Can the health dials be shifted?

The Productivity Commission this week released the first of scheduled five-yearly reviews of total productivity in Australia.  It’s a commendable initiative from Treasurer Morrison and will complement the Intergenerational Report as a snapshot of ongoing economic performance.

Some 40 pages of the document – Shifting the Dial – address healthcare, and what might be done to address fundamental limits to both efficiency of delivery and actual population outcomes.

In particular, there’s a range of sensible suggestions, including:

  • Increased use of telehealth;
  • Proper integrated care;
  • Reducing the use of ‘low-value health interventions’; and,
  • Reorienting activity-based funding for hospitals, to reward hospital avoidance rather than simply the provision of services.

The PC notes that waiting times in doctors’ offices imposes costs on Australians of approximately one billion dollars annually.   Many of us have experienced the frustration of those waiting times whilst watching the clock and wishing for a speedy return to our offices.  If use of the MBS telehealth numbers could be expanded, many of us could avoid that wait, have our consultation from a place of our choice and, if telehealth was used for just 10 per cent of consultations, contribute to saving over $300 million annually in travel and waiting times.

Likewise, the recommendation to reduce the use of low-value health interventions and introduce ongoing reviews of the Medicare Benefits Schedule.  These are sensible suggestions and it is good to note the PC’s recognition of the work currently being undertaken by the Robinson Review which is progressing well, particularly given the level of consultation built into its methodology, and necessary to its success.

Unfortunately, the ambition of the report may exceed its impact, for two reasons.  The first is the typical problem of political constraints.  As an example, the Report notes:

“GPs are the clinicians that Australians most frequently see and are highly trusted.  They will often deal with people who have already acquired chronic conditions or have their time diverted readily into reassurance work – treating people who have minor ailments, many of which would resolve without any treatment.  Yet the aspiration for primary care is that GPs play a prominent role – within the broader, primary health care sector, in preventing chronic conditions.” (p.46)

Well said, but the quickest way to raise the hackles of any medical or allied health college is to suggest that lines be blurred between different healthcare franchises.  It’s a curious phenomenon, because we expect people entering medical training to seek the opportunity to practice at the top of their profession, rather than at the more mundane maintenance end, but it’s a real problem.

Some solution to this does need to be found: it’s beyond contest that the largest return on medical investment is preventing chronic disease – both in the first instance as well as stopping progression to hospital ‘frequent flyer’ status – but the community naturally remains focused on timely treatment of illness and injury in the present, not the future.

The second limitation in Shifting the Dial lies in glossing over some of the economic realities of retail healthcare.  In particular, on pharmacy, it finds:

“A new model of pharmacy would adopt now-available technology – for example, e-scripts and machine dispensing of drugs – and recognise retailing as incompatible with a genuine clinical function for pharmacists.” (p.72)

There are some inevitable and sound objections here, which go to what pharmacists do and might do.  The first is that vending machines are unlikely to contribute to quality use of medicines, or to identify where there is poor compliance: pharmacists are key players in ensuring people understand how and when to take their medicines.

And second, the complementary retail business of pharmacies has an important role in reducing pressure on medicine prices either to consumers or the government.  Separating the two would be a source of upward pressure.

The two issues we’ve raised here have an important intersection: pharmacists could be as important as GPs in preventive health – particularly smoking and alcohol.  And they could take some of the basic work away from GPs – for example simple wound care.

But none of this is a simple as the PC would like it to be.  Integrated care requires fundamental change to training of all professions at the tertiary level.  It also requires more flexibility in healthcare finance in order to introduce indifference to who is the primary care leader.  That requires a political risk appetite we haven’t seen of late, but perhaps this report is a start.

Alastair Furnival and Catherine McGovern