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Two health reformers speak out

Before jetting off to a new job in Canada a few months ago (read more about this aspect here and here), health reformer Stephen Duckett took time out to reflect on his experiences from the trenches at both the state and national level.

As CEO of Queensland Health’s Centre for Healthcare Improvement, he helped drive changes in Queensland post the revelations of the Bundaberg fiasco, and also had a hand in national reform efforts as a member of the National Health and Hospitals Reform Commission.

His article in the latest Medical Journal of Australia is worth reading.

Amongst other things, he:

• suggests that the macro level reforms proposed by the NHHRC will  not and can not change the internal workings of hospitals and other health care facilities. “Levers for that are in the hands of individual managers and staff, and are not amenable to change with the levers in the hands of the NHHRC,” he says.

• stresses the importance of political commitment to enable reform. The Qld Government has had this but NSW has not. “Unfortunately, the recent Garling Inquiry does not appear to have stimulated the same fundamental reform in New South Wales that Queensland embraced,” he says.

• details some of the reforms undertaken by Qld Health, including that it has run the the largest leadership development program in Australia (not only in the health sector), with more than 5000 managers and supervisors (just over half of whom were clinicians) participating in 2-day workshops to improve leadership skills.

The MJA also has another interesting article for those with an interest in health reform. It’s probably no coincidence that the author also hails from Queensland – Dr Ian A Scott, Director, Department of Internal Medicine, Princess Alexandra Hospital, in Brisbane.

It is especially valuable reading for those who are expecting the forthcoming tsunami of medical student numbers to resolve workforce maldistribution and inefficiencies.

An excerpt:

… does an increase in overall clinician numbers necessarily equate with improved health care and outcomes? Studies in the United States suggest a weak link between population health and doctor supply; primary care is a possible exception. Geographical regions with 60% more doctors than regions with the lowest per-capita supply perform no better in measures of mortality, quality of care, or patient satisfaction with care or perceptions of access. If more doctors are needed, more primary care doctors than specialists are likely to yield better outcomes at lower cost. These findings have implications for the diminishing proportion (currently 27%) of Australian medical graduates entering general practice. Finally, previous supply increases in the US and Australia have not led to more doctors working in under-served communities with clearly documented unmet health needs.

Scott also says that “clinician productivity is being sapped by bureaucratic imposts and inertia, poor human resource management, and failed systems of organisational governance”. He proposes some solutions, including:

•  clinical interventions that are ineffective or of very marginal value should be discouraged, thus diverting time to more effective interventions

• dysfunctional non-electronic clinical information systems, which create duplication and waste time, must be digitally reformed. Electronic personal health records stored on patient-authorised web-based portals or patient-held “smart cards” would allow rapid access to patient data from different providers across multiple sites, thus improving patient safety and saving time and resources

• health care organisations, both small and large, should re-engineer current models of care that constrain clinician productivity. Recent large-scale service redesign projects in the UK and Australia have achieved modest success in making better use of clinics, operating theatres, hospital beds, and community services. Countless examples of small-scale innovations, both successful and unsuccessful, remain unreported and thus are not disseminated

• current role delineations, job descriptions and award structures may be impeding the efficient alignment of skill sets with clinical tasks and thus require change. Appropriate delegation of medically supervised, protocol-led, lower-complexity tasks to newly defined positions of nurse practitioners and physician assistants has the potential to free up doctors for more higher-complexity tasks in settings where research suggests dividends in service enhancement, such as clinics and nursing homes

• fundamental changes to the Medicare Benefits Schedule. The current MBS overpays procedural specialists and other narrowly scoped practitioners involved in one-off operations or consultations, and underpays cognitive, generalist clinicians dealing with chronic disease over the long term

• Public involvement in efforts to rationalise and prioritise health services is possible and should be encouraged in guaranteeing a more sustainable health care system.

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