Demolish, rebuild: How I'd fix our health system

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.

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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.

Published in Medical Observer 20 May 2019 https://bit.ly/2Jxltj0