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Re-floating the Titanic won’t save Australian healthcare

Introduction by Croakey: As daunting as system reform is, it is also long-needed and the Albanese Government must not get stuck in arguments about how best to re-design the Titanic, writes Professor Ian Hickie.

Hickie is Co-Director, Health and Policy and Professor of Psychiatry at the University of Sydney’s Brain and Mind Centre. His article, below, was originally published at the Pearls and Irritations blog, and is republished here with permission.


Ian Hickie writes:

Back in 2008, I had a book contract to describe the obvious failings in Australian healthcare. It was planned to challenge the national myth that our system was ‘exceptional’, literally ‘best in the world’. I didn’t persist as Prime Minister Kevin Rudd was promising sweeping national reforms and there was genuine community enthusiasm for a major revamp of Medicare.

How I wish that I had persisted! The glaring structural faults in the system have simply grown wider and deeper over the last 15 years. Now the Federal Health Minister Mark Butler is saying in public what his predecessors would only discuss in private. Our 1980’s style Medicare no longer delivers a fair, equitable or sustainable system.

Real bulk-billing rates are in free-fall. Traditional general practice, and its underlying small-business model, is in crisis. Various professional groups accuse each other of rorting the system. The obvious inequities in access to and costs of high-quality care in key domains like mental health, aged care and chronic disease management challenge any illusion that we have a well-functioning or universal healthcare system.

But, a senior colleague just remarked to me ‘we can’t expect the Albanese Government to turn the Titanic around too quickly’. The Titanic analogy is most apposite. Every developed country believes it has the best healthcare system, awash with the latest design and technology features. Sadly, all those 20th century healthcare systems, just like the Titanic, have major design faults.

The reality is that all our systems have been taking water for some time. That sinking feeling was driven by increased community expectations, rising diagnostic technology and treatment costs, lack of appetite for genuine innovation and major pressures on workforce supply. And then they all hit the same iceberg, namely the COVID-19 pandemic!

So, how to respond? How do you undertake major structural changes, when our systems are sinking fast? How do you immediately care for those with the least capacity to respond? How do you shift the entrenched historic practices of the professional groups who really control the delivery of healthcare? How do you prioritise health rather than hospital-based care? In the end, Rudd failed and PM Julia Gillard was left to deliver a limited national ‘hospital’ plan.

How do you shift precious public dollars, and new investments, from old and failing practices to 21st century, more efficient delivery systems? How do you finally get the healthcare system, which has strongly resisted genuine use of new data systems and accountability for its expenditures, to respond?

How do you deal with the overwhelming political and community fear that any change may make things worse?

Redesigning outmoded systems

The recent 2023 Budget announcements contain some serious directions for reform but the reality is most of the key players are still stuck on redesigning last century’s outmoded systems. Most professional groups are no real help with these new challenges, many simply argue for more money to be spent propping up their existing business models.

So, where will change come from?

In the early 20th century, crossing the North Atlantic by boat was the only transport option. By the middle of the century, air transport presented new fast, safer and more economic options. In the 21st century, the digital transformation of healthcare delivery, alongside new approaches to patient-focused rather than provider or insurer-focused financing, offer real alternatives.

One clear development (though not necessarily the best) that is already well underway is the ‘uberisation’ of healthcare. New entrepreneurs, backed by new technologies, are offering a range of services (rapid clinical assessment, prescription medicines, allied healthcare, tracking of outcome) direct to a public that is willing to pay for highly-personalised and convenient care.

Consequent to the impact of the pandemic, a range of telehealth services are now common, accessible and valued by the public. The digital and personal tracking technologies that sit behind more efficient forms of care delivery and coordination are the subject of massive investment internationally.

Previously, very tight regulation of health services protected doctors, and their business structures, from competition. This will not continue and new regulatory systems that permit genuine competition will emerge.

Another is the inevitable end to the medical hegemony that characterised 20th century healthcare. Many more non-medical healthcare providers (think nurses, pharmacists, psychologists, physiotherapists, rehabilitation specialists) are being trained to provide a whole range of services. They are valued by the public and have demonstrated throughout the pandemic their willingness to step up to key roles in illness assessment, vaccination, monitoring of healthcare, provision of medicine and other non-medical therapies.

The challenge for the Albanese Government is not to get stuck in the arguments about how best to re-design the Titanic.

A major shift in the public discourse, offering to invest in a new system with a range of person-centred financing and delivery innovations, is urgently required.


See Croakey’s archive of articles on health policy and systems

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