“Business as usual is not an option” announced Robyn Kruk when, as chair, she embarked on the WA Department for Health‘s Sustainable Health Review (SHR). The implication is that the business of illness will have to change. Some will perceive this as an opportunity; others a threat.
It would be surprising if the final report, due to be presented to the Minister in November, did not incorporate international trends which prioritise population health in a community context to curb ever-growing sick care expenditures
In the U.S. the Health 3.0 framework draws on evidence to optimise population health over the life span, in a community-integrated health system. In the UK, previous NHS chief Lord Nigel Crisp recommends adopting practices from developing countries with limited resources which empower communities to obtain better health outcomes. While a recent report from the European Commission that emphasises the critical role of primary care in overall health outcomes, specified community-oriented care as one of the 10 domains of assessing primary care performance.
Closer to home, South Australia established a Health in All Policies (HiAP) unit based on the European model that calls for a whole-government approach to strengthening health systems by influencing the social determinants of health.
SA’s HiAP, which is supported by government mandate, seeks support from all departments to integrate population health into their policies and programs, even those traditionally not considered to influence health. This approach recognises that health is influenced by a wide range of determinants and tackling complex healthcare issues requires collaborative policy responses.
It is uncertain if the SHR will call for this approach as there has been a history of reluctance to the HiAP concept in WA.
In the CSIRO’s Future of Health report, it urges discussion on the need for, “…a fundamental shift in our paradigm of healthcare from treatment to prevention…[to]…reduce the financial burden on healthcare and improve quality of life for all Australians.”
The report was informed by the diverse perspectives and technical expertise of over 30 organisations who, like Ms Kruk’s review, indicate change is an imperative. Compared to other OECD countries, Australia spends more than any other on an average 11 years of ill health.
Future of Health finds only 20% of a person’s life expectancy and quality of life influenced by clinical care, which equates to a poor return on investment given the nearly $200 billion spent on health in 2016-17.
The Inverse Care Law
The availability of good medical care tends to vary inversely with its need within the population it serves. This inverse care law operates more completely where medical care is most exposed to market forces. The market distribution of medical care is considered an outdated social form, which would further exaggerate the maldistribution of medical resources.
The recommended shift to a culturally-tailored, proactive management and prevention model that addresses the inequalities in social and economic support, and the physical environment are hampered by our current fragmented and inflexible illness focused system.
A practical example is demonstrated by the fact that less than 20% of GPs know when their patient was seen in an emergency department. And yet, care coordination seems like an achievable task in the face of designing a health system capable of addressing individual needs.
The current one-size-fits-all approach to care is doing more harm than good. For instance, Australians living in rural and remote areas tend to have lower life expectancy, poorer mental health outcomes, and higher rates of disease and injury. While the CSIRO report supports a technology-driven, tailored approach, their “precision health solutions” may lead to further disparities.
The Inverse Care Law (ICL), introduced by Dr Julian Tudor Hart, could be applied to CSIRO predictions of the increasing prevalence of technology in improving health outcomes.
The report includes several fascinating examples of using these technologies to help keep Australians healthy, to assist with chronic care and after-care including health apps (there are already 318,000), AI platforms, bots, virtual reality, augmented reality applications, robots, behaviour monitoring sensors, virtual counselling/CBT/assistance and voice monitoring.
While the pursuit of technological advancements is well intentioned, there is no substitute for empathy, compassion and warmth provided by people. Furthermore, these digitally dominant scenarios are costly to develop and expensive to use.
Advanced applications of technology are unlikely to serve those who need the most care now. Borrowing from Dr Tudor Hart, I suggest a parallel law: the Inverse Digital Access Law i.e. those most likely to benefit from technological advances are the least likely to be digitally literate and able to afford access thereby increasing health inequity.
First on the CSIRO’s list of several enabling themes is, ‘empowering the consumer’ as they are an underutilised resource. However, there is no mention of an acclaimed example of the health outcomes that can be achieved when the ‘consumer’ becomes the owner and manager of their own healthcare service.
The South Central Foundation in Alaska has for years drawn the attention of global health leaders for its achievements such as a 36% reduction in hospital days, a 42% reduction in urgent and emergency care services, and a 58% reduction in visits to specialist clinics.
The foundation established the ‘Nuka System of Care’ where people using the system are ‘customer-owners’ and the whole system is based on what customer-owners want – trusting, accountable and long-term relationships that provide a better understanding of the context in which a customer lives.
These relationships are the basis for the culture of trust that encourages the foundation’s shared decision-making, a critical component of consumer empowerment.
The WA Primary Health Association seeks to empower consumers through the promotion of a patient-centered medical home model. An essential component of the model is providing the right care at the right time driven by the patient’s preferences.
At a recent event convened by WAPHA entitled Working with Primary Care to Manage Demand, reference was made to the 10 Building Blocks of High-Performing Primary Care which was developed by Prof Thomas Bodenheimer, Amireh Ghorob Tolhurst and others at the University of California.
The model serves as a roadmap to design care services and structure delivery using a person-centered approach.
Amireh has recently settled in Perth and brings from San Francisco a wealth of experience in training healthcare providers to engage with patients collaboratively so they ask “What matters to you?” and not “What’s the matter WITH you?”
In Australia, the 10 Building Blocks model is guiding transformation efforts at WAPHA, the Agency for Clinical Innovation, and Coordinare South Eastern NSW Primary Health Network.
While there is uncertainty as to precisely how the business of illness will change, the impact on providers is certain. Empowering providers to share in shaping and implementing changes will make all the difference in what healthcare will look like in the future.
Thus, It is a pertinent question to also ask ourselves, “What matters to you about the future of health?”
References available on request
The author wishes to acknowledge the suggestions provided by Amireh Ghorob Tolhurst
ED A/Prof Bret Hart is a public health physician and an adjunct clinical associate professor at the Curtin Medical School.