We now have a health system
resembling an old cottage, with so many renovations and add-ons, especially in
relation to payment, that it would be reasonable to ask whether we should
demolish and rebuild.
The multiplication of
bureaucratic complexity and endless tinkering with fees and reimbursements may
provide employment for those who enjoy that sort of thing.
And it is time that compromises
can be found that work for a bit. But it is a stupendous waste of resources.
To contemplate a complete rebuild
of our health system is frightening, I admit.
Several years ago, I was
addressing a parliamentary committee exploring health and Malcolm Turnbull, a
member of the committee, asked me what I would do if tomorrow on waking I was
to discover I had been made minister for health.
I replied that I would go back to
bed and pull the doona over my head hoping that the nightmarish prospect would
pass with a little more sleep.
But these days I would answer
differently. Three aspects of a new system commend themselves.
First, there would be a new
system of paying for healthcare. Moving towards a system that is genuinely
understood by all to be for all, and paid for through progressive taxation in
which remuneration is fair and generous, would be desirable.
We would seize opportunities to
develop policies and reorient investment that would better serve our purposes.
A new system that promoted
integrated care would be welcome. Primary care and general practice would be
front and centre.
Second, I would invest in
developing strategies that took prevention seriously at the level of the social
determinants.
This would require activity
beyond the boundaries of the existing health system. It would be expensive,
tedious and demanding.
But it could lead to new
‘sanitary reform’ of our society and a new era of prevention. These reforms
would be an essential step in preparing to meet the health challenges of the
now inevitable climate change.
The great contemporary epidemics
(or syndemics as they have come to be called because they travel together) of
obesity and diabetes also demand a preventative approach.
The new system would seek active
involvement with industry on urban design, transport and food.
Finally, I’d take a long look at
what people want from healthcare in the same vein as the late Professor Ed
Pellegrino, a US renal physician who was renowned for his work in medical
ethics.
His survey of cab drivers
identified three priorities: a doctor to be there to transfer the anxiety for
patients taking the next step when confronted with a health challenge, for
example finding a breast lump; a health system capable of saving life from
trauma or infection; and a system able to provide cure where possible, and
relieve pain and suffering.
Let’s examine what we would need
in an ideal health system, built from scratch, to meet these three goals.
The first would require
high-quality primary care available 24/7 face-to-face and online for remote
settings.
For the second, emergency
ambulances and EDs are required. But at present these are encumbered by huge
inpatient loads with patients stuck in wards when many could be managed in the
community with integrated services.
There is plenty of room for a
radical rebuild here.
Third, curative and caring
services, currently the source of out-of-pocket payment chaos, also deserve a
radical rethink and reorganisation.
Hospital beds still dominate and
limit the exploration of effective reform options. Outpatients might be
reinvigorated with benefit.
In all of this rethinking and
redesign, we should remember the huge variety of expectations people have of
healthcare.
In 1976, Newcastle medical
school, where I worked for a decade, sought to put the patient at the centre of
the curriculum.
To find out what the community
wanted from our graduates, we visited several community groups, including a
nursing home and a school to meet young parents.
Expectations varied widely and
wildly. A father insisted he wanted a doctor who didn’t keep him waiting. A
grandmother wanted a doctor who listened. A senior nurse who had had aortic
aneurysm surgery simply wanted a competent surgeon even “if he (sic) had no
bedside manner”.
My guesses in this article are
only that. To successfully rebuild our health system, a lot of architectural
inquiry across society would be the first, and most essential, step.
But we should not baulk at the
idea of radical change. Good health demands it.
