Obstacles to Health Reform

The problem with health reform is that even when major redesign is necessary, many ‘reformers' continue to think incrementally. Some believe that major redesign is impossible, that political timidity and acquiescence have become a way of life for many health ministers. They see the individual parts of the system working reasonably well, and fail to see that the system as a whole is inefficient and unfair. They ignore the obvious fact that the uncoordinated programs are provider-driven. Journalists are under-resourced to really understand a very complex system, yet patients encounter its failings every day.

Australia's so-called ‘health system' lacks clear underpinning values and direction. It lacks leadership - not money. Our health leaders lack the will for health reform because they are strongly influenced by the vested interests that abound in health - doctors (particularly specialists), state health bureaucracies, parochial political interests, private health insurance funds, pharmacies and the pharmaceutical companies.

The health ‘debate' is about placating these vested interests rather than listening to the community and patients. Ministers spend their energy in the financing of health programs, when production and delivery of health care is sclerotic. They are concerned with funding individual announcement-driven health programs - pharmaceuticals, aged-care etc, rather than integrating all health care.

Our health care structures have outlived their useful life. They were never designed as a ‘system'.

The need for major structural reform takes us well beyond the health portfolio as it is currently conceived. Our failure to invest in preventative health care, and the way we waste health resources have major economic consequences. Any political party that is serious about micro-economic management must be concerned about the structural problems of health. Tony Abbott speaks of health as a ‘dog's breakfast', but has made no serious effort to fix the mess.

System problems that require structural change

1. No consistent values or principles

There are no consistent values or principles to guide health programs. The Centre for Policy Development (CPD) illustrated this point in ‘A health policy for Australia: reclaiming universal health care'^[1]:

‘Some services are provided for free, while others receive no government support. Some services are covered by tax-funded insurance, but at the same time there are incentives for people to opt out of sharing and into private insurance. Politicians talk of ‘universalism' and a ‘commitment to Medicare', while encouraging the development of a two-tier hospital system. Politicians talk about ‘individual responsibility' while encouraging people to hand responsibility over to health insurance corporations. Governments, particularly Coalition governments, speak vaguely about the virtues of a private sector, but in only a few areas of health care is there a degree of market competition; in general, health care has been cosseted from market forces. Labor politicians sing the praises of bulk billing while supporting high co-payments for pharmaceuticals.'

Year by year, our health programs becomes less coherent, with a confusion of values and principles. Do we want a social welfare type health system to serve the poor, or one based on the principle of a universal high quality system available to all?

At the CPD, we assert the importance of social solidarity and a high quality single insurance system as design principles to guide future programs.

2. People under pressure.

People working in health are under great pressure. Morale is low and frustration is high. Dedicated people - particularly nurses - are leaving their professions. We expect too much of them. They see no effective solution in sight. We can't have all we want in health - and ministers should say so, and involve the community in real engagement and consultation on the costs and consequences of different funding options. Instead, ministers allow professional and dedicated staff to labour under heavy work pressures in dysfunctional environments.

3. Health workforce structures and practices are archaic

Our health workforce structures are a major economic burden. Health is our largest industry, approaching 600,000 employees or 7% of our civilian workforce. About two thirds of health expenditure is labour cost^[2]. More efficient workforce practices are essential. The problems arise not because of individual failure but because of failure to address the structural inefficiencies. Archaic work practices deny career opportunities, especially for nurses and allied health workers.

The Productivity Commission in its ‘Potential Benefits of the National Reform Agenda, February 2007' estimates that a 5% improvement in the productivity of health services would deliver resource savings of around $3 b each year. I think this estimate is extremely conservative. The system is rife with demarcations and restrictive work practices. For example only 10% of normal births are delivered by midwives in Australia. In the Netherlands it is 70% and in the UK 50%. There are severe shortages in some specialties, e.g. geriatrics and emergency; locums are used widely to fill the gaps. There are large numbers of foreign trained doctors and nurses which present ethical and professional problems.

As the Productivity Commission (Jan 2006) described our 19^th Century system:

‘There are fragmented roles, responsibility and regulatory arrangements ... inadequate co-ordination between governments, planning, education and service providers ... inflexible regulatory practices ... perverse funding and payments incentives ... and entrenched custom and practice.'
Auctioning of doctor provider numbers by postcode, for example, would quickly address the geographic misallocation of doctors across Australia, but it is not even considered.

We need role renewal and the creation of new types of health workers. We need upskilling, multi-skilling, broad-banding and team work. We need integration of education and employment.

Blue-collar workers are fair game for workforce reform, but not professionals in health and the law. No health minister in Australia has yet addressed the dysfunctional workforce structure and workforce practices. The Medical Benefits Scheme (MBS) could be one lever to help influence change.

The productivity improvements and career advancements would be even further enhanced if we could speed up the so-far glacial introduction of IT capability, which would be a great enabler of safer and more efficient health care. The IT revolution, which has driven so much productivity gain in other parts of the Australian economy, has passed the Australian health sector by.

These options are explored more fully in recent papers by Jill Iliffe (‘A New Approach to Australia's Health Workforce'[3]) and by Peter Brooks (‘Health Workforce reform: rising to the challenge'^[4])

4. Medicare is being threatened.

The government is actively subsidising the growth of private health insurance (PHI). Projecting Australian Institute for Health and Welfare recorded premium rates; the PHI subsidy will cost the taxpayer $4.8 b in 2007-08. In addition, there is a tax loss of the 1% exemption from the Medicare Levy for all with PHI, estimated to cost $890 m in 2005-06. This tax loss escalates each year because the $50,000 individual exemption has not been indexed since 1999.

There are also other government subsidies to private health insurance, including TV advertisements in the run-up to the next election. In total, these subsidies for private health insurance are approaching $6 b per annum. But that would be an under-estimate, because it does not include the effects of higher utilisation and weak cost controls that inevitably flow from private insurance.

Every country that has a large PHI sector has associated high costs. The US is the standout example, which is now desperately trying to unscramble the disaster PHI has wrought. Countries that have pioneered public health insurance such as the UK and the Scandinavian countries have much lower health costs with comparable and sometimes better health outcomes (see ‘Paying for Health' by CPD fellow Ian McAuley^[5]).

Moral hazard is involved with all insurance (‘I don't care what it costs if I have insurance') but Medicare has the advantages of equity, efficiency and buying clout to contain cost increases and ensure better monitoring of the quality of care. PHI is a passive price taker in the market. Fortunately, Australian PHI has not yet followed the example of PHI funds in the Netherlands who contribute to the cost of members' trips to Lourdes! But it might not be far away.

The trend to a two-tier health system in Australia is a serious threat. If only a handful of us want to jump the health care queue it is probably manageable. But when the government subsidises wealthy people in PHI to jump the queue, we are on the way to crippling Medicare. Tony Abbott says that the Howard Government is the best friend Medicare ever had. Words are one thing. Actions tell a very different and alarming story.

Reclaiming a universal public insurance system is critical. To some, such a system has connotations of a free public and ‘socialist' system. A universal system however does not have to be free. We are much richer than we were 30 years ago when Medicare was established. At CPD, we recommend a rationalised and simplified system of co-payments to avoid some of the problems of moral hazard. Neither do we suggest that health delivery should be by public facilities alone. Far from it, we believe that a mix of public and private delivery is desirable. Australian private hospitals would be over $1 b better off per annum if the government subsidy was paid directly to them and not via the PHI financial intermediaries. Contrary to outdated ideology, the policy issue is not ‘private hospitals versus public hospitals'. The issue is ‘who better provides value for money, including the quality of the service.'

In the three years of the next federal government, $18 b will be spent on subsidies to PHI. Just think of the new priorities that could be addressed with that sort of money - mental health and indigenous health, primary care, prevention and dental care. The capital cost of rolling out 200 primary health care centres across Australia to serve an average catchment of 100,000 persons per centre, would be around $4 b.

$18 b over three years could transform Australian health - what a political opportunity!

5. The personal, public and social cost of mistakes.

After examining more than 14,000 hospital admissions in NSW and SA, the national cost of harm from healthcare (adverse events) in our hospitals was estimated at $4.17 b per year in 1995-96[6]. At least 50% of that was avoidable or preventable and would nationally represent nearly 500,000 preventable hospital bed-days, every year. Commenting on the report, Professor Richardson from Monash University said:

‘Medical errors have been responsible for the death of more Australians per annum, than the average annual death rate of Australian soldiers in WWI (15,800). Permanent disabilities per annum approximate the annual rate of casualties in WWI (62,500). ... The conservative estimate of the unnecessary death rate (in hospitals) is about the same as would occur if the Bali bombing occurred every week of the year, year after year.' (ANZ Health Policy January 2005)

Whilst this issue has been clearly identified, there is a lack of commitment to solving this problem, despite numerous committees and tens of millions of dollars. In 2004, the Federal Government provided $580 m to subsidise medical indemnity premiums for doctors. It addressed the symptom and not the problem. Bundaberg Hospital is not a one-off, attributable to foreign doctors. The problem is endemic. Bundaberg Hospital is the tip of a very large iceberg.

A decade ago the $4.17 b the estimated cost of harm in hospitals (adverse events) represented 23% of recurrent costs in all hospitals. Assuming the same percentage of avoidable mistakes in 2004-05, the cost to Australian hospitals (i.e. taxpayers) would have been $6.5 b. This would be a conservative estimate, because ageing and the complexity of cases would have increased significantly in the last 10 years. There is a paucity of data, but on the basis of available information, it would not be unreasonable to estimate, very conservatively, that the cost, both within and outside the health system, of mistakes would be about $9 b per annum or about 10% of total health expenditure in Australia. At least half of that is preventable - $4 to $5 b each year.

Healthcare delivery can be described as "good people working in a faulty system". We are not dealing with performance issues by individual doctors and nurses, but rather, the ‘system' in which they provide their care. The responsibility lies with tho who have custodial responsibility from a leadership, governance, funding and management perspective. There is a conspiracy of silence. This is a public health, ethical and financial problem of large proportions. It is a scandal. The risks from terrorism are miniscule by comparison.

