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Unhealthy addictions get in the way of health reform

One of the troubles with the health debate is that so much of it is driven by narrow sectoral, institutional or professional interests.  The National Rural Health Alliance is one of the few organisations that takes a holistic view of the community’s health.

The editorial from the Alliance’s latest Partyline publication raises many issues that are pertinent – our addiction to doctors and fee-for-service health care, for example – and not only for those living in rural areas.

It says:

“Reforming the health system would be much simpler if it were not for a number of addictions or fixations Australians tend to have.

For one thing, we depend too much on our doctors.  Almost whenever governments look to roll out a national plan – whether for immunisation, childhood obesity, mental health or diabetes – the easiest thing to do, both logistically and politically, is to dump it in the laps of the GPs.

This would be all well and good if they weren’t already so busy – and if the location of GPs reflected the distribution of the need for primary care.  But it does not.  What it does reflect is the collective outcome of the decisions of individual doctors, many of whom see themselves both as clinicians and business people.

Feminisation of the general practice workforce and changes in its cultural mix mean that the balance between clinical, family and commercial determinants of doctors’ business decisions has changed.  It is a challenge to attract Gen Y professionals of all kinds to communities with cultural and spatial characteristics with which they are not comfortable or familiar.

In recent years there has been an encouraging expansion in the employment of practice nurses, who help general practitioners to focus more on what they and they alone are competent to do.  More of such changes in the distribution of activities that in the past have been seen as ‘doctoring’ need to be encouraged.  The current moves to give selected midwives and nurse practitioners access to the PBS and MBS is an important part of this.

If the structural, financial and attitudinal challenges can be met, it will allow physiotherapists, nurses, podiatrists, oral therapists, paramedics, physician assistants and others to contribute more to what has traditionally been thought of as ‘doctoring’.

A second limitation on reform is a fixation on fee-for-service health practice.  It would help if, in redesigning the health system, we were more confident about consumers’ indifference about the funding system underpinning services on the ground, and about the range of business models preferred by practitioners themselves.  Not all doctors or physios want to be running their own business and their professional associations are likely to be relaxed as long as there is no intention to remove the option for individuals to engage in fee-for-service.

People in rural and remote areas are familiar with the situation in which a local authority, for example, is underwriting the local GP’s income and perhaps providing accommodation or a place in which to practise.  This is an example of how fee-for-service can be retained in a mixed payments system.  If, despite such a system, it is still impossible to attract a GP who wants to be a fee-for-service business entity, the options include the employment of a salaried doctor.  Such a service is neither a threat to other models or inherently second rate.  It is much better to have primary care provided by a GP than by the emergency staff at a hospital – which often happens in isolated regional centres that are short of doctors and other primary care providers.

Third, as was confirmed by the first round of health reform announcements, as a nation we tend to be fixated on hospitals and their (undoubtedly essential) services, rather than on the broader health system.  The rather dysfunctional part this addiction plays in the current health reform agenda is described elsewhere in this issue of Partyline.

As a nation we have failed to advance as quickly as we might have done with ‘hospital in the home’ type care, and on support for rehabilitation and care for people in their own homes.  through more allied health positions for example.  Improved application of technology can help in several ways, including for patient monitoring and messaging, discharge planning and other continuity of care, and e-health records.  The government’s renewed emphasis on a health promotion agenda should help in this respect but it will also require workforce changes to augment the supply of professionals who provide domiciliary care.

Finally, we have a bad case of the aorta syndrome.  It is not letting governments off the hook if we are encouraged to assume greater responsibility for our own care and illness prevention.  One doesn’t need to be a critic of the Nanny State to agree that “Aorta look after me” is both an ineffective and unaffordable approach to personal health and wellbeing.”

Comments 2

  1. Jennifer Doggett says:

    This is a great diagnosis of the underlying problems with our health system and why current reform efforts won’t fix them. What is interesting is where these addictions come from – often they don’t seem to reflect consumer values and preferences. For example, studies repeatedly show that consumers have a high degree of satisfaction with services performed by nurse practitioners (for a recent example see the article by Sandy Middleton in the current Australian Health Review). However, we still direct the vast majority of Medicare funding to services performed by a GP – even where there is good evidence that a NP can perform the service safely and effectively. We spend large sums of money to attract and retain doctors in rural communities without asking the community members whether they would prefer to spend these resources on other health practitioners. We force both doctors and consumers into a fee-for-service structure, regardless of whether or not this reflects their preferences or supports the provision of best practice care. We don’t expect people to have the same preferences in relation to food, housing, education or other areas of life but somehow when it comes to health care we think a one-size-fits-all approach will work.
    Disclaimer: I get paid to promote the AHR

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2017 conferences
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Australian Palliative Care Conference
2018 conferences
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