethical challenges and risks widening existing health inequities across the Australian population.
Professor Virginia Lewis, who holds a Research Chair in Community Health, cofunded by cohealth and La Trobe University, suggests learning from our experience with e-health during the COVID-19 pandemic and ensuring we keep patient experience at the centre when introducing new technologies in the future.
“We need to make sure we preserve the human element of healthcare while implementing mobile health and e-health,” she says. “We need a good understanding of where something like remote monitoring works well and where personal contact and a face-to-face visit with a health professional is beneficial.”
Dr Kim Webber, former Executive Lead – Strategy, Impact & Development at cohealth, echoes this view, stressing the relational nature of healthcare and that this could be undermined if technological-driven reform is driven by clinician or business needs, rather than those of consumers.
Dr Richard di Natale, cohealth public health adviser, GP and former leader of the Australian Greens, sees technology as driving a major shift in the clinician-led model of healthcare as entrepreneurs enter the market with tech-based solutions allowing consumers to monitor their own health and engage with health providers in non-traditional ways. This, he says, comes with both potential benefits and risks, and it is important that we plan for both.
“In 50 years people will be using technologies that today we can’t conceive of,” he says. “Policymakers need to make sure we have a rigorous framework to evaluate them so that governments can take advantage of technologies which are good for patients and deliver good value. We currently have a framework for evaluating medicines and technologies but it’s not built for the emerging individual healthcare technologies – we need to move quickly, otherwise these will get away from us.”
Di Natale cites a lack of understanding of new technologies within government as one of the barriers to an effective system of regulation and evaluation.
“Often the people who hold institutional power don’t understand new technologies,” he says.
Di Natale notes that it took a pandemic to accelerate uptake of existing technologies such as e-health, stating that ideally in the future we shouldn’t need external pressures such as this in order to progress evidence-based reforms.
He highlights the need for planned, evidence-based and value-driven approaches to adopting new technologies, coordinated across sectors and jurisdictions.
Continuing with our current ad hoc and piecemeal approaches will make it difficult for future governments to direct health spending into technologies that deliver maximum value to the community. This could lead to increased spending on low value technologies or even those which have a harmful impact on community health. It could also mean that those who are already marginalised being further disadvantaged through unequal access to health technologies or through having their personal data used to discriminate against them in areas such as insurance or employment.
Climate and planetary health
The World Health Organization has called climate change the biggest single threat facing humanity and we can expect climate disruption to increase over the next 30 years, even if we were to act immediately to significantly reduce our carbon emissions.
Di Natale nominates two main ways in which climate change will impact the health system of the future. Firstly, it will result in an increase in extreme weather events, leading to a greater demand for emergency response and acute healthcare services. Secondly, given that our health system is a huge consumer of resources, it will require us to focus on increasing overall health system sustainability.
He also suggests that the health impacts of climate change may force us to broaden the current narrow focus on health policies and programs to include environmental and other determinants of health, such as access to affordable energy, heat-resistant housing and green spaces in the community.
“We need to see the home and urban environment as part of health infrastructure. Currently the design of our houses and cities is determined more by developers than human health,” Di Natale says.
As with many other determinants of health, Webber also reminds us that climate change will have a disproportionate impact on those with the least resources.
“The quality of public housing is an issue,” she says. “People in high density, high rise apartments struggle to stay cool in the summers – sometimes air conditioning is only available in the common rooms. People who are sleeping rough are also impacted adversely.”
Webber suggests a need for more public messaging around heat to educate the community about how to reduce its health impacts. She also warns health services to prepare for increasing numbers of climate refugees, who are likely to have high healthcare needs and, unless policies change, will not be eligible for Medicare.
Even if we step up adaptation and mitigation efforts, the impact of climate change will still be devastating. However, investing in our emergency response capacity now will ensure we are in a better position to protect communities from the worst climate-fuelled natural disasters in the future. Resourcing the community health and social services sectors will ensure they can identify people at risk and put measures in place to reduce the inequitable impact of climate events on the most vulnerable.
These changes need to go beyond the health system to include improved urban design, including more climate-resilient housing, public transport and green spaces. Dealing with the problems of housing affordability and renters’ rights will also help reduce future high rates of housing instability, which exacerbates the adverse impacts of climate change.
If we fail to take these actions, our health system will become increasingly overwhelmed by the impacts of climate change.