The clear evidence in aviation safety is that the worst thing is to cover up safety problems and scapegoat those involved. There must be a culture of openness and transparency so that there is continuous improvement, with problems identified and responsibility widely shared. In aviation, investigations of accidents and near misses are very thorough but not judgemental. Reporting is encouraged and the remedies address both the proximate problems, and more importantly, the systemic problems.

Health is very different. There is a major cultural problem, whereby health practitioners - highly professional in their own specific areas - have little knowledge or experience of other industries and different ways of thinking and doing. As at the Bundaberg Hospital, junior staff, who often notice mistakes, are excluded and victimised. Complex systems need a healthy culture to minimise risks. Health doesn't have a healthy culture.

In addition to these cultural issues, there are a whole range of organisational issues that health must address - rigorous peer review, accreditation, particularly of small hospitals, reliable and efficient recording, better hospital systems, consolidation of clinical services, clinical accreditation, but above all else, responsiveness, openness and transparency in addressing the problems.

Importantly, hospitals must bridge the gap between corporate governance and clinical governance. They often operate in parallel, but not together. Who really runs hospitals? If our patients were protected by many of the elements of our workers compensation statutes then they would be safer in hospital. If our health corporations (public or private) were subject to the public reporting and accountabilities of listed companies, then many current attitudes and practices would rapidly change.

The personal and public costs of avoidable mistakes are the large elephant in the room that we ignore.

6. Erratic and inexplicable practice variations.

There are large variations in the pattern of service delivery that are clinically inexplicable. Robertson and Richardson[7] (MJA, 2000,173, pp 291-295) found ‘startling variation' in the use of well-known procedures in Victorian hospitals. Standardising the data, they found, for example that the observed variance to state-wide data was 13.4 times greater than expected for coronary angiography. For cataract extraction it was 15.4 times greater and colonoscopies, 45.3 times greater.

They also found ‘in the 14 days following a heart attack, men and women admitted to a private hospital were 2.2 and 2.27 times more likely to receive angiography than their counterparts in public hospitals'. They were 3.43 and 3.86 times more likely, respectively, ‘to undergo revascularisation (coronary by-pass surgery, angioplasty, and stent)'.

In the reviews that I chaired in NSW and SA, the same very large practice variations were obvious, and across a wide field with no discernible difference in health outcomes. Birth by Caesarean sections is probably the best known example with some areas quite notorious for interventions well above statewide averages.

These variations highlight two very obvious problems, or perhaps a combination of both - under-servicing and over-servicing through perverse financial incentives. Whether it is over- or under- servicing, it represents a misallocation of resources, or in plain English, waste.

These variations identified over 25 years ago have still not been addressed. There has been some discussion that publication of the data would help correct some of the more obvious variations. But doctors have invariably won the argument that the public wouldn't understand or might draw wrong conclusions from publication. As with quality and safety, there is little information or concern about the inequity and inefficiencies involved. Another elephant in the room.

Thanks to Tuonela 

7. We have a sickness model rather than a wellness model.

The Australian Institute of Health and Welfare (May 2007) identified 14 preventable health risks. The top five were tobacco smoking, high blood pressure, high body mass, physical inactivity and high blood cholesterol. These 14 preventable health risks accounted for 32% of the total burden of disease and injury in 2003. Yet only 2% of health funds are spent on public health and prevention. The rest is spent on medical services in treating sickness. Our health model is fundamentally flawed. It needs redesign to focus on keeping people well.

8. The importance of primary care.

We have a hospital-centric health system in which we regard hospitals as the first resort rather than the last resort. Our public debate is all about hospitals - waiting lists and congestion in emergency departments. Ministers produce health plans but they are really hospital plans. Just follow the money trail and see where the money really goes. The fact is we have too many hospitals and hospital beds when we need health resources out in the community.

All the international evidence is that a health system oriented towards primary care achieves better health outcomes, lower rates of all causes of mortality for overall lower cost and greater equity than a health system centred on hospitals.

In ‘A new approach to primary care for Australia', a paper by Jennifer Doggett published by the CPD in June this year^[8], we set out a primary health care system in Australia with indicative costings. We envisage that most of the multi-disciplinary primary health care clinics would be privately run. Some would be a mix of public and private, and there would be a mix of remuneration patterns - fee for service and salary.

Such a system would have major benefits in itself. It would provide an ideal platform for tackling key health priority issues, particularly mental health and indigenous health. It would also introduce a new structure in which to develop 21^st Century work practices. A major roll-out of primary health care clinics would, over time, greatly relieve the pressure on state hospital budgets.

9. Fragmentation of Commonwealth and State health programs.

Another major structural problem is the fragmentation, gaps and lack of integration of commonwealth and state health programs, estimated to cost over $1 b p.a. The public doesn't give a hoot who supplies the services, as long as they are supplied safely, efficiently and on time. At the CPD we have proposed a ‘Coalition of the Willing^[9]' - establishing a Commonwealth/State Health Commission in any state where that state and the commonwealth could agree. We have set out pooling, coverage and governance arrangements. It is doable; provided there is political will and a willingness to let competent experts get on with the job within their areas of expertise.

But there is not only fragmentation and compartmentalism between commonwealth and state health programs. It often seems that the commonwealth's two major health programs, MBS and PBS operate in separate and unrelated silos. Through the Pharmaceutical Benefits Advisory Committee mechanism, the PBS has an excellent process of cost benefit analysis of prescription pharmaceuticals. Strangely, that process has not been extended to hospital and medical treatments under the MBS. We need cost and benefit checks across the whole of health care, including the inexplicable pattern of practice variation.

Both commonwealth and state programs at present are structured around providers. We need to fundamentally redesign program structures around users. In the 1960s manufacturing fundamentally changed in such a way. Whereas previously a car firm would have an engine division, an assembly division, etc., it changed to a small car division, a commercial vehicle division, etc. It made them focus on customers. Governments have picked up the rhetoric when they talk about program design, but it's not reflected in health programs.

10. The system is not driven by patient and client needs. It is provider-driven.

A major structural problem is that patients and clients are ignored. The debate is invariably between ministers and doctors. All the information and advice I have seen show that when informed community members are consulted, they have clear priorities. And it is not more hospital beds or shorter waiting lists or fertility treatments. Their priorities are mental health, indigenous health, prevention and primary care.

There are proven methodologies to tap the informed views of the community, e.g. citizens' juries. But in opposing community engagement, many doctors contend that patients don't really know what they need. Some ministers argue that they represent the community - so why should they consult the community?
The CPD has also published proposals for community engagement^[10] to introduce countervailing power in health.

11. The community is confused.

Not only is the community excluded, but also it is confused by what is on offer. The aged and the frail find it almost impossible to navigate the system. Others are not much better off.

Consider for example Medicare safety nets. Once your out-of-pocket medical expenses in a calendar year exceed $1000, you are reimbursed by the commonwealth for 80% of any extra out-of-pocket expenses. That is provided you have kept receipts. On the way, you may have accumulated eligibility towards what is known as the ‘gap threshold'; when the accumulated difference between the scheduled fee and the medical rebate, which is only 85% of the scheduled fee, reaches $354.50, all future claims are reimbursed at 100% of the scheduled fee. These safety nets relate to medical expenses only, and they operate on an individual basis. The safety net scheme for pharmaceutical benefits by contrast is on a family basis. And if you accumulate $1500 or more in out-of-pocket expenses in a financial year (not the calendar year of the safety nets) you can claim a 20% tax rebate on the excess over $1500. That's just the start, without going into special schemes for pensioners and others, the special but restricted programs for physiotherapy services, or the subsidies for PHI.

Not surprisingly, the community is confused, and those who thrive are accountants and those who use them.

12. Costs are escalating rapidly.

The problems outlined above contribute significantly to our escalating health care costs. I have indicated where budgetary ‘savings' could be made, e.g. abolition of the $6 b plus annual subsidy for PHI; enhanced workforce productivity, $3 b p.a; reduced avoidable adverse events, $4 b plus p.a; and reduced waste of $1 b plus p.a. through lessening Commonwealth/State duplication. That's $14 b of tax wasted every year.

This waste must be seen within the context of a worsening trend of overall cost rises. In the 10 years to 2004-05, health expenditure at current prices grew at 8.3% p.a. - more than double the GDP growth rate. In the same decade, real growth of health expenditure has been 4.8% p.a. compared with population growth of 1% p.a. At the state level, health budgets are taking a higher and higher proportion of total expenditure, often over 30%. Ten years ago health represented 8.1% of GDP; it is now 9.8% ($90 b).

The Productivity Commission (Health Workforce Study, January 2006, p.25) estimates that health care expenditure could account for at least 16% of GDP by 2044-45. The growth of health expenditures is driven by unrealistic community expectations, ageing, high technology costs and these fundamental design problems. We don't need to spend any more real dollars on health. There is a huge volume of fat and waste in the system. We need better value for money through fundamental redesign.

Why don't we address the problems?

There are several reasons why we fiddle with incremental issues when we need to address fundamental problems.

• Health is a complex and large system and that most of us, unless we have chronic illness, have only intermittent contact or interest with.
• Governments have a fool's paradise view that revenue from a once in 50-year mining boom will continue.
• Health professionals have an introspective view of the system, rather than looking at the system from the outside or as a whole.
• The system is built around provider interests, who are determined to maintain their privileged and protected positions.
• Whilst public employees work hard in the health system, they have inadequate interest in efficiency and system improvement.

But after examining Australian health as an outsider for over 7 years, I have come to one particular conclusion as to why we do not address the big structural issues. It is that there is insufficient political will to manage and contest the vested interests that abound in the delivery of healthcare. The health lobby that delivers health care, doctors, pharmacists, state health bureaucracies, PHI funds and pharmaceutical companies are given a summary veto on reform.

All of our attention is on the financing and demand side. That is what Medicare does. Medicare is the means by which we finance the established health delivery programs.

What we badly need is micro reform in health care to address the great structural problems on the delivery side that I have mentioned above.

