A Healthier Future for all Australians - Final Report June 2009
1.6 Moving from complacency to action – the critical need for health system reform
1.6.1 A second tipping point
Over the past 16 months, we have been on a journey with the Australian community to develop a long-term reform plan for our health system. That journey has been nothing short of epic. Indeed, it was described by the Australian Medical Association upon our establishment as a ‘health trek…to go where no Commission has gone before”79! We were not alone in our journey; other bodies have been commissioned to examine the future role and functioning of health promotion and illness prevention, primary care and maternity services within our health care system.80 However, we have been tasked to look at the need for reform from an overall whole system perspective.Experts in many areas gave us the benefit of their opinions along the way; health professionals working at the coalface patiently explained their concerns and aspirations; and organisations representing individuals, professions and various health sectors met with us and shared their vision for reform. Lastly, but equally as important, people from every walk of life shared their experiences and their ideas for ‘fixing’ the whole or parts of our health delivery system. This fact-finding mission suggested to us that there was an overwhelming sense that:
In every dimension and at every level, the Australian health system is not just fragmented, but atomised. Like iron filings scattered randomly on a piece of paper, its many players are influenced by different motivations, which in turn draw them in different, often opposing directions… More than ever, the Australian health system is in need of a magnet to align its efforts – strong, determined leadership fuelled by a bold, unifying vision..81
We received substantial feedback on our Interim Report which assisted us to refine our reform directions and formulate a cohesive approach to bringing these recommendations together into a plan of action. Many responded to specific reform directions and provided useful suggestions; others commented on the package of reforms and noted the need for a single, focused and overarching blueprint for reform82. Almost all encouraged us on the path of substantive health system reform:
The College would firstly like to convey its congratulations to the Commission for producing a report which puts Australia firmly on the path to true health reform. We would like to state our support for many of the initiatives proposed in the report, in particular the development of a National Health Promotion and Prevention Agency, Comprehensive Health Care Centres with enrolled populations, a commitment to ‘Closing the Gap’ in Indigenous health, the inclusion of school based health literacy education, and the commitment to the expansion of Specialist Outreach Services, which have particular impacts in our Indigenous and rural and remote communities.83
We have attempted to make sense of the vast array of concerns and problems brought to our attention, which affect the performance of our health care system. We have looked to other countries to compare and contrast problems and solutions. We have always looked to our people, our health professionals and industry experts to affirm our ideas and guide our recommendations.
Our conclusion – that there is an urgent need for substantive health system reform – aligns with many who have communicated with us along our journey. Our health system has reached a gateway, a second tipping point, beyond which the easy options have been exhausted and only the tough decisions remain. The door has shut on ‘point solutions’ and another opened to transformational change in the way we govern, fund and deliver health care services.
1.6.2 A moment in time for concerted action
The urgent need to resolve existing pressures, service gaps, safety concerns, inefficiencies and inequities, combined with emerging challenges, will lead to an increased but changed demand for health care and the need to achieve value-driven supply. Now is the time for action if we want to safeguard the health and wellbeing of future generations at an affordable cost to our nation.All developed countries struggle to reconcile the implicit tension between three objectives: equitable access, high quality outcomes, and low cost. The trade-offs among these goals are inherently determined by social values and are played out through the political process. Evidence would suggest that an efficient health system can occur in a variety of forms and that the optimal structure is determined by social objectives84. What balance should we have between public and private funding and provision of health services? Should all citizens contribute more in taxation to pay for health services in remote and rural areas if it will provide fairer access? What do we define as good quality health outputs and outcomes that we seek from our health system?
Some authors85 have espoused the view that all health care systems around the world are becoming financially unsustainable due to a toxic combination of global forces including demographic changes, the increasing cost of medical technology, and an epidemiological shift towards more complex diseases. It has been suggested that governments have relatively few options and most will converge either haphazardly or methodically towards a common health care model.
What is important to remember is that there is no optimal level of expenditure on health services provided that society considers that, however measured, the benefits outweigh the costs86. Therefore, the key is to ensuring that there is a clear objective measurement of the benefits and costs and that, in producing the health services, waste of resources and dollars is minimised.
Whether or not a common model unfolds internationally, there are clearly no simple one-step solutions such as higher government investment – we know that higher spending does not correlate with higher quality health care, nor better outcomes. Health care systems are notoriously resistant to reform in a large part because of the competing objectives of access, quality and cost. Vested interests and structural complexity bedevil attempts to ‘tweak’ the health system and nudge it in the right direction. Many proponents of health care reform tend to favour incremental adjustments but these rarely address the interdependency among seemingly autonomous actions and have unanticipated consequences. We need to move beyond point solutions and protection of vested interests if we are to maximise the health and wellbeing of current and future generations.
In the following chapters, we outline a comprehensive framework for health care reform which recognises the interdependencies of health care and takes action to shape incentives so that supply and demand find a socially acceptable equilibrium. We will describe an agile, self-improving, and sustainable health system which puts the health and wellbeing of people and families firmly at its centre.
79Editorial (2008), ‘Big challenge for new Commissioners’, Australian Medicine, 20(5): 3.
80Other groups included the Preventative Health Taskforce, the National Primary Health Care Strategy and the Maternity Services Review.
81P Nicolarakis (2008), Submission 328 to the National Health and Hospitals Reform Commission: First Round Submissions.
82For example: Parliament of Australia (2009), The interim report of the National Health and Hospitals Reform Commission – a summary and analysis, Research Paper.
83Royal Australasian College of Physicians (2009), Submission 127 to the National Health and Hospitals Reform Commission: Second Round Submissions.
84J Richardson (2005), Priorities of health policy: cost shifting or population health, Australia and New Zealand Health Policy, 2(1).
85J Anscombe, (2008), Health care out of balance. How global forces will reshape the health of nations. (A.T.Kearney, Inc).
86J Richardson (2005), Priorities of health policy: cost shifting or population health, Australia and New Zealand Health Policy, 2(1).
