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Australian health system is in need of much better resources

15 December, 2006

Prue Power, the executive director of the Australian Healthcare Association, speaks exclusively to Rodney Appleyard from about what is wrong with the current health system in Australia and what needs to be fixed to make it work better.

She says that one of the major challenges for the Australian health system includes improving equity of access to the services for everybody regardless of their capacity to pay.  

Can you describe why the Australian healthcare system is currently suffering from a lack of equity?

Australia’s policy response to health sector challenges over the last two decades has entailed a shift of focus away from equity towards cost containment and cost-effectiveness. The major reason underlying this shift is a fear of escalating costs due to demographic changes, new technology, increased consumer expectations and supplier induced demand for services.

The AHA believes that an effective health system must ensure equitable and efficient distribution of high quality services through adequate public funding and appropriate use of incentives (financial and otherwise) to achieve agreed objectives.

The following critical factors must be in place to underpin such a system:

Effective governance: 
Governance structures must allow for clear authority, direction and control, to manage budgetary issues, employment and industrial matters, risk and compliance with regulations/legislation as well as clear accountability for safety and high-quality clinical outcomes.  There must be clear accountability of provides to funders.

Capacity to ensure a high level of safety and quality: 
Achieved through effective monitoring and reporting of the following key indicators: 
- Per capita utilisation of all services regardless of setting (acute, residential, community);
- Timeliness and availability of access for each service type broken down by socio-economic status, location and ethnicity;
- Whether services are appropriate and safe (free from avoidable harm), based on standards and are responsive to patient/client needs;
- The degree of integration and coordination of services;
- Effectiveness of outcomes;
- The degree of efficiency in the use of resources;
- The level of skills and knowledge of the providing individual or agency;
- The capacity of the system to maintain a sustainable quality of care through its workforce, facilities and equipment and to be responsive to change and emerging needs; and
- The identification and qualitative assessment of emergent causal factors and trends that have the potential to compromise optimal performance.

Integration and coordination of services across the continuum of care: Incorporating both the traditional approach to curing individual illness and the population health approach, which focuses on early intervention, preventing/reducing illness and disability among high-risk populations as well as promoting healthy lifestyles. 

The components of an integrated health-care system include:
- Collaboration on a multi-sectorial or whole of government basis, encompassing sectors dealing with cultural, political and environmental issues, workplace and living conditions, education and transport, as many determinants of ill health are located in sectors such as these, outside the direct control of the health sector;
- Incentives to ensure that care is given in the most appropriate setting by the most appropriate provider and a focus on meeting the community's health-care needs including a sensitivity to culturally diverse and Indigenous populations;
- Matching service capacity with community need;
- Collaboration between all sectors within the portfolio, including providers, to ensure objectives are met;
- Partnership and teamwork across all health worker disciplines; and
- Strengthening primary health care services in order to provide integrated, accessible health care services.  Clinicians providing these services are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and practising in the context of family and community as well as ensuring appropriate referrals and links with other parts of the system.

A workforce that is appropriately matched to the services being provided and which meets the demands of a rapidly changing health system: 
This will require a systemic, sector-wide approach that links health sector redesign and workforce development.  It will need to involve innovative approaches to balance service commitments and training requirements that improve inter-disciplinary communication and team work.  The approach should incorporate clear strategies, policies and well-designed and publicised incentive schemes for the recruitment and retention of health professionals, particularly in areas of special need. 

Accountability to the community: 
Processes must be transparent and open to allow for representative consumer and community involvement in decision making.  It is no longer acceptable that systems and institutions exclude consumers.  In addition, change can only be achieved with the broad support of the community. 

It is also critical that the system develops and continues to apply valid, reliable and sensitive outcome measures and that the results are published in comprehensive and timely reports to the community and stakeholders.

Ethical decision making: 
Integration of ethical decision making and action at all levels in the workplace is critical.  Values and ethics are critical to good governance.

Information/communication technology:
The creation of a healthcare information network should be of the highest priority for governments.  Improving patient safety is a primary motivator for facilitating the flow of information/communication technology between providers, patients, and payers of care.  Lack of data is a major source of medical errors that could be prevented through an accessible and accurate electronic network. 