There are none of the corrective or stabilising factors in health that have been established elsewhere in the economy over the last 20 years - a floating dollar, an independent reserve bank, and a flexible labour market. It was ministerial and political decisions that made these changes possible. We are not seeing the same in health. Yet if we can take the example of the Reserve Bank, we can see the benefits that could occur in health if ministers would stand back from day to day health management and allow independent and professional people to tackle the hard decisions - hard decisions that ministers so far have been unable to unwilling to take.

Manufacturing reform went down a consistent and patient path. It was steered by John Button with a great deal of consultation. It was more than just a courageous ministerial decision.

Rather than address the big picture issues and the health lobby, ministers retreat into media management and micro-management. Some defend their performance by asserting that the Westminster tradition of ministerial responsibility requires ministerial micro-management! The short-term and urgent supplants the long-term and important. Politics pushes out policy.

So what can be done?

Firstly, in at least some states, ministers need to get themselves out of the media loop and micro-management. They need to instruct their senior executives to manage and explain a very complex and costly health system. Senior executives must be given real responsibility and not just accountability. Letting managers manage would be a great improvement. Hopefully it would also provide ministers with the thinking time to address their major areas of responsibility - values, principles and long-term structural problems. They need to keep out of the day-to-day health panics.

Secondly, we need a national, independent and professional authority to explain and drive health reform, subject to government policies and guidelines. In Ontario, Canada, in 1996 the provincial government set up a Health Services Restructuring Commission, not only to advise on restructure in health but also to implement the restructuring. Ministers recognised that they were too subject to pressure by vested interests in the health sector and that a more arms length and independent commission could achieve outcomes that ministers couldn't. Ministers had shown that they were unwilling or unable to address necessary closure or rationalisation of hospital and clinical services. The Commission made significant progress and after a period, handed back its powers to ministers. A key in the Commission's success was public education so that the public could better understand and accept the necessary changes.

In Australia, the Health Insurance Commission and the Pharmaceutical Benefits Advisory Committee are two independent statutory bodies that work effectively in the public interest. They do not detract from ministerial responsibility. The SA Premier proposed an independent commission to manage the Murray Darling Basin, explicitly conceding that there is value in ministers standing back in order to better manage the vested interests who make good administration of the Murray Darling Basin very difficult. Working with a clear mandate, as the Reserve Bank does, an independent and professional health authority is necessary to explain and drive health reform.

Thirdly, I would urge federal and state Treasurers and Finance Ministers and their departments to actively engage themselves in the long-term issues that are contributing to the rapidly escalating health expenditures. They should insist ‘no more money without structural reform'. Treasurers, Finance Ministers and their departments are not as beholden as Health Ministers to the health lobby. They are health outsiders - a distinct advantage. Greater involvement by Treasurers, Finance Ministers and their departments in health delivery could be a major factor in promoting fundamental reform. They could start by insisting that funding in the next Commonwealth-State Health Care Agreement be dependent on substantial and measurable improvements in health workforce productivity, and building a health system focused on primary care and not hospitals.

Administration of the $6 b annual subsidy to PHI should be transferred to Treasury, who would quickly recognise it for what it is - corporate welfare and not a health program.

It is significant that it was the Treasurer who commissioned the Productivity Commission to report on health workforce issues. It wasn't health ministers. I am not holding my breath on the outcome of the Productivity Commission's report, because implementation will be left largely to Health Ministers and their bureaucracies. I hope nevertheless it is the beginning of a major interest by Treasurers, Finance Ministers and their departments across Australia in health.

The fourth suggestion is that we need a two-stage approach to health reform. The first stage would include such issues as dental health, commonwealth-state fragmentation, prevention and primary care. I think the needs in these areas are clear and most of the solutions incontestable. The second stage of reform could include a public inquiry such as the Romanow Royal Commission in Canada^[11] on such issues as reclaiming universal health insurance; the rationalisation and simplification of co-payments, and quality and safety. Such issues are complex and require public understanding and support for reform. Romanow was very important in underlining the social values - the importance of community - in any restructuring of health in Canada.

The Productivity Commission recognised the need in 1997 for an enquiry. It recommended ‘a broad public enquiry into Australia's health system'. It was ignored. It is long overdue.

An inquiry would be an opportunity to involve the public in asserting its key role in health. Unless there is public understanding and support the vested interests will continue to make it difficult for the public interest to be asserted through government. An enquiry will open up the sector to detailed public examination, and make reform politically easier for governments. We need countervailing power in health to give ministers the political will to manage the vested interests and assert the values of a national system of health care. Such a national enquiry should be continued over time through a professional and independent statutory authority that reports publicly to both the Health Minister and the Parliament along the lines proposed above.

The nervous nellies will still say that it can't be done - that ministers in today's political, economic and media climate can't be expected to stare down the vested interests.

But Australia has a good record in fundamental change. Curtin did it in modernising the economy in 1942. Whitlam did it with Medicare in 1975, despite a long and vitriolic campaign by the medical lobby. Fraser buried White Australia in the late 1970s. In the 1980s, Hawke and Keating gave us tariff reform and financial deregulation that laid the basis of our present prosperity. Howard has given us indirect tax reform and an independent Reserve Bank. The historical evidence shows that Australians will accept fundamental reform if it is cogently argued and the community is well-informed.

Further, what we are proposing in health is within a sector that is growing rapidly. Health expenditure is growing faster than total expenditure. The health workforce is growing at almost twice the rate of the total workforce. No-one should really fear for their jobs with structural reform in health. Australian blue-collar workers over the last two decades in textiles and auto manufacturing - when structural reform was introduced in a contracting market - faced much more serious problems. All change presents problems and some pain, but in a growing market and with our history of reform, I believe that we can address the serious system failures in Australian health. Political will is the key.

The political party in Australia that can demonstrate its determination to address these structural problems will also demonstrate its economic management credentials. Health is our largest and fastest-growing sector. It is our least efficient. The problem is not Medicare, which is a financing arrangement. The problem is the uncoordinated and inefficient health delivery programs that Medicare funds.

Endnotes

[1] Centre for Policy Development, ‘A Health Policy for Australia: reclaiming universal care', http://cpd.org.au/paper/health-policy-australia-reclaiming-universal-care

[2] http://www.pc.gov.au/study/healthworkforce/finalreport/healthworkforce.pdf

[3] Iliffe, J, ‘A New approach to Australia's Health Workforce', Centre for Policy Development 2007, http://cpd.org.au/paper/new-approach-australias-health-workforce

[4]Brooks, P, & Ellis, N, ‘Health Workforce Reform: rising to the challenge', Centre for Policy Development 2007, http://cpd.org.au/article/health-workforce-reform-rising-to-the-challenge

[5] McAuley, I, ‘Paying for Health Care', Centre for Policy Development 2007, http://cpd.org.au/article/paying-for-health-care

[6] Wilson R et al. ‘The Quality in Australian Health Care Study' MJA 1995; 163: 458-471

[7] Robertson, I & Richardson, K, ‘Coronary angiography and coronary artery revascularisation rates in public and private hospital patients after acute myocardial infarction', MJA 2000; 173: 291-295

[8] Doggett, J. ‘A New Approach to Primary Care for Australia', Centre for Policy Development 2007, http://cpd.org.au/paper/new-approach-primary-health-care-australia

[9] Menadue, J, ‘Breaking the Commonwealth/State Impasse in Health: a coalition of the willing', Centre for Policy Development 2007, http://cpd.org.au/article/health-coalition-of-the-willing

[10] McBride, T, ‘Time to talk to Australians about a sustainable and fair health system', Centre for Policy Development 2007, http://cpd.org.au/article/health-reform-time-to-talk-to-Australians

[11] MacKean, J, ‘Principles and Practice: a better system of health care', Centre for Policy Development, 2007, http://cpd.org.au/article/principles-and-practice

This is the full text of a briefer speech delivered at the Australian Health Care Reform Alliance's 'National Health Reform Summit' on July 30, 2007

A New Approach to Australia's health workforce

In this new paper Jill Iliffe argues that any serious attempt to improve Australia's health policy must address the capacity, efficiency and flexibility of our health workforce.

Download the paper, 'A New Approach to Australia's Heatlh Workforce' (pdf)

The health workforce comprises around 5% of the total workforce in Australia, and absorbs around two thirds of Australia's total health spending. Health spending itself is about 9.7% of GDP.

Australia employs similar ratios of health professionals to the OECD average; however the rate of employment growth in the health system, concentrated among allied health and complementary health professionals, is now twice our rate of population growth.

Health workers are highly diverse, ranging from entry level workers educated at a Certificate II or III level, to highly qualified professionals with Bachelor, Masters or PhD qualifications. It is this specialisation that makes evidence based workforce policy and management essential.

Why do we need to reform health workforce policy?

• The ageing demographics of both health care consumers and the health workforce;
• The need to shift the focus of health service delivery towards prevention, early intervention and self-management;
• The need to evolve existing workforce roles to match these new modes of health servicing;
• Inherently conflicting service, educational and funding interests between the commonwealth, state and territory governments;
• An uncoordinated health education regime, whereby system demand and supply are poorly measured and matched;
• Fragmented clinical training - no central funding, measurement or profiling of the clinical training resources and outcomes within the system;
• The need to practicably integrate relevant innovation and technology into clinical and administrative practice;
• The need for work/family balance among health workers in a long-lived, double-income society;
• Poor distribution and utilisation of the health workforce relative to requirements;
• Workforce shortages and erosion, as a consequence of the unsustainable structures within this changing health environment; and
• Australia's resulting reliance on permanent or temporary migration of health workers;

'A New Approach to Australia's Heatlh Workforce' recommends:

That the National Health Workforce Strategic Framework be properly executed by all Australian governments, to:

• collaboratively involve all health stakeholders in policy development;
• produce evidence-based health workforce policy and planning, linked to the broader health system;
• ensure and sustain supply;
• distribute workforce to optimise health care access and meet the needs of all Australians;
• use skills and knowledge to the optimum, and foster workforce adaptability;
• ensure that the health workforce is always skilled and competent; and
• produce health environments where people want to work.

