10 November 2017
Dr Ayman Shenouda
PC Report: We can do better in health
The recently tabled Productivity Commission Report ‘Shifting the Dial: 5 year productivity review’ takes a broad policy lens on only on a few key areas which it states are likely to impact overall economic performance over the medium term. Health, of course, made it into this five-year review of the nation’s productivity alongside education and cities.
Overall the report turns to technology as an enabler for change and in parts more government control. The report suggests some major policy shifts to achieve a number of efficiency measures. Applying automation to healthcare as a cost reduction strategy specifically to achieve a smaller pharmacy workforce is one such shift. There are some familiar ideas floated throughout with many not pursued in the past for good reason. There is a lack of emphasis on the role of general practice in the health discussion which in turn weakens the piece.
A quick snapshot
While there are a number of recommendations for health against Healthier Australians many seem short on detail (and evidence). The sharpest shifts are pointed at education system reform, while health seems a little less disruptive. This is, of course, other than the recommendation for pharmacies to be turned into automatic dispensing outlets! In terms of the rest, well tackling those low-value healthcare procedures is really already in train and an important efficiency measure. Creating scorecards for the performance of providers to enable patients to compare outcomes is another idea which has merit but there are many higher priorities to pursue first.
There’s certainly a push to utilise more both the PHNs and LHNs to help overcome the federal and state funding standoff and related care gaps. This is both positive and problematic in terms of enabling integration. On one hand it will force more joining up through a funding means but on the other it will be reliant on forging strong relationships with general practice. The latter is not made a priority in this paper and instead implies more control (of general practice).
The paper states the need for a new funding pool for the PHNs and LHNs towards population health activities including some commissioning of GP services.There is certainly a need to create better structures and incentives to realign toward prevent and chronic disease management and localised solutions makes the most sense. However, the commissioning approach to procuring medical and health care services is still a work in progress in my view and much much more effort is required to engage general practice. That is the only way to establish trust and work through to those new ways of working in partnership with general practice.
The positives …
The overall positives of our healthcare system in terms of outcomes are at least acknowledged. We’re living longer, with less disability. Against OECD countries we have high overall health outcomes with the greatest life expectancy at birth. The third greatest life expectancy at birth in fact at 82.8 years (2015). On prevention and injury, we’re seeing a reduction in smoking rates and few deaths on our roads. And perhaps most importantly for a report focussed on fiscal pressures we’re spending less on health when compared to the other OECD countries.
And the negatives …
But holding us back, according to the report, noting this is from a perspective of lost productivity, are the 27.5% of adults who are obese and the 11 years spent in ill health which is the highest in the OECD. The last being despite having the third-highest life expectancy in the developed world.
It doesn’t hold back …
There are some scathing comments around some of the broader perceived negatives driving costs up. The comment in setting up the need to defund low-value healthcare procedures is both harsh and without (strong) cited evidence:
“Unjustified clinical variations, including the use of practices and medicines contraindicated by evidence, remain excessive, an indicator of inadequate diffusion of best practice, insufficient accountability by practitioners, and a permissive funding system that pays for low-value services.”
The example used here is knee arthroscopy which again is something we all knew about. The new Australian Commission on Safety and Quality in Health Care Standards developed to discourage the use of arthroscopy for patients with knee osteoarthritis is mentioned, yet criticised as it is an advisory and able to be ignored. The report cites some other examples to illustrate their concerns around quality: 75% of bronchitis treated with antibiotics, against best practice; and 27,500 hysterectomies without a diagnosis of cancer.
In finding efficiencies in health the report states:
“Doing better with our health resources can act as a safety valve for mounting fiscal pressures.”
This, of course, is quite obvious and not without (current) policy focus as finding healthcare efficiencies have really dominated the policy debate for nearly a decade. The report states that ‘some suggest that approximately 10 to 15 percent of health spending is used inefficiency due to poor quality care’. That last statement is (again) not referenced but let’s assume ‘some’ have stated it. We all know that the system is far from perfect but there are also many parts worth protecting including the gains realised in primary care. In this report, the efficiency measures are embedded in the detail, not necessarily making it to the recommendations and worth noting.
Observations on the detail
The report states that the patient experience of care receives little focus as a goal of the system. It accurately picks up some failures in terms of enabling choice – palliative care being one. But, it is in primary care where patient centred care remains core and where stronger gains have been realised. Particularly in terms of patient empowerment and ensuring prevention is prioritised and this is not really highlighted here. I really don’t think the review has reached out much at all to general practice, otherwise we would see this reflected more in the solutions.
I think the piece gets to the real issue where it states the current system encourages activity, not outcomes. It includes one of the strongest statements in this report:
“Australia’s messy suite of payments are largely accomplices of illness rather than wellness, only countered by the ingenuity and ethical beliefs of providers to swim against the current.”
From a primary care perspective, I agree that those limited MBS payments oriented towards preventative health and chronic disease are too narrow and inflexible limiting both outcomes and reach. But when considering other payment options, it worth remembering that general practice is a private business model and needs to remain as such. Whether that be maintaining fee-for-service combined with risk-adjusted capitation payments but particularly for pay-for-performance initiatives – ensuring continued practice viability must factor strongly. For this to work, pay-for-performance should only be used to drive quality improvement in certain priority areas – similarly to how the PIP currently operates - and be part of a mix of payment arrangements, not the sole driver.
