The troubles of private health funds are currently dominating the health debate, although this is being carefully framed by all the usual vested interests as an issue about the public health system.
Here’s a suggestion for something else we could be talking about that really is of significance to public health: whether the way we fund and organise primary care needs a major overhaul.
This conversation could start by looking at the NSW town of Coffs Harbour which, along with many other regional centres, has become home to increasing numbers of refugees in recent years.
It says much about the problems of our primary care system that when the refugees began surfacing at Coffs, they often ended up at the local Aboriginal health service, because the mainstream services could not meet their needs.
As I reported recently in Australian Rural Doctor magazine, many of the area’s GPs were too busy, or unwilling, or not set up to cope with the complex needs of these patients.
Thanks largely to the hard work and dedication of a public health nurse, Coffs now boasts a refugee health clinic, which has arisen as a collaboration between the local area health service and division of general practice.
It gives many hints about what a good primary care set up might look like more broadly. The clinic runs more like an Aboriginal health service than a standard general practice, with a nurse being the first point of patient contact, and the GPs acting more like consultants. It does comprehensive assessments before referring patients for ongoing management by mainstream health and dental services, and coordinates this care.
The GPs who help staff the fortnightly clinic are paid an hourly rate. Fee-for-service just doesn’t enable provision of the sort of care that is needed.
The idea that fee-for-service medicine is ill-equipped to meet the challenges facing our health system is, of course, not at all original. The point is increasingly argued, even in that bastion of medicine-for-profit, the U.S., as per this article in The New England Journal of Medicine:
The fee-for-service system of provider payment is increasingly viewed as an obstacle to achieving effective, coordinated, and efficient care. It rewards the overuse of services, duplication of services, use of costly specialized services, and involvement of multiple physicians in the treatment of individual patients. It does not reward the prevention of hospitalization or rehospitalization, effective control of chronic conditions, or care coordination.
Sadly, it’s very difficult to generate meaningful community discussions about such issues when those with the greatest stake in the current system rule the airwaves, as evidenced by the coverage of the recent private health insurance changes.
My other gripe about the current health debate is that it so often remains narrowly focused on the financing arrangements. If that’s all we ever talk about, we’re in danger of losing sight of other things that also matter.
As we move towards health reform, we also need to be considering how to empower individuals, local communities and services to create the changes that will serve their needs, as is happening at Coffs Harbour.
There are other examples around the place — after years of struggling to attract and retain nurses, Tennant Creek has come up with a novel solution to its perennial workforce problems. The town has begun training its own nurses, thanks to an unusual joint venture between the health and education sectors.
And in the border cities of Albury-Wodonga, cancer patients have gained better access to a wider range of services in recent years. These gains have occurred because a coalition of locals, including doctors, service managers and community representatives, has had the will and the acumen to break down the boundaries that once characterised the area — not only the geographic ones but also those between services and providers.
National health reform wasn’t needed to get the private, public and community sectors working better together in the Border Cancer Collaboration. But it’s telling that the Collaboration faces an ongoing struggle to secure long-term funding. It seems that good will, creativity and altruism too often occur in spite of the system rather than because of it.
So there are a few ideas, just for starters, for how we might switch on a different type of health debate.