A change in policy is essential for Australia's health care system to be sustainable, and the following should proceed immediately:

• introduce an independent health reform commission to examine the best model of health funding, and the best ways to utilise the Australian health workforce;
• establish and strengthen community health centres across the nation, staffed by primary health care teams that include existing general medical practitioners; and
• conduct comprehensive national workforce planning, linking education places to workplace needs.

Funding health care – a principled approach

How we got into a mess

We have a cobbled-together set of funding mechanisms for health care in Australia.

Successive administrations have been guided by the (real or perceived) health priorities of the time, their partisan ideologies, the influence of pressure groups, and constraints on government finances. They have tended to build on, rather than replace or overhaul, existing funding arrangements.

Priorities have shifted. In the postwar years the need for affordable pharmaceuticals, particularly life-saving antibiotics, saw the birth of the Pharmaceutical Benefits Scheme. In the seventies and eighties Medibank and Medicare were developed to provide universal cover. Equitable access to medical care was a priority. At present there is recognition of the need for more resources for illness prevention and health promotion, mental health, and the health of the most disadvantaged in remote regions.

Partisan ideologies have played their role. Labor governments have tended to favour universal and free service delivery. Coalition governments, while nominally preferring the use of market forces, have favoured private insurance as a means of funding health care, even though private insurance, in its suppression of price signals at the time of delivery, is no more a ‘market' mechanism than Medicare. Coalition governments have also tended to see the government's role in health care as a residual or ‘charity' one, with the well-off encouraged to opt out of any shared system.

Pressure groups have had strong influences. In 1946 the British Medical Association (yes - the British Medical Association) successfully blocked the Commonwealth's attempt to introduce a universal health care scheme along the line of those operating in European democracies. Retail pharmacists and medical specialists have been particularly influential - the former in terms of keeping pharmacy separated from other health care services, and the latter in terms of restricting the throughput of postgraduate medical schools. Once groups gain privilege, as the health insurers have done, they are able to use some of their gains to mount strong lobbies to sustain their privilege.

Another constraint on policy is set by the vigilant state and Commonwealth treasury departments - guardians of the public purse - who see budgetary constraint as a priority, even to the extent of overriding other economic considerations. Hence Labor in office was never able to implement a comprehensive dental scheme, and governments of all persuasions have always found that funding of established programs, such as hospital care, has crowded out other possible priorities with good returns, such as public health. We cannot have it all, but the dividing line between what is financed privately and out of our taxes shows no coherent logic.

Then there are the Commonwealth-state demarcations, which are the legacies of states' long-standing role in funding public hospitals and constitutional legal battles.

The result is a highly complex set of funding arrangements, illegible to the outsider, and bamboozling to anyone tyring to infer any underlying principles - for there are no underlying, coherent principles.

If the reader's patience allows, consider the following partial guide to health funding:

We have free public hospitals, but have to pay $30.70 for pharmaceutical prescriptions. If we have private insurance, generously subsidised by the government, some ‘ancillary' services such as dentistry are covered (only up to a capped amount), but if we choose to rely on our own savings for our ancillaries or private hospitalisation, we get no support. The safety net scheme for medical benefits is on an individual basis; for pharmaceutical benefits, by contrast, the safety net is on a family basis. Then, while safety nets operate calendar years, there is a twenty percent tax rebate for medical expenses above $1500 in a financial year, with different definitions of what qualifies as a medical expense.

And that's not to mention concessions for certain disadvantaged groups, such as concession card holders.

The result of these influences is waste and inequity. Although Australia's health care outcomes, on most criteria, are good by international comparisons, particularly in comparison with the USA, we could do far better. In many aspects we have combined some of the worst of all possible arrangements. We have large bureaucracies, not only in governments, but also in health insurance funds - whose administrative overheads are now around one billion dollars a year. For many health needs there is a mixture of ‘free' and paid services. When there is such a mix there is a natural drift to the free services, even though some paid services may offer better value. In some cases the free services are publicly funded, but in many they are funded through private insurance; the Coalition Government fails to understand (or does not want to understand) that private insurance carries the same incentives for over-use that Medicare carries, but without the strong market power which gives single national insurers the capacity to control use and to keep prices under control. (For an explanation of the economy-wide costs of private insurance, see the InSight article Paying for health care)

In terms of equity, we have developed a ‘two tier' hospital system, thanks to the generous subsidies for the well-off to use private insurance (particularly the one percent tax break, which more than pays private insurance premiums for anyone with an income above about $70 000). When public hospitals become a ‘charity' or residual service, there is no guarantee that their quality will be preserved. (And, conversely, the linking of private insurance to private hospitals ensures that they never come to compete alongside public hospitals.)

Cleaning up the mess

A case can be made for a universal, ‘free', tax funded system of health care. And a case can be made for a system in which most people pay for most of their health care for most of the time - essentially a competitive market system, with safety nets for those with very high needs. The former could be classified as ‘socialist', the latter as ‘free enterprise'. Private insurance is neither, for while it is private, it carries all the distortions, and more, of bureaucratic systems.

Nowhere in the developed world is health care left entirely to the market. Even the most ‘dry' economists accept that there are market failures in health care, and even the most rational and disciplined consumers cannot plan for their health care needs. We all opt to share the costs of our health care to some degree, and the most efficient and fair way to do that is through the taxation system.

On the other hand, a universal, free system has drawbacks - in particular an imbalance between supply and demand. Long queues are an inevitable outcome of a free system, and there often has to be a heavy hand of intervention to ensure scarce resources are applied where they can do most good.

But a universal system doesn't have to be free. ‘Universalism' in health care essentially refers to equality of access (in contrast to the two-tier hospital system we have now). Co-payments serve a function in that, if well-structured, they can convey some price information, and can help direct resources more efficiently, particularly around the borders of health care. At present, services such as physiotherapy, podiatry and similar therapies tend to be under-used in comparison to other services which are higher cost but free at the point of delivery.

Nor does universalism mean all services have to be provided by the public sector. The private health insurance lobby has been very effective in a scare campaign, suggesting that without private insurance we will not have private hospitals, but private hospitals can easily be placed on the same funding basis as public hospitals. Indeed, competition between private and public service providers can be quite healthy.

Most of those who have contributed to the CPD's policy development accept that Australia can have a universal health care system, with carefully structured co-payments. The underlying principle in such a system is collective insurance, helped by some use of market signals to the extent that they do not cause hardship or deprive people of necessary care.

Some have argued for an entirely free system, and it is possible that Australians would be willing to pay the extra tax and to tolerate the extra management which that would entail. That question is one to be resolved through community engagement.

Rationalisation of financing, of course, would be part of a larger process of reform, in which the presently disparate elements of health care are brought together in one integrated system, designed around the needs of consumers.

Such a reform process would break from the bipartisan tradition of incremental change, referred to above (known by the political scientist Charles Lindblom as ‘muddling through'). Sceptics may wonder if such change is possible, pointing to the extreme caution the Labor Party is showing in relation to health policy. But Australia has a good record in achieving change, such as tariff reduction, tax reform and financial market deregulation. There would be few losers from any basic reform of health care. Perhaps some bureaucrats may have to find alternative employment, and the private insurers would have no role, but they are only a high-cost overhead. Those delivering health services will always find their skills in demand, in both the private and public sectors.

Time to talk to Australians about a sustainable and fair health system

Introduction

Consumer and community voices need to be centrally involved in both discussing and influencing government decision making. As well-meaning as the professions, health services, and government bureaucracies are, they are inevitably driven by their own professional, governmental or commercial paradigms and, in some cases, self-interest.

Yet an effective system should operate primarily for the benefit of the users of the system: health consumers, their families and communities. It is time in 2007 that our health system was not only sustainable, but also a national system, underpinned by nationally agreed (but locally implemented) values and principles. This doesn't seem so much to ask in a country of only 20 million people.

What crisis?

Why do I and many others say there is a crisis looming?

Firstly, there are obvious strong and potentially unsustainable pressures on - and gaps within - the current system. These have been well canvassed elsewhere, including in Health care reform: a journey of courage [1] (and in the Centre for Policy Development's A health policy for Australia: reclaiming universal health care)[2], and on the website of the Australian Health Care Reform Alliance (AHCRA).[3] The problems include an ageing population, increasing use of (often expensive) technologies and consistently higher than inflation cost-rises, a very fragmented primary health care system, dire workforce shortages, and a very complicated public-private mix (have you ever tried to explain our system to anyone overseas and noticed how their eyes bulge?).

However, apart from rare collaboration (e.g. the recent joint action on the mental health system), the various tell-tale signs (even alarm bells in some case such as dental services) do not seem to have galvanised Australian governments into significant united action (For example, there is no committee of senior officials from the various state, territory and federal governments that meets around primary health care - the very core of the health system - despite the sector's reliance on their various funding streams).

The second indicator is the explicit acknowledgement by so many inside the system that a crisis is looming. In fact AHCRA itself was formed because 46 significant national and state health organisations (representing health professionals, health services and consumers) agreed that the current system was too fragmented and would be unsustainable without some radical action.

There are parallels with the water crisis, where governments have been reluctant to label the accumulating plethora of telltale symptoms as a major national problem, until faced with the bleeding obvious (and now it may be too late to solve it fully). In the health system, we have a similar looming crisis with far-reaching implications, but one similarly immune to short-term simplistic patch-ups. Further, like water, it is a crisis that needs a national solution, not nine different solutions. Kevin Rudd's recognition that Federal-State duplication is a major issue needing urgent action is encouraging.

It is clearly time for a national health system, not fragmented by myopic funding systems, lacking a shared vision and values. So the Health Issues Centre and AHCRA strongly believe that a meaningful (and we use that term carefully) national dialogue with citizens and consumers is needed to help build the first national vision and framework for health care. This does not necessarily mean that only one government would end up running health care. But it does mean that all governments in Australia would use this vision as the basis of their health planning. No such common goals or principles (in which citizens and consumers have had any say) currently exist.

