NACCHO Aboriginal Health news: Prevention rather cure lost in medical jumble

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“Lack of an effective infrastructure to help us avoid illness is a serious flaw in our healthcare system that needs urgent attention. Its establishment will require more money for Medicare but save us a fortune and provide us with a healthier population. We are frustratingly insular when it comes to introducing the changes contemporary Australia needs to meet health-related demands”.

John Dwyer  emeritus professor of medicine at the University of NSW writing in THE AUSTRALIAN

THERE is a lot that is disturbing about the federal government’s flirtation with a $6 co-payment for a service from a GP. Certainly no signal to the community that healthcare is expensive is needed. Last year we spent more than $29 billion from our hip pockets to subsidise our taxpayer-funded health system.

Most commentators have criticised a co-payment, as it will act as a further deterrent for poorer Australians to seek the care they need, yet provide only paltry savings in a $120bn-a-year health system. Studies show that already too many patients delay seeking help and fail to take prescribed medications because of the costs involved. With the exception of illness caused by excessive alcohol consumption, all risk factors for serious disease are more prevalent in less advantaged Australians. Healthcare in our wealthy country is distressingly and increasingly inequitable.

However, the major frustration with the current debate is associated with the lack of political understanding of the changes we do need to make to provide better health outcomes from a system that is financially sustainable. We do need to extract far more health from the dollars we invest in our health system but cost-effectiveness can only be tackled with a whole-of-system analysis not just a focus on the federally funded Medicare program that supports the delivery of primary care.

If the government were serious about reducing the cost of our health system while improving outcomes and equity, it would start by tackling the appalling waste and inefficiency associated with having nine departments of health to care for 23 million people. Not only does this result in duplication costs estimated to be between $3bn and $4bn annually, the associated jurisdictional mess that sees states responsible for hospitals and the federal government responsible for primary care perpetuates all the inefficiency associated with a lack of patient-focused integrated services. We are the only OECD country so burdened.

This compartmentalisation is represented by Health Minister Peter Dutton’s focus on the cost of Medicare. Hospital expenditure dwarfs primary care expenditure. In the real healthcare delivery world, the success or otherwise of our Medicare-funded primary care system has a significant influence on how much we need to spend on hospital care. Indeed the pertinent truth is that hospital funding into the future will be manageable only if a modernised and remodelled primary care system can reduce the demand for hospital admissions.

The Productivity Commission reports that between 600,000 and 750,000 public hospital admissions could be avoided annually with an effective community intervention in the three weeks prior to hospitalisation. An average hospital admission costs at least $5000 while a community intervention to prevent that admission would cost about $300. Better quality control and attention to the evidence base supporting procedures to avoid unnecessary interventions would also save us billions of dollars.

Most of the $18bn provided annually by Medicare is utilised for treatment available from our GPs. Primary care is doctor-centric and sickness-orientated. We visit our GP because we have a problem, not to get help to stay well. GPs are swamped with patients with chronic and complex diseases most of which could have been avoided or minimised as they are related to unhealthy lifestyle practices.

Lack of an effective infrastructure to help us avoid illness is a serious flaw in our healthcare system that needs urgent attention. Its establishment will require more money for Medicare but save us a fortune and provide us with a healthier population. We are frustratingly insular when it comes to introducing the changes contemporary Australia needs to meet health-related demands.

Around the world the trend is to establish primary care systems that encourage citizens to enrol in a wellness maintenance program and benefit from the delivery of healthcare by teams of health professionals working as “first among equals” in the one practice, integrated primary care. Medicare would cover the services provided by the team.

The psychology associated with voluntary enrolment is important. The philosophy involves acceptance of the concept that we need to take more responsibility for our own health but, when necessary, with personalised and ongoing assistance from appropriate health professionals. The infrastructure involves having such a prevention program available from one’s primary care practice and is not necessarily delivered by doctors.

Contemporary primary care should also provide earlier diagnosis and intervention in potentially chronic conditions, team management for established chronic disease, and care in the community for many who are currently admitted to hospital.

The benefit of spending more on Medicare to reduce hospital admissions is a no-brainer if one is looking at the cost of the entire system but, of course, our governments don’t do this. The savings would more than cover the expense of introducing integrated primary care into Australia.

The Abbott government will probably govern us for six years. It should commit to taking us on a health reform journey so that in six years the above changes and the introduction of a single funder for our health system are providing us with far more health from the available healthcare dollars. To be talking about $6 is to trivialise a major policy challenge.

John Dwyer is emeritus professor of medicine at the University of NSW.

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