The challenge of reforming the health system

The challenge of reforming the health system

The challenge of reforming the health system

The challenge of reforming the health system

In light of the recent Budget, APA General Manager, Policy and Government Relations Simon Tatz writes that money without reform just won’t cut it.

Australia has one of the best health systems in the world, ranked in the top 10 by numerous independent reports and studies.

Our spending on health, especially primary care, is among the highest in the world.

Figures from 2017–18 show that governments spent approximately $185 billion on health goods and services, with over $63 billion (34.2 per cent) expended on primary care services.

The May 2021 federal Budget provided even more funding across a range of key health areas: aged care, mental health, rural health and women’s health. More money is always needed.

As the population grows and ages (and the pandemic and its consequent financial impacts increase demand on community mental health and allied health services), increased investments will be needed in every Budget.

But money without reform won’t deliver the health system Australia will need in the future.

The case for reform has been set out multiple times over the years.

One of the best analyses in challenging how health is currently focused, delivered, funded and incentivised is the 2017 Productivity Commission (PC) report, Shifting the Dial: 5 Year Productivity Review (click here).

Looking at the fee-for-service model, whereby most primary care services such as GP visits (and a limited range of nursing and allied health services) are funded under the Medicare Benefits Schedule (MBS), the PC offered valuable insights and recommendations.

The PC found that the ‘international and Australian experiences with integrated care indicates that, if properly implemented, it leads to gains in health outcomes for patients, improvements in the patient experience of care, reductions in costs, and improved job satisfaction for clinicians.’

Summing up the system, they said that although ‘Australia has been searching for a more coordinated system for nearly two decades, realising the goal has been elusive.

This reflects systemic deficiencies in the structure of the healthcare system—its funding, governance, linkages, attitudes—that inevitably act as stumbling blocks.’

Reinforcing what many of us know, the PC found that Australia’s ‘fragmented funding and governance systems for healthcare’ do not deliver the best outcomes for patients.

The reason is that our ‘federal system and its hybrid private–public nature’ and current funding mechanisms encourage ‘activity’ not ‘outcomes’.

Of particular interest to physiotherapists, the PC recommended that funding ‘be directed at allied professionals, who have a smaller scope of practice than GPs, can have lower caseloads and therefore may be more available for rapid professional development.’

These Productivity Commission reports, along with the Aged Care Royal Commission, Victoria’s Royal Commission into Mental Health and literally dozens of parliamentary inquiries, all acknowledge and recommend changes to health funding models to improve patient outcomes and deliver savings.

The government seems well aware of these challenges. They have already signalled their commitment to preventive health and reform to primary care, and the Budget certainly splashed about the dollars to improve existing health services.

There are many good initiatives and increases to funding in the Budget; however, more funding without reforms can end up being just more money poured into struggling systems.

There was a lot lacking in this Budget, particularly in valuing skills to progress models that remove barriers to care to set us on the reform journey.

As the PC and other reports keep telling us, there must be investments in ways to better use the existing workforce and skills.

Supporting multidisciplinary and interdisciplinary care, and dismantling unnecessary barriers in a patient’s health journey, requires structural changes.

The APA has called for referral pathways that fund access to the most appropriate care without a gatekeeper.

The way the MBS is currently structured excludes physiotherapists’ patients from receiving MBS benefits unless they visit a GP first to carry out the administrative task of writing a referral.

This just adds unnecessary complications and time and cost to the patient. It doesn’t contribute to any improvement to the standard of care.

When a physiotherapist is presented with an injury, condition or comorbidity that is outside their scope of practice, or they see a patient who needs ongoing care and management, they refer their patient to a GP.

Patients who disclose mental health issues likewise find their physiotherapy (and allied health) door to be the ‘wrong one’ because they have to be referred to a GP supported by MBS funding.

Because of the way the system is funded, physiotherapists often need to refer to a GP even when their professional assessment is that a medical specialist is the most suitable health professional for their patient.

In cases such as these, the physiotherapist will write a detailed letter to their patient’s GP, outlining the course of treatment given, the response and which medical specialist the patient should see.

This necessitates a GP consultation that is driven purely by funding structures.

For those living in rural, regional and remote areas, the health system is often frustrating, difficult to access and unnecessarily expensive. The government has thankfully addressed some of these problems in the Budget.

There’s a strong package for the rural health workforce and for rural health services more broadly. This funding will help tackle rural health disparities and strengthen access in what has been a challenging time for regional, rural and remote Australians.

The $123 million investment in rural health workforce and training under the Stronger Rural Health Strategy is a very good initiative.

So, too, the package to increase the value of the Rural Bulk Billing Incentive—a vital measure to improving access to general practice and reducing out-of-pocket costs for rural and remote Australians.

However, improving access for patients and ensuring that health service providers can maintain their viability in rural areas needs a much broader focus beyond general practice—it must include physiotherapy and other allied health services.

To facilitate greater access to rural healthcare, targeted investment and realignment of funding priorities to enable multidisciplinary care to occur is needed.

The almost $10 million to add 90 workplace training packages through the Allied Health Rural Generalist Pathway as an early-career workforce solution is a good measure.

However, recognition of rural practitioners as a highly skilled, supported and valued resource is also needed to incentivise career choices in rural health.

In valuing skills, there is a need to formally recognise in policy the APA’s Physiotherapy Career Pathway as a skill acquisition pathway acknowledging the advanced clinical skills held by rural physiotherapists in addressing unmet service need.

As the well-worn mantra goes, this is a good first step, but much more reform is needed to provide better patient journeys and outcomes.


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