Why is it time for a citizen and consumer engagement?

We have called the required approach an ‘engagement' rather than just ‘consultation' for one main reason. We are seeking deliberative thoughtful conversations with Australians over this critical issue. This may sound like jargon to some, but it implies a stronger involvement than just a search for instant answers. We think this is an important distinction.

The case for such engagement can be made from a few perspectives. The obvious corollary from the case for a national system is that for such a significant policy move, citizens/consumers have a right to influence national frameworks that will shape health care for decades ahead. It is commonly argued that significant citizen and consumer engagement is needed when public policy is at a key turning point.[4] This usually occurs when a society is reassessing its options, setting priorities, or mapping the boundaries of major change. The current debate about the future of health care has now reached this point.

A more basic case is that citizen engagement in policy reform is part of a democratic approach to governance in Australia. This is already happening in a range of sectors at lower levels. Indeed, active involvement by consumers, carers and community members is gradually spreading throughout the health system. Certainly at the health coalface, consumers increasingly want better information and more input into decision making on their own (and their family's) treatment and ongoing care.

Consumer participation is becoming an accepted part of the modern health care approach, now cemented into hospital and community care accreditation standards[5]^,[6], quality and safety guidelines[7] and some governments' policies[8]. There are now many hundreds of examples around Australia of consumers' input and involvement at the service level (e.g. feedback, input into new developments); and at the organisational level (e.g. advisory committees, or consumers on quality committees)[9]. Although there is yet relatively little formal evaluation of the impacts of this trend, there is much anecdotal evidence of its value.

So involvement in higher level decisions about the future of the health care system flows naturally from this participative movement, and is increasingly expected by Australians. Such counsel about the bigger questions or about broad directions for change is currently rarely sought, but it could easily be so. As Macfarlane has written: "it is their (citizens') health and their money"[10].

Lastly, the other strong case for citizen/consumer involvement at such a crucial point is that change needs to reflect the community's values. When major reform was being considered in Canada, a country-wide consultation was undertaken. The head of the reform commission, Romanow, noted:

Citizen and consumer engagement can help to clarify how deeply held values are evolving with changing circumstances, as is happening now in our society and health care system (e.g. rapidly changing technologies, rising community expectations, ageing population).

John Menadue has similarly argued that "unless the Commonwealth and State governments involve the community in setting priorities in health spending, we will not make real progress in systemic reform.... Unless the community is locked in through appropriate structures and processes, health reform will not happen. The public must be connected".[12]

So what type of national consultation do we need?

The federal and state governments should jointly run a national engagement process with citizens and consumers, aimed at eliciting some consensus on the main values, principles and priorities for the future of the Australian health system. This process would be based on a set of principles, described below, so that it was legitimate and credible, transparent, meaningful, information-rich and deliberative (i.e. seeking thoughtful, not merely instant, responses) for participants.

What would such an exercise produce?

Importantly the results should be the critical set of inputs for the development of a national vision and framework for an ‘Australian Health System'. Either the Council of Australian Governments (COAG) or a newly formed Health Reform Council, reporting to COAG, should oversee this. These results would comprise a set of key principles and values that participants (as citizens and consumers or carers) believe should shape the health system in the future. They might act as a sort of ‘design brief' or set of criteria against which system change should be judged.

What might such an approach look like?

There are several alternative ways of conducting this engagement exercise, depending on the resources available. We have sketched an ideal approach (and we believe the future of the health system deserves a comprehensive approach) as well as a proposal for a more limited (and less costly) consultation with lower, but still valuable impact.

An ideal approach

Community engagement can be as long as a piece of string, but we are proposing a complementary set of methods to both inform all Australians of the need to consider the future of the system (to alert people to the issues and to stimulate national debate) and seek in parallel specific views from a smaller but reasonably representative sample of citizens/residents. Thus it will involve both broad marketing techniques and targeted consultation.

The first set of methods, aimed at the whole population, might include communication via TV, radio and print media to prompt public thought and debate. Some national, broadly accessible, good quality, easy-to-read information should also be made available (via the web, hard copy, translated versions), with a variety of opportunities for people to offer feedback (eg via workbooks, websites, postcards).

The information provided to stimulate discussion would ideally be agreed by all stakeholders in advance, so it was (relatively) non-political, unbiased and factual. In reality that is a near impossibility, but an accepted level of consensus will need to be reached. Ironically, in an exercise to consult the community, getting the professional and political stakeholders to agree on the base information to distribute may be hardest part of the process (but indicative of what often happens and why consumers must have a say!).

This set of ‘whole of population strategies' would open up access to all, but the input garnered would need to be interpreted cautiously. The responses received from such an exercise always run the risk of being biased towards the louder, more organised, better resourced or the more ideologically driven. That is why the second part of the exercise has been proposed.

Participants for the latter consultation should be drawn from three main groups:

• citizens selected at random - this would form the bulk of participants - a sample of as little as 1000 people may be statistically sufficient;
• high users of care who depend heavily on an effective system, and who have considerable experience of how the system meets or fails their needs (e.g. those who are chronically ill) - sufficient individual consumers and carers need to be involved that their different views are captured; and
• high needs or traditionally hard to reach population groups, including those with special vulnerabilities (i.e. the homeless, people with disabilities) who have special prevention and care needs that are not necessarily met, or who may under-use the system.

There is a wide range of newer potential engagement methods available. Unlike the more traditional mechanisms (seeking written submissions, consultation/town hall type meetings) these methods provide the opportunity for people to engage in representative, well informed, deliberative processes that lead both to recommendations on specific issues as well as a strong sense of people's underlying values and principles. That is, participants get good quality information to help them see the bigger picture, and the processes allow time for people to really explore the information and come to conclusions from a broader community perspective, not just their own (This contrasts with normal telephone polling, for example, which provides no extra information and seeks instant opinions, not thoughtful responses.)

A variety of methods should be used, none perfect by themselves, but which in combination should provide a fuller picture with less bias than any individual method. Methods might include citizen's juries, deliberative councils, websites, televoting, round tables, citizens' assemblies, and ChoiceWork Dialogue among others.[13]

For example, citizens' juries (CJs) are one of the more widely practised of the new techniques worldwide and have been used in Australia and extensively overseas. A CJ brings together a group that is representative of the profile of a local community or the population as a whole (ideally chosen at random). Participants are asked to consider an issue of local or national importance, usually involving a matter of policy or planning. Although participants are called ‘jurors,' they also serve as lawyer and judge during the process. Information is presented in a quasi-courtroom, formal setting, and jurors are asked to reach consensus on the issue as representatives of a collective public voice, and not out of self-interest.

The CJ process is designed to allow decision-makers to hear directly from citizens, to learn about their values, concerns and ideas regarding an issue of public importance. The great advantage of the CJ is that it yields citizen input from a group that is both informed and (relatively) more representative of the public at large than typical methods. Its disadvantage is that decisions can potentially be shaped by the provision of unbalanced information, its presentation, and the general lack of understanding by average citizens of the very sick, chronically ill or highly disadvantaged.

ChoiceWork Dialogues (used by the Romanow Commission in Canada) engage representative groups of ordinary "unorganised" people to tackle a complex problem (what balance of services do we need in this community?) and make value-based choices. Participants are given the opportunity to "work through" conflicting values and difficult choices in order to reach judgments on an important issue. ChoiceWork provides an opportunity for people with differing views to find common ground and move forward together. Again, not only is the decision reached of interest, but so are the values voiced in making such choices.

Televoting is a less participative process and allows citizens to cast ballots on specific issues, but differs from conventional polling in a number of significant ways. Televoting provides a randomly selected, statistically significant sample of respondents with balanced, factual background material on an issue before they are polled. The Televote allows easy access to more detailed information, and time to consider the information and issue/s before making a decision. It is a useful follow-up when more in-depth methods (such as above) have identified some key values or principles and confirmation or prioritisation is needed from a larger group of citizens or consumers.

The involvement of a sample of citizens will give a sense of the views and priorities of ordinary Australians. However, this sample of general citizens may not appreciate the special needs of those forced to use a lot of health services because of their chronic conditions. Similarly, the needs of minorities may not be sufficiently understood by all citizens, especially as experience shows that such groups are often under-represented in mainstream exercises. Specific involvement of these three groups will therefore provide a more balanced set of outcomes.

Numbers consulted do not need to be large if random sampling methods are used and the findings from the various methods are triangulated. However, they do need to be enough to be defendable and legitimate or the exercise may be considered futile.

Internationally such large scale consultations or engagements are not new, and broad community exercises have been undertaken in the UK, Sweden, New Zealand, France and especially Canada, as noted above.

More modest versions

More modest versions of the above could be undertaken. For example, the broader marketing of the consultation to the public could be left out, and the focus could be on the specific consultations. Further, some overlap with other already planned consultations could enable some processes to provide local answers and views, as well as underlying values and principles useful to the national exercise.

General principles

However it is undertaken, the community engagement process clearly needs to be seen as legitimate by the community, along with key health interests and politicians. If lacking, it will be perceived as a waste of time. There are several ingredients to legitimacy. The process should:

• be non-partisan
• be transparent, and run by an independent organisation

• be information-rich for participants, that is they receive good quality, readable, full information on which to base their responses
• be deliberative, i.e. people will get the chance to listen, question and discuss before giving their final views
• use a variety of methods (to minimise biases) and triangulating findings
• be well resourced and facilitated
• be non-burdensome and respectful of participants' contributions .

It should also be meaningful for participants, i.e. the findings should be linked to some genuine policy processes, such as suggested above. This list may seem a tall order, but in our opinion most of it is viable with careful planning.

What is already happening?

AHCRA are planning a very simple consultation this year to pilot some of these approaches and to feed some early community perspectives into the National Health Summit in July 2007. The Alliance will also be talking to private funders to seek funding for some further pilots of the proposed approaches, and approaching governments over time to discuss these proposals.