At the community health level, this would mean higher rates of acute problems relating to extreme heat as well as a range of chronic conditions, such as heart disease, asthma and mental illnesses. Without an increase in resources to meet these demands, there will be more preventable deaths among those at higher risk, including the elderly, people with chronic conditions and disabilities and those with other disadvantages.
Patient and community involvement
The role of patients and the community in our health system has changed dramatically over the past 30 years and this trend promises to continue into the future in ways that could fundamentally change the relationship between consumers and providers.
Di Natale has noticed this change over the course of his career and can see both positives and negatives in increased access to information. On the positive side, he agrees it supports consumers to take more responsibility for their own health but on the negative side he says misinformation is rife and for some consumers it can heighten anxiety.
He sees this ongoing trend as leaving behind the old model of consumers handing over all responsibility for care to their doctor towards a new approach with a doctor in more of a consultant role, working with patients to discuss options and jointly develop treatment plans.
Di Natale warns that inequitable access to health information will reinforce existing patterns of privilege and disadvantage. He cites research showing that currently information about basic health issues, such as nutrition, varies significantly with socioeconomic status. He argues that this inequity is likely to increase as technologies available in the future to monitor and diagnose health conditions are not shared equally across the community.
Lewis suggests that a high priority for improving patient and community engagement in healthcare should be to become more skilled at sharing the power appropriately between health services and consumers, a relatively new concept for our health system, which she says we are still navigating.
“It’s important that we work out the complexities of this relationship in order to maintain autonomy for each party, while recognising their different skills and experiences,” Lewis said.
“Our current approaches lack subtlety and are not always effective but hopefully in 30 years we will have worked out how to share power and have a more sophisticated approach to co-designing services, which recognises differences in power and differences in what parties bring to the partnership.”
If we fail to transform these dynamics, the promising trend of increasing patient and community engagement may fizzle out after not being successful in delivering what either group wants. This will be a missed opportunity for achieving the benefits that come from moving away from a provider-centric approach to healthcare.
Facing the future
Our health system of 2050 will have to address some “known knowns” such as climate change, an ageing population and increased rates of chronic disease. It will also face “known unknowns” such as technological advances and changing community preferences – and no doubt some “unknown unknowns” as well.
As we prepare for these future challenges, it is worth asking what the role of the community health sector will – or potentially could – be.
The community health sector once played a major role in the provision of primary healthcare in Australia but since the 1970s this role has dwindled. Will this trend continue or will 2050 see a return to the centrality of community health centres as providers of integrated, place-based primary healthcare?
A strengthened and expanded community health sector would have the potential to address many of the health challenges expected in the future. Community health centres already have expertise in delivering the type of multidisciplinary and coordinated care required for the effective prevention and management of chronic disease and, as outlined above, they would have the ability to implement many reforms that are difficult to achieve within traditional general practice due to opposition from the medical profession.
One pre-requisite for an expanded role for Community Health Centres is increased awareness of this sector at the federal level among politicians and policymakers. Because Victoria is the only state with a generalist community health sector, there isn’t an awareness among policymakers in Canberra of the potential of community health as a scaled up model.
That may be about to change, as the recent Strengthening Medicare Taskforce recommended a move away from episodic care delivered by GPs towards a multidisciplinary, team-based approach, mirroring the community health model of care.
Successful advocacy by the community health sector to decision makers at the federal level could see a health system in 2050 which, in addition to having Aboriginal Community Controlled Health Organisations or ACCHOs, has a national generalist community health sector that runs on the principles of community involvement in governance, and which provides interdisciplinary care, and is successfully advocating for greater action on the social determinants of health.
However, without such advocacy to policymakers, existing community health services risk becoming further marginalised, providing only niche services in specific areas with little broader awareness of their role or potential.
In this scenario, we will continue to see policymakers still making futile efforts to make a private general practice sector based upon fee-for-service address increasingly complex health and social problems. This will prove ineffective and inefficient, and ultimately will be damaging for the health and wellbeing of Australians and for our social fabric.
• This article is published in collaboration with cohealth as part of their Health Equity Champion membership of the Croakey Health Media funding consortium. The article was researched and written by Jennifer Doggett and edited by Dr Melissa Sweet and cohealth.
See the first article in this series, It’s 2050. How is our health system holding up?
Download and share the Caring for our Future e-publication