The focus on enabling stronger integration is of course key and the stumbling blocks preventing more of it is put down to system deficiencies in the structure of our healthcare system – funding governance, linkages, and attitudes. More linking between PHNs and LHNs – fusing those government layers - at the regional level will achieve more integration. It’s about partnerships or more specifically, cultivating relationships between hospitals and GPs that will create these formal linkages to bring about stronger prevention, early intervention, and chronic disease management.
The word partnership is key here and for this to work we would need to see a genuine partnership with general practice, not seek to control it (as the earlier commentary suggests in imposing new funding models). This emphasis really highlights the greenness of this policy piece as it is general practice where the opportunities lie, yet so many opportunities have not been pursued here.
Reassuringly, this report also states that the solution is not to destroy the current system which it states would result in a policy adventure with many risks and uncertain outcomes. Instead, we should focus on those parts of the system already making that required shift towards a more integrated patient-centered system. Some might still say that this report takes us on a journey of (policy) misadventure. This might be true (in parts) but there are some areas worth testing.
Here's a short synopsis on the key recommendations
There are six key recommendations arranged against five identified problem areas – integrated care, patient-centered care, funding for health, quality of health and using information effectively. The recommendations:
2.1 Implement nimble funding arrangements at the regional level
2.2 Eliminate low-value health interventions
2.3 Make the patient the centre of care
2.4 Use information better
2.5 Embrace technology to change the pharmacy model
2.6 Amend alcohol taxation arrangements
I’ve hand-picked a few areas here.
The first recommendation (2.1), to implement nimble funding arrangements at the regional level, calls on all governments to allocation (modest) funding pools to PHNs and LHNs for improving population health, managing chronic conditions and reducing hospitalisation (at the regional level). This recommendation would provide a flexible fund to PHNs and LHNs to work through more localised solutions. It is the type of flexible funding solution we’ve called for in primary care for years but the enclosed word ‘modest’ is interesting.
This initiative builds on the PHN/LHN partnership discussion throughout the chapter and would help address some of the key barriers to integration. But, in my view, this would also require significant, not modest, funding levels to make a real difference and address current gaps impeding integration.
There are some real opportunities to pursue through general practice in order to address some of the clear service gaps or policy failures identified. Palliative care in the home being one of them. Building capacity of general practice in population health to invest in those preventive measures is another. The PHNs were sees an opportunity to enable more GP-led care particularly in preventive care and integration with the LHNs were already part of their remit. Therefore, this specific initiative is almost wholly reliant on general practice and it is disappointing not to see that emphasis made.
Eliminating low-value health interventions (2.2) states that progress to limit low or no-value services has been slow. There remain too many unjustified medical procedures (some we covered off earlier). The report also highlights that Australian procedure rates are markedly higher than other comparable OECD countries. There is also some discussion around patient expectations contributing and more broadly health literacy and the need for improvements there. Broader solutions include the faster development of clinical standards and ‘do not do lists’ by the ACSQHC. The report states that Medical Colleges should also disseminate best practice (which already occurs in general practice). De-funding (interventions) mechanisms as well as removing the tax rebate for private health insurance ancillaries is also discussed.
A key recommendation (2.3) to make the patient the centre of care is of course welcome. It is already a core value in general practice and expansion is really key to fixing our healthcare system. Empowerment measures including improving patient literacy and embedding patient-centered care in training all very important and picked up in this report.
The report highlights that ‘the OECD has characterised Australia as relatively poor in its capacity to collect and link health data’. As part of the solution, the PC suggests a new role for the ACSQHC in placing the patient front and centre. This would involve developing well-defined measures of patient experience of care. It would capture outcomes from a patient perspective to help build a picture of how the system is working at the grassroots level. I agree patient-reported outcomes measures or PROMs is important but this should only be used as a balance measure. Outcomes measures (high-level clinical), as well as process measures (evidence-based best practice in driving improvements), must continue to be prioritised if we have any chance of realising our health gains or goals over time.
Recommendation 2.4 (and 2.5)
Recommendation 2.4 picks up on this broader theme around data capture and related shifts in the previous recommendation. It calls for the establishment of the Office of the National Data Custodian. This change would help to ‘remove the current messy, partial and duplicated presentation of information and data, and provide easy access to health care data for providers, researchers, and consumers’. Much of the remaining parts to this recommendation sets up the requirement for a new model of pharmacy. The next recommendation (2.5) of course deals with the shift to pharmacy automation and The Pharmacy Guild of Australia’s response to it is worth reading.
The final recommendation (2.6) has a focus on public health initiatives and recommends moves towards an alcohol tax system. Interestingly, it falls short on measures to curb sugar intake despite the strong obesity emphasis throughout. Market control through voluntary reductions in sugar content (by major manufacturers of SSBs) is instead floated. This perhaps was one of the key areas worth exploring in enabling a more productive workforce and alleviating those 11 years spent in ill health. The report falls short here. I would welcome an expanded discussion including a stronger focus on physical activity as a key prevention measure.
For more information: Inquiry Report No. 84. Shifting the Dial: 5-year Productivity Review 3 August 2017
Dr Ayman Shenouda