Benefits of Community Engagement

There would be a broad set of benefits from the practices above:

• giving Australian citizens and consumers a variety of opportunities to become involved, and helping provide a citizens' vision for health care;
• enabling citizens and consumers to make thoughtful and productive contributions that can act as building blocks to shape the future of public health care;
• increasing public awareness about the difficult choices of health prioritising in a cost-constrained environment;
• tapping the public's ability to give meaningful information to policy-makers about their important underlying values and principles;
• increasing social cohesion by ensuring that diverse voices are heard;
• increasing understanding among those involved about how deliberations with governments proceed, and of what is or is not possible in a representative democracy; and
• building some consensus and community trust, hence decreasing the fear of change.

Costs

Good quality consultation does not, and should not, come cheaply. There is a litany of poorly resourced and implemented consultations in Australia to prove that case. However, the likely costs are still very modest. The smaller scale approach (citizens juries, televoting and smaller scale deliberative councils) might just be able to be run for under $600,000. Adding an Australia-wide communications strategy to stimulate country-wide debate would probably cost several times that amount.

These costs are a drop in the ocean, in the context of making a system sustainable which currently costs over $87 billion per year[14]. They are also minimal in relation to estimated cost savings if a more rational health system, based around citizens' stated values, could be created. Recent analyses estimate that one to two billion dollars are wasted each year in duplication within the current system, where both State and the Commonwealth run parallel bureaucracies[15].

Crucially, the findings from a national consultation could move us towards a system that is more closely based on what Australians want and need, not just what the diverse interest groups in health care want. This has been neatly described in the title of the Victorian health participation policy ‘Doing it with us, not for us'[16].

Conclusion

The proposals above are ambitious. However, the future of the health system is a crucial issue. The current system has clear gaps (although blind spots to decision makers) and a significant degree of unfairness. We believe that creating a health system based on a national set of values and principles (regardless of who actually runs the services) is a necessary step forward to create a sustainable and sensible system. And of course, citizens and consumers clearly need to play a central part in shaping that move.

[1] John Dwyer, 2006, ‘Health care reform: a journey of courage'. Accessed at http://cpd.org.au/node/3858

[2] Centre for Policy Development, 2006, ‘A health policy for Australia: reclaiming universal health care'. Accessed at http://cpd.org.au/paper/health-policy-australia-re...

[3] http://www.healthreform.org.au

[4] Maxwell, J. et al, 2002, ‘Citizen's Dialogue on the Future of Healthcare in Canada', Commission on the Future of Healthcare in Canada. accessed at www.healthcarecommission.ca

[5] Australian Council of Healthcare Standards, 2006, ‘The ACHS Evaluation and Quality Improvement Program (EQuIP) 4, Standards'

[6] Quality Improvement Council, 2004, ‘Health and Community Services Standard - 5^th Edition'.

[7] Victorian Quality Council, accessed at www.health.vic.gov.au/qualitycouncil

[8] Department of Human Services, 2006, ‘Doing it with us not for us - Participation in your health service system 2006-09: Victorian consumers, carers, and the community working together with their health services and the Department of Human Services'. Melbourne.

[9] www.participateinhealth.org.au

[10] MacFarlane, D. 1996, ‘Citizen participation in the reform of health care policy: A case example', Healthcare Management Forum, Vol. 9, No. 2, pp. 31-35.

[11] Romanow, R.J. 2002, ‘Building on Values: The Future of Health Care in Canada- Final Report'. Canadian Government Publishing, Ottawa. Accessed www.healthcarecommission.ca

[12] Menadue J. 2003, ‘Health Reform; Possible Ways Forward', MJA 179(7) 367-369.

[13] Health Canada. 2000, ‘Health Canada Toolkit for Public Involvement in Decision-Making'. Health Canada.

[14] http://www.aihw.gov.au/mediacentre/2006/mr20060929...

[15] Drummond, M, 2003, Presentation to National Health Summit on Estimates of Savings, August 2003, Canberra.

[16] http://www.health.vic.gov.au/consumer/pubs/doing.h...

Principles and practice: a better system of health care

About a decade ago, the Canadian Government recognised that its forty year old Medicare system was in urgent need of reform or ‘renewal' as they termed it. The problems they faced would be familiar to Australians: doubts about sustainability, waiting times, crowded Emergency Departments, poor access to care for minorities and Indigenous people, looming workforce shortages, chronic disease and the demographic shift.

The Canadian Government's first and seminal action was to create a Health Transition Fund (HTF) to stimulate creative thinking about how to change the culture and practice of the system to make it more responsive, effective and efficient. The premise was that building up an inventory of evidence-based innovation would smooth that transition. A joint effort of federal, provincial and territorial governments with a budget of $C150 million, the HTF supported about 140 different pilot projects or evaluation studies across Canada between 1997 and 2001. Initially, four key theme areas were studied: primary health care; pharmaceutical issues; home care and integrated service delivery. As the program developed and submissions were received, other topics were added: children's health; seniors, mental, rural and indigenous issues.

The impact of the first HTF was out of all proportion to its moderate cost. With four fifths of the investment devoted to provincial projects, cooperation between federal and provincial authorities improved dramatically. Many projects actually altered policy and practice: a most significant outcome has been the distinction drawn between ‘primary medical care reform' which is concerned with the way the initial contact between a patient and a medical care provider - usually a GP - is provided and ‘primary health care reform' which is concerned with population health, preventive medicine, health education and promotion.

Almost half of the HTF projects were concerned with primary health care, focusing on broadly based community health programs that feature the best use of a region's health providers to maximise the health of the patient population and the best use of the health resources of the system.

The importance of keeping people well as a strategy for minimizing the pressures and costs of acute care was strongly advocated. Health Canada identified three major challenges in 2001 and I suggest that these apply equally in Australia today:

First, disadvantaged groups have significantly lower life expectancy, poorer health and a higher prevalence of disability than the average Canadian

Second, various forms of preventable disease and injury continue to undermine the health and quality of life of many Canadians; and

Third, many thousands of Canadians suffer from chronic disease, disability or various forms of emotional stress and lack adequate community support and help.

In addressing these challenges, Health Canada initiated a Royal Commission on the Future of Health in Canada. The Commissioner, Dr Roy Romanow, once First Minister of Ontario, summarized his recommendations thus:

In terms of modernizing the system's foundations, I propose establishing a Canadian Health Covenant that expresses Canadians' collective vision for health care and that outlines the responsibilities and entitlements of individual citizens, health providers, and governments in regard to the system. We need consensus on why the system exists, what it is intended to achieve and how its component parts should fit together. This is vital to restoring the public's confidence in the system.

I also am proposing to modernize the Canada Health Act by updating the principle of Comprehensiveness to include priority diagnostic and homecare services, by clarifying the principle of Portability to guaranteeing portability of coverage within Canada, and by adding a sixth principle of Accountability.

Finally, I am proposing the creation of a Health Council of Canada. This inter-governmental Council would serve as a meeting place and focal point for collaboration among governments, providers and citizens in establishing overall system objectives, common indicators and benchmarks, criteria for measuring, tracking health and reporting to Canadians on system performance.

It is too early to claim that these initiatives have transformed the Canadian health system. There are still delays in accessing some elective procedures and access to needed medical care is still far from universal, but there are strong signs of improvement and some constructive innovations are changing ideas about the priorities a modern twenty first century health system should adopt.

For example, there is a clear indication that equity and economic efficiency are inseparably linked. We too must find ways of keeping people well, of providing timely solutions to simple problems before they become complex and costly to fix.

We know that the burden of disease falls most heavily on the least affluent, the most disadvantaged. Do we care? Do we care if someone cannot afford to see a dentist, a podiatrist, a physio, a GP or to get a prescription filled? We wring our hands about the health of aboriginals and their appalling life expectancy but is our anxiety for their welfare or about the reflection their condition casts on international perceptions of our culture? The homeless, the mentally ill warehoused in our prisons, do we care? Population health demands proactive thinking. It is about more than the provision of primary care services even if those services are adequate - and they are not.

The example of the Association of Ontario Health Centres is explicit:

Our vision is rooted in a care model that provides comprehensive primary care services, delivered by multi-disciplinary teams of professionals practicing within a health promotion framework. This means that by working with individuals, families and groups we increase individual and group capacity in building health communities. In fact, we are a key source of community infrastructure with which to deliver a range of integrated community-based services and to respond to health-related community concerns. Our member centres are specialists in delivering primary health care that is integrated with other social and health services partners.

Our care model is highly effective for all Ontarians. At the same time, it is a resource for people who encounter a diverse range of access barriers such as language, literacy, poverty and geography. It also works for those with other social-cultural barriers and who are at high risk for developing health problems.

Our Association engages in research, develops policy and advocates in support of this community centred primary health care model. Our member centres are located throughout the province and we work directly with communities who want community primary health care.

The need to staff their multi-disciplinary primary health care teams has obliged the Canadian Provinces to devote very significant resources to recruiting and training Nurse Practitioners and other health therapists, educators and allied health professionals. As more patients experience their care, Nurse Practitioners are proving increasingly popular wherever they have been employed. And graduate RNs are beginning to appreciate the new career paths and the much increased job satisfaction that post-graduate Nurse Practitioner qualifications provide.

Election year directions for Australia

We have not yet seen the pre-election health care proposals of the major parties but we can hope that they will include some of what Canada has done. For example,

• An Australian Health Covenant through which the Australian people express ‘their collective vision for health care' and ‘outline the responsibilities and entitlements of individual citizens, health providers and governments in regards to the system' is surely overdue.

• An Australian Health Council should monitor and report to the people on the health of the health system, encouraging cooperation between the states and the Commonwealth, fostering innovation and communicating best practice. The Australian Institute of Health and Welfare (AIHW) does a wonderful job in collecting and publishing the health system data, but it is not independent and does not report to the people.

• A broad ranging committee of enquiry similar to Romanow is needed to address medium to longer term health issues that need public discussion and expertise. The State based Enquiries, the Australian HealthCare Alliance, the Productivity Commission and the Blame Game reports have identified significant shortcomings in the arrangements now in place in Australia but all of these lack the authority of a Royal Commission.

