When asked to write about international issues in healthcare for a recent column in The Health Advocate, Dr Patrick Bolton, a National Councillor of the Australian Healthcare and Hospitals Association, identified a few interesting questions, including:
Would we get better health returns from disinvesting in healthcare in order to be able to invest more in areas such as tackling global warming or in promoting greater equity?
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Challenging the status quo in healthcare
Patrick Bolton writes:
When I think about healthcare in an international context, one issue which comes to mind is how much Australia spends on health and whether that really is best use of our limited resources. It is well known that we fall towards the top, but within the pack, of OECD nations on healthcare expenditure per capita. For that, it is generally recognised that we get a pretty good healthcare system. Not one without opportunities for improvement, but value for money on the outcomes, so long as one ignores the clamour of dissatisfaction that seems to come from most stakeholder groups.
What follows from this is whether it is worth investing more in our health system – given the law of diminishing marginal returns – and even whether we should consider disinvesting in health so that we can invest in other areas where we get a better return. One area that comes to mind is in reducing greenhouse gases and global warming. I reckon investment there is likely to provide greater health and welfare benefits than the same investment in health. Another potential area for investment is in supporting the health and welfare of less advantaged people, either overseas or at home.
Investment that supports health in third world countries is more effectively spent on infrastructure than directly on health services. One of the lessons learned from overseas through the work of Marmot and Wilkinson is the significant role that equity appears to play in determining the health of nations once basic infrastructure needs have been met.
The health of the people of Costa Rica is better than the health of black Americans, notwithstanding that the former earn around 10% of the latter. The reason for this is thought to be the greater social equity in which the people of Costa Rica live. So, another area that we might want to disinvest in healthcare in favour of would be greater equity and social inclusion within Australia.
It’s not necessary to go overseas to find people whose health status is comparable to that of the third world. The health of Australian Aborigines remains behind not only that of other Australians, but also behind that of Indigenous peoples living in other countries settled by Europeans, such as the US and Canada. While issues remain, those countries have had considerable success in addressing health problems among their native peoples over the last 30 years, something Australia has yet to successfully emulate.
Another issue that comes to mind when thinking about health in an international context is Australia’s apparent excessive use of acute hospital beds. There is a respectable body of opinion that argues that this is a data artefact. The magnitude of the issue, and the potential savings, if it really exists, suggest that robust analysis and debate about this would be worthwhile.
As a doctor working in Australian hospitals I used to acknowledge the data, but wonder which of the patients I was seeing I could realistically not admit. I am coming around to the view that the role of hospitals should be to support patients whose dependency needs cannot be met by less intensive models of care. This model makes nursing requirements the main determinant of hospitalisation. The corollary of this is that, in general, the medical needs of patients for diagnosis and treatment could be managed through alternative logistic arrangements if the healthcare system were engineered to support them.
A related issue, which perhaps lends credence to the notion that Australia does have more acute hospital beds than it needs, is the data from the US which suggests that up to one-third of medical procedures are unnecessary. The main determinant of the provision of medical services in that context appears to be the supply of doctors providing those services, rather than proxies for patient need. This has to be a target for productivity improvement in an increasingly resource constrained and accountable healthcare system.
It’s tempting to comment on the internationalisation of the health workforce. On the one hand I am not sure how important that is to Australia. The barriers, particularly to doctors, to entering Australia remain high. On the other hand, I am perplexed by the failure of the much vaunted increased number of health graduates to materialise over the last five years. I accept as a matter of fact that the universities are turning them out, but I still face shortages of junior doctors in my pleasantly located inner metropolitan teaching hospital. If they are not going overseas I am not sure where they are going!
The last international issue I want to mention is reform. I noted in one of my first columns for The Health Advocate that the UK and New Zealand experience had been that reform was hard to stop once it had been started. The health reform genie has escaped from the bottle in Australia. Given the unclear and probably equivocal effects of the first round of reform, a second round seems inevitable. But, if overseas experience is to be relied upon, that is no more likely to solve our problems than the first attempt.
I guess the bottom line about overseas experience is that we need to learn from it so that it can be applied for our own benefit.
• Thanks to the Australian Healthcare and Hospitals Association and The Health Advocate for allowing republication of this article.