Research and development:
Funding should be available for a comprehensive research and development program which is intrinsically linked to healthcare delivery.

Public-private sectors:
Integrated involvement of both public and private sectors in service provision, health advancement and health evaluation programs is required to ensure access and avoid duplication of services. 

Public funding must be sufficient to ensure provision of high quality services that meet objectives, including in areas of need.

How badly are people in socially disadvantaged sectors affected by these inadequacies?

For example, health outcomes for Indigenous Australians are so much worse than those of other Australians that this issue can only be described in the strongest terms:

- The life expectancy of Aboriginal Australians is 20 years less than that of other Australians;
- There are nearly three times as many deaths among Aboriginal Australians as would be expected for the population as a whole; and
- Indigenous Australians experience an earlier onset of most chronic diseases, have more GP consultations and are more likely to be hospitalised than other Australians (The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. ABS, 2005). 

Significantly, Australian Indigenous health status not only lags behind the general Australian population, it lags behind that of comparable populations in other countries such as the United States, Canada and New Zealand (Paradies Y, Cunningham J. Placing Aboriginal and Torres Strait Islander mortality in an international context. Aust N Z J Public Health 2002).

The is a well recognised nexus relating poor Indigenous health to inadequate investment in infrastructure and the need for community controlled services (Griew R, Sibthorpe B, Anderson I, et al: On our terms: the politics of Aboriginal health in Australia in Healy J, McKee M, editors. Accessing health care: responding to diversity. Oxford: Oxford University Press, 2004).

Housing and educational opportunities for Aboriginal people fall below the standard expected by the broader community. 

The specific application of these issues in healthcare include on-going barriers in Indigenous access to the Medicare and the Pharmaceutical Benefits Schemes, contributing to substandard levels of healthcare service provision (Bridging the treatment gap for Indigenous Australians. Joan Cunningham, Alan Cass and Peter C Arnold Med J Aust 2005; 182 (10): 505-506) and an under-representation of Aboriginal People among the ranks of healthcare workers.

How much damage is the Government's current strategy inflicting? 

A focus, by all Australian governments, on cost reduction in the public health sector, rather than the cost-effectiveness, has put considerable pressures on institutions in the sector which impact greatly on their recruitment and retention capacity.  For example, in just ten years, funding of public hospitals dropped from 30.7% of recurrent expenditure on health in 1991-92 to 26.7% in 2001-02 [AIWH Australia’s Health 2004].  This causes a feeling of hopelessness and loss of morale among members of the health workforce and adds to difficulties with retention.

Furthermore, doctors and nurses don’t want to work the same hours and make the same lifestyle sacrifices that their fathers and grandfathers took for granted.  Although doctors still work longer than most, their average working week dropped by 2.7 hours in the 5 years to 2001. Nurses also decreased their total average weekly hours by 1.6 hours in the 6 years to 2001. However, all healthcare providers are generally working shorter hours than they did a generation ago.  Between 1996 and 2001, there was an overall decrease in the average hours worked from 30.9 to 30.8 per week. 

The impact on demand presented by the changing demographic and epidemiologic environment is exacerbated by the shortages we are facing, particularly in nursing, pharmacy and many allied health professionals.  New entrants are not being attracted to these professions. Our current health workers are very often dissatisfied with their working life.  They almost always enter these professions with aspirations to make a difference, but soon feel undervalued in the face of growing pressures from the system.

Shortages, coupled with a reluctance to move into outer metropolitan and rural/remote regions, has lead to a growing number of ‘areas of need’. 

The rate of health workers per 100,000 population decreases with increasing geographical remoteness.  Despite the fact that Australia has a universal and publicly funded health system, there are significant inequities in access to health services between communities.  People living beyond the cities have limited access to a wide range of health professionals compared to metropolitan communities. 

Consequently, rural areas in particular have become increasingly reliant on overseas trained doctors.  However as recent events have shown, there is often insufficient supervision, support and orientation or cultural training to ensure these doctors are adequately prepared to practice in Australia.

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