As previewed at Croakey, a recent health system simulation aimed to generate creative and effective solutions to tackle low-value healthcare.
Five key messages emerged from the discussions, according to Yvonne Zurynski, Associate Professor of Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, and the coordinator of the NHMRC Partnership Centre for Health System Sustainability. (And you can read a Twitter summary from the day here.)
Yvonne Zurynski writes:
We need to talk about waste: it is one of the heaviest burdens on our health system today.
Waste comes in many guises, some of which are easy to see, such as equipment that can only be used once before being thrown away.
Not so visible or easy to accept is waste that comes from providing people with treatment that delivers no discernible benefit, and in fact may cause them harm. This is called overdiagnosis and over-treatment or low-value care.
Current estimates are that approximately 30 percent of healthcare delivered to patients is low-value care, or simply waste.
Few people know that approximately 40 percent of prostate cancer in Australia is over-diagnosed. These are cancers that would have had no impact on the person during their lifetime, but when treated can lead to serious side-effects – not from the cancer but from the treatment.
All this comes at a personal cost to patients and an economic cost to the health system.
Moving beyond the comfort zone
The NHMRC Partnership Centre for Health System Sustainability (PCHSS) recently convened some 80 health system experts and stakeholders representing diverse groups in the healthcare system, and tasked them to explore potential solutions to reduce low-value care.
The Australian health system is notoriously siloed so bringing people together from different groups is good but not enough. We needed to take them out of their comfort zone.
“No one has designed a human system more complex than the health system,” said Professor Jeffrey Braithwaite, lead of the PCHSS and founding director of the managing body, the Australian Institute of Health Innovation, Macquarie University.
Health systems are more complex than global stock markets, more complex than commercial airlines and the military. This means the challenge of fixing them can only be achieved when people accept the complexity, step outside of their siloed areas of concern and explore the issues from different angles.
According to Elizabeth Koff, Secretary, NSW Ministry of Health, who opened the event, we need to drive change to deliver care that is patient-centred, high-quality, equitable, accessible, based on latest data and research, while working within fiscal constraints.
A challenge to think differently
We challenged our expert audience to think differently, and to look at low-value care from a perspective alien to their own. That’s where Braithwaite’s health system simulation game came in.
Everyone at the event was asked to represent a different stakeholder group to their own.
Real-life doctors became journalists for the afternoon, while real-life consumers took on the role of health ministry officials, and so on.
The 10 groups – doctors, nurses, allied health professionals, health consumers and NGOs, journalists, the Treasury, Prime Minister and Cabinet, Australian Department of Health, state ministries for health, and private corporate concerns – set to work. 
Art really did imitate life. The groups discussed the problems and solutions – earnestly and in-depth – whilst staying within their own siloed stakeholder groups they had been assigned to.
So strong was the siloed thinking that it was 45 minutes before people began to move between groups.
The private corporate concerns visited the office of Prime Minister and Cabinet, but the health consumers group continued to discuss amongst themselves and weren’t visited by anyone.
Eventually however, by the end of the simulation, few people were sitting at their designated table – success!
This is the crux of solving a problem in a complex adaptive health system – no one group can do it by itself. We need to step outside of our comfort zone, be brave, and engage with others to find common ground and a shared language.
So now that everyone is talking to each other, how do we reduce low-value care?
Ideas after the simulation game were abundant and here are a few highlights.
1. Keep people out of hospital
Strengthening primary care and prevention is seen as key to reducing the over reliance on hospitals for non-acute care.
By delivering care in alternative health settings, for example, through ‘hospital in the home’ services and ensuring allied health professionals and nurses are supported to work up to the limit of their licence, we can reduce pressure on GPs and the specialist workforce.
Adjusting limits on the number of Medicare funded services allied health professionals such as physiotherapists can deliver may also be an effective way to support returning people to work and improving national productivity.
2. Make better use of data and analytics in decision-making
Understanding the needs of each patient better can lead to more effective and efficient delivery of healthcare.
Access to the big data already collected by health systems, plus the use of sophisticated analytics, is required to deliver more precision medicine – treatment tailored to the specific needs of the patient, delivered in the right place, at the right time and for the right healthcare spend.
Data can also be used to identify where and why low-value care is occurring. This information can then be fed back to providers and consumers to support behaviour change.
For example, routine Vitamin D testing for people not in identified risk groups is not recommended and yet we spend millions of dollars on Vitamin D testing in Australia without any links to improved health outcomes. This is waste.
3. Organise the system to reward value-based healthcare
Currently, the health system rewards for the volume of care delivered, rather than value-based care that produces the best outcomes for patients.
Improvements are needed in the transparency of decision-making and performance reporting in healthcare. This includes building reliable data sources about care quality, safety and cost rather than just volume of care delivered, and ongoing analysis of data to support decision making.
Transparent learning health systems with a blame-free culture to support constant learning is highly desirable.
4. Integrate healthcare services
Integration is needed through cross-sector partnerships, team-based care, shared decision-making, amalgamation and transparency of data and appropriate incentives for change.
5. Put consumers at the centre
When consumers are supported to take an active part in decision-making, care improves. With education and confidence-building, we can empower consumers to be active in demanding better care while also recognising and questioning low-value care.
Tackling low-value care is something that we can all do.
It seems that thinking globally and acting locally applies equally to environmental sustainability and to healthcare sustainability. This video by Professor Paul Glasziou is helpful to understanding more.
Participants at the event were left with a challenge that we hope will be taken up more broadly – what is one thing you can do to nudge the healthcare system to become more sustainable?
• Yvonne Zurynski is Associate Professor of Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, and is also the coordinator of the NHMRC Partnership Centre for Health System Sustainability.
For more information
• Read a Twitter summary from the day here.
• Also see our Too Much of a Good Thing series, which is investigating how to reduce overdiagnosis and overtreatment in Australia and globally, and is published as a collaboration between Wiser Healthcare and Croakey.