• The regions of Australia are not homogeneous and one size does not fit all. Social, economic, climatic, demographic variables should dictate a need for an effective, routine public consultation process. An Innovation Fund to support and pilot test new approaches in the delivery of primary health care would, as in Canada, deliver major benefits.

• First things first. The basis of an effective health system must be primary health care, the service provided to the patient when they first recognise that they have a problem. The ‘one-stop-shop' neighbourhood health centre, always open, is increasingly seen as the most efficient and effective use of resources, where a multi-disciplinary team is able to provide most non-acute care, including diagnostic procedures and maintenance procedures such as renal dialysis for which most patients must now visit a public hospital. The need for such centres can be seen in the crowded Emergency Departments of public hospitals, crowded because the people have nowhere else to go for often trivial problems.

• General Practice is changing, the traditional family doctor now rare with doctors ageing as fast as the rest of the population. Increasing numbers of female GPs work a two or three day week; perhaps no more than one in five urban GPs works a five day week. Many practices have been acquired by commercial interests and now employ considerable numbers of salaried and part-time GPs and Practice Nurses. As in New Zealand and Canada, some practices now employ effective teams of allied health professionals. For this trend to have a major impact on population health, there must be a reconsideration of the Medical Benefit Schedules to ensure that the least affluent in society - who have the heaviest burden of disease and the most destructive lifestyles - have access to the full range of these services.

• The restrictions placed on medical school places for doctors and nurses a couple of decades ago - a knee jerk reaction to rising health care costs - is responsible for serious and growing shortages of doctors and health professionals. The recommendations of the Productivity Council's exhaustive Report on Australia's Health WorkForce must be implemented. The costs of medical education also need examination. If HECS fees are so high that specialisation attracts too many graduates away from general practice, that effect should be recognised and countered.

• The funds invested by Commonwealth and State authorities in prevention, health promotion and health education are totally inadequate. It seems extraordinary that, when the positive returns from preventive programs exceed four times their cost, there is so little interest in them. For example, current debate about national curricula ignores the need to provide all children with a knowledge of health theory and practice; and very many schools now fail to provide students with regular participation in compulsory team games and physical activity. It is not enough for people, young and old, to have a theoretical awareness of their personal responsibility to maintain a healthy lifestyle: they need easy, affordable access to the providers of interesting, challenging community based recreational activities.

Finally, the involvement of the people, locally and nationally, in decisions about priorities for their health system and the delivery of their health services - envisaged by Romanow as a Covenant, and mooted in Australia as citizen juries - would introduce a most important element of realism into decision making. John Menadue has spoken about ‘the hospital tail wagging the health system dog' and glamorous, exciting acute techniques and drugs will always attract headlines. But the things that matter most are the basic necessities involved in keeping people well. And Government seems reluctant to establish effective, affordable, accessible strategies for keeping Australians well.

Health Workforce Reform: rising to the challenge

Australia needs a radical rethink of the way it delivers and resources its health services. Robert Fogel (Nobel Laureate in Economics) predicted that the economies of developed nations would be ‘driven' by health by the mid 2020s, expending between 20 and 25 percent of GDP in that area. A recent report for the US predicts a doubling of spending on health by 2016 to $4.1 trillion dollars USD - and that nation currently devotes over 16% of its GDP to health. Australia's health economy is heading in a similar direction, yet despite this expansion numerous reports over the last ten years have indicated an increasing inability of the Australian health care system to deliver appropriate and timely care to Australians. This is reflected by the continuing concern about waiting lists for surgical procedures and specialist consultations in public hospitals, long waiting times in the private sector for particular specialties and increasing disparities between the delivery of care in major centres and in the rural sector. The increased demands on the health system are being generated by a number of factors which include the ageing population, an increasing burden of chronic disease, a more demanding population in terms of provision of health advice and services and a health workforce, that along with the workforce in general, is somewhat less committed to providing the 24/7 service of yesteryear.

Our inability to deliver appropriate health services to Australians is dictated by a number of factors which demand reform. These include inefficiencies with the multiplicity of organisations (Commonwealth, State and professional) that administer and fund the health sector, outdated industrial practices which protect the health professional ‘silos' and a lack of willingness on the part of any of these groups to address reorganisation and the productivity gains that might flow from this.

It should be acknowledged that this is a worldwide phenomenon with the most recent World Health Organisation Health Workforce Report estimating that there would be a global shortage of over four million doctors, nurses, midwives and other health workers over the next decade. As a nation we have become far too dependent on international health graduates (medical in particular) and have become (somewhat unwittingly) part of the international trade in health workers which often deprives developing countries of one of their most important ‘assets' - health workers.

Concern in relation to the health workforce led the Australian Government to request the Productivity Commission to develop a report on Australian's health workforce (which was handed down in December 2005). A summary of the Commission's proposals is shown in the table below.

Productivity Commission Recommendations, 2005

In any implementation of the Productivity Commission's findings it is important to ensure that certain groups in the community are not marginalised and that efficiency gains are used to create a more patient-focused health system. It was disappointing that the Council of Australian Governments meeting (June 2006) which considered the report did not accept the majority of the recommendations, but the document remains a significant blueprint for innovation and change in the health system.

General Practice

Australia still has one of the best health systems in the world and it is underpinned by general practice. General practice has been under threat in this country for some years as the incentives (work organisation and remuneration) for engaging in specialist practice rather than in general practice are significant. There is some evidence to suggest that general practice is undergoing a minor ‘renaissance' with numbers enrolling in the General Practice Education and Training Australia (AGPT) program increasing steadily over the last few years. General practice and primary care should continue to underpin the Australian health care system and incentives need to be created to ensure that graduating medical students are drawn to this discipline. Incentives should be created to fund general practitioners appropriately and reduce the ‘earnings gap' between general practice and the specialties. The disciplines of general practice and health promotion need to be expanded and incentives provided to encourage general practitioners to work in rural areas as well as in the city. One issue that needs to be addressed is that of the isolated practitioner whether he or she be in a rural centre or in a city. Professional isolation leads to diminishing job satisfaction and may have a significant effect on quality and safety issues relating to service delivery. Technology now provides many ways for health professionals to maintain contact over quite significant distances whether this is a simple telephone line, video conferencing, exchange of data (x-rays, pathology tests) over the internet or other mechanism. Teleconsulting could be expanded to provide remote access to specialist's consultation - the technology is available yet little incentive (provision of MBS telemedicine item numbers) has been provided by the Government.

Health Promotion/Public Health/Primary Health Care

Less than 10% of the health budget is directed to health promotion and disease prevention. In fact, we have an ‘illth' system not a health system. Australia has one of the fastest growing epidemics of obesity in the world and this will lead to a significant burden of diabetes, heart disease, arthritis and other associated conditions over the next century. As with global warming, we have taken some time to acknowledge that this epidemic of obesity is a reality and that we need to do something about it. This can be best achieved by concerted intersectoral and community effort. Public health education should be strengthened at all levels. We should, for example, provide school children with a good health curriculum - teaching them about the most important asset they have (their own body) and how to look after it both physically and psychologically. This will need cooperation between health and education jurisdictions at all levels of government. The community needs to be far better informed and engaged in decision making about issues such as advertising of ‘junk food', substance abuse and stress. This is not about creating a ‘nanny' society, it is about establishing a society in which our children can grow up to be healthy and look forward to the same longevity as we have. It should be remembered that there is evidence that our children may be the first generation on this planet to have a shorter lifespan than their parents. The primary health care workforce should be increased with new models of ‘carers' and lower level multiskilled health workers who can contribute to team care of the chronically ill and aged.

Role Delineation

The health workforce currently makes up just over 11% of the total workforce in Australia and it has been suggested that we need a significant increase in this number to around 20% if we are to maintain the delivery of health services that we currently have. This expansion will be driven by the increased funding. To date four options for meeting this increased demand have been identified:

• Extending the role of existing health professionals (nurses, allied health professionals).
• Creating new types of health workers e.g. clinical assistants, physician assistants, surgical assistants, carers
• Improving efficiency by using information technology more effectively in the health industry.
• Placing more emphasis on prevention and health promotion.
  
  

Role redesign can involve the creation of new autonomous roles - ‘nurse practitioners' for example - or roles in which non medical practitioners work under the supervision of someone else (usually a medical practitioner) - the delegated care model. Supervision of the person providing delegated care may be face to face or remote using video or other communication links for medical supervision.

This type of model has been accepted in the United States for some thirty years (physician assistants) and has been more recently trialled in the United Kingdom, parts of Europe and in Canada. We will need to look at some of the models that have been developed in these countries and to examine them rigorously in an Australian context. Underpinning task substitution is the notion of generic descriptions of health competencies that cross professional boundaries. The ‘skills escalator' that has been developed for the National Health Service (NHS) in Britain is a useful example of this. The skills escalator is a nine-level career framework that starts with supporting roles and then moves to assistants and senior assistants, assistant practitioners, qualified practitioners, senior or specialist practitioners, advanced practitioners, consultant practitioners and finally more senior posts as seen in Figure 1. It provides a wide variety of entry points into health care careers, encourages and recognises life-long learning and acquisition of new skills and is used in an environment that seeks both job satisfaction and service efficiencies by delegating roles, work and responsibilities up and down the escalator where appropriate.

Figure 1

Underpinning many of these concepts is the idea of the health professional as part of a health care team. This is very important for the management of complex chronic disease, and it emphasises (using the skills escalator) the importance of training ‘generalists' who have a clearly defined set of generic health competencies and who can rapidly assess multiple system disease, manage chronic cases and be involved to a certain extent in health promotion and disease prevention. The World Health Organisation recently identified five core competencies required for delivering effective health care for chronic conditions:

• Patient centred care
• Partnering (linking patients, providers and communities)
• Quality improvement
• Knowledge of information and communication technology
• Understanding the public health perspective moving from individual to whole of community care.

There are many situations where already existing health workers might be retrained to take on tasks that they have not previously undertaken. This could include radiographers taking on a role in reporting x-rays, ultrasounds and other images, pathology technicians becoming involved in the reporting of routine pathology (an extension of the PAP smear and other screening programs) and nurses taking on a role in minor procedures such as endoscopy and minor surgery. Podiatrists might be involved more in foot surgery and optometrists in cataract extraction. Ambulance officers can play a significant role as primary care providers in rural areas and programs are already being developed to expand their role.

Increasing efficiencies of current health workers

Health workers at all levels complain about the amount of paperwork that they now have to engage with in the health system. This can be anything from obtaining authority for Pharmaceutical Benefit Scheme (PBS) items, obtaining geriatric assessments, or accessing practice incentive payments. Significant efficiencies must be attainable in hospitals where doctors and other health workers are weighed-down by their administrative burdens. Options should be investigated for increasing the use of electronic ordering and improving the ‘flow' of patients and paperwork, particularly in areas such as accident and emergency and hospital admissions. For example, how many times does a patient being admitted to a major hospital have her history taken from the time she arrives in the Accident and Emergency Department to the time she is finally in a bed in the ward?

The situation in geriatrics/aged care is a case in point. To access home care, each agency providing services generally conducts an assessment at admission. This is repetitive and frustrating for the clientele. This problem could be resolved, at least in part, by aggregating service providers into one organisation. Separate assessments are only necessary for specialist aspects of assessment and care planning. In hospital care, there is often duplication of assessment procedures among professional groups. Although each professional group is trained to perform ‘holistic' assessments, there is often repetition in both the interview and documentation process. Parallel duplication also occurs throughout the course of a hospital admission, for patients with complex needs. Admission assessments are conducted by the medical, nursing and allied health staff, then nurse discharge planners, then geriatric consultation services and the ACAT services. With each contact, there is a repeated patient interview, and telephone phone calls to relatives, who are surprised at the poor communication and coordination between hospital staff.

Far more flexibility could be introduced in the workplace with timing and duration of shifts, job sharing and distribution of workloads.

Increasing efficiencies of training medical specialists

Training of doctors involves at least three different ‘agencies' - universities, postgraduate medical committees (an arm of State health departments) and the Royal colleges. There are currently few formal links between these organisations and little attempt to look at the vertical integration of curricula. We need to be asking ourselves whether it should really take five to ten years to train medical specialists from the time of graduation to independent practice when in an increasing number of situations that independent practice is going to be in a relatively defined area of medicine (endoscopy, arthroscopy, cataract extraction, coronary angiography to name but a few). Training of doctors and other health professionals is still time-based to a large extent rather than competency based, and the training programs do not have the flexibility that is present in many other industries. There is an urgent need for universities, health departments and medical colleges to engage in a meaningful dialogue about how vertical integration of curricula can be achieved and to create some practical examples. Flexible, online postgraduate and continuing education programs with competency based assessment and recertification are the way of the future. This could enhance workforce training and job satisfaction as well as the implementation of research through knowledge transfer.

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‘System issues'

The health system is naturally driven by the acute care hospital sector and there is still poor coordination between out of hospital services (primary care and general practice) and hospitals. Australia does not have a coordinated primary care policy, with medical practice managed by the Commonwealth with little provision for allied health and other services. The recent expansion of the MBS to allow non-medical access should be extended. Physiotherapists could be involved in screening musculoskeletal injury and ordering radiology; pharmacists could at least handle repeat prescriptions in patients with chronic disease or carry out medication reviews. States and territories tend not to have well developed primary care policies and programs which leads to a lack of coordination between hospitals and primary care in the community. At a regional level role delineation and clinical service networking is still poor (particularly between hospitals), although this is being addressed in some jurisdictions. The transparency of funding streams for health remains a challenge but could be improved by clear lines of responsibility and communication. This is particularly true in relation to Commonwealth and State responsibilities.

Policy Issues

Significant improvements in health could be made by:

1. Increasing the proportion of the health budget dedicated to public health activities - specifically designed to improve the health literacy of the population as a whole and ‘at-risk' groups in particular:

• Community public health campaigns
• Increased training of health promotion advocates (cross sectoral, including school teachers)
• Increased emphasis on disease prevention in health professional education programs
• Development of individual and community incentives to maintain health

2. Improving productivity by reviewing the structure of health delivery systems (National, State and Local) to address inefficiency, duplication and waste:

• Review and implement where appropriate the Productivity Commission Report into Australia's health workforce.

3. Developing new types of health workers including:

• Carers;
• Physician Assistants;
• Health ‘trainers' (coordinators of care particularly for chronic disease);
• Hospitalists.

4. Reviewing incentives for the provision of health services to disadvantaged groups (rural and remote, Indigenous, disabled etc). This should include the development of funding incentives to attract health workers to train and work in rural and remote Australia and with these groups. It would also include a review of the use of and funding for technology to improve access (telehealth, telemonitoring etc.) for both patient and provider.

Conclusion

This paper has attempted to identify some of the elements of health workforce reform. It should not be viewed as a panacea but as the start of a long journey to improve the health system. There is little doubt that we will not be able to provide the health service which will be demanded by Australians in the future unless we redesign the health system and restructure the health workforce. These are significant challenges and there is no one or easy ‘fix.' The health workforce currently makes up about 11.3% of the total workforce in Australia and this may have to increase to around 20% of total workforce by 2020 if we are to maintain the level of health service provision that the community has become accustomed to. Our challenge is to ensure that this expanded workforce is flexible, able to deliver patient-centred care, can partner and work as part of a health care team, uses information and communication technology and is dedicated to a public health perspective and quality improvement. This is our challenge - why don't we rise to it?

How an Ambulance Service can contribute to the health care continuum

The rationale

The primary role of all ambulance services is emergency pre-hospital medical care, although they generally provide both emergency response and patient transfer on behalf of the health sector. They provide easy access to health services, particularly out of hours, and contribute significantly to telephone triage and telephone health services through sophisticated communications infrastructure. In recent times it has become apparent that increasing health system pressures cannot be resolved only by adding resources, but must also be addressed with new methods of service delivery.

The ambulance service is ideally placed to be part of the first line in the continuum of health care, and can significantly contribute to ‘treat and transfer' or ‘treat and leave' programs. If ambulance services can develop towards an out-of-hospital, clinical care service rather than merely pre-hospital clinical care, they could substantially add to functionality of the health system. This could be through more efficient transfer of patient information; more efficient movement of patients; an ambulance service with a public service - rather than profit driven - philosophy; and patient treatment regimes consistent with the broader health system.

By integrating ambulance services into the health system generally, their respective strategic agenda are aligned, increasing efficiency, and providing an opportunity for an ambulance service, with its relevant expertise, to influence the outcome of ‘health' initiatives.

The service

Ambulance services are the primary providers of a 24/7 response to medical and trauma related emergencies. They provide a disciplined and organised system, allowing a timely response of appropriately qualified health care workers - often to potential or confirmed medical emergencies. Although medical retrieval teams are provided by the major trauma centres, coordination of the team and rescue helicopter is provided by the ambulance communications centre, and also crewed in most instances with intensive care paramedics.

Ambulance services provide the equipment, expertise and experience in the emergency intervention, assessment, management and transport of patients in a variety of controlled, uncontrolled, and disaster environments. Whilst a wide variety of both professional and non-professional people can provide individual aspects of this service to varying levels, ambulance services are in the best position to deliver these services on the whole. In addition, modern ambulance services operate state of the art, 24/7 communication centres with experienced and highly trained telephonists, call takers, despatchers and clinicians. This makes them ideally suited to co-ordinate the ad-hoc crew requests being placed on the health system. In doing so, they can co-ordinate the response of the health system to ensure the right clinical/medical resources are provided to the right patient within the right timeframe for their medical needs.

Given the pre-hospital clinical environment of ambulance operations, being part of the health system ensures consistent patient care from the home or event to the hospital, i.e. a "system" approach to health care rather than individual health units working in isolation from - and sometimes opposition to - one another. An ambulance service provides the first point of contact with an incident, as well as a patient, therefore it provides early warning to the health system of its operating environment as a whole. This enables a degree of flexibility in the health system response to an event, allowing flows of patients to be adjusted or anticipated according to system performance. This provides a more efficient model in terms of resources and cost and can enable the redeployment of resources to other areas of the system, e.g. lower on-site staffing levels and higher on-call capacity. Continuous, seamless patient management from an initial incident to definitive care and recovery work well when all components are part of one system.

Currently, ambulance services make a huge range of unmeasured contributions to patient outcomes. These include the minimisation of clinical harm; the early reduction of myocardial workload and hyoidea in myocardia infarction; the early defibrillation in sudden cardia arrest; the early restoration of vital organ perfusion in major trauma, the rapid transportation of the time critical patient, to definitive care, and so on. Anecdotal opinion is that the activity of interventions, length of stay, and morbidity all decrease with the early intervention of paramedic care. To consider ambulance as anything other than integral to a health system is wrong.

The profession

An ambulance service provides paramedics who operate in an autonomous environment, remote from the backup and support of a full hospital. Long gone are the days when "ambo's" were simply "stretcher bearers".

Today's paramedic is a highly trained clinician, and a fundamental link in the delivery and continuity of patient care. Defining the place of paramedics within health and the health service continuum, establishes them as professionals operating within a professional entity.

Paramedics are able to provide appropriate treatment to patients in their own and immediate locality, taking the treatment to the patient rather than patient to treatment. This is regardless of whether the patient is suffering a minor wound or illness, chronic illness or major trauma. Paramedics will become increasingly well placed to provide out of hospital care, thanks to advances in Intensive Care education and training, and the introduction of practitioners or extended care paramedics.

The integration of ambulance services within health has not reduced its responsibilities for emergency response, nor its role in the State Disaster Response plan. Paramedics often respond with and work alongside emergency service organisations and play a vital role within the emergency management framework. However, the prime reason that they are involved is the potential for a patient to require clinical care. Consequently ambulance services maintain and enhance the relationships between other emergency service agencies and the health system as a whole.

Whilst ‘paramedic' is a unique specialist area of health care provision, so is podiatry, chiropractic, nursing, etc. All ar