The economic slump is no excuse for governments to wimp out on health reform; in fact, it may even be a help for those wanting to achieve genuine change.

That is one of the clear messages from an international analysis of health systems that have managed to transform both the way they work and the results they achieve.

The analysis was presented at a University of Sydney seminar this week by Steven Lewis, an adjunct professor of health policy at the University of Calgary, who is just about to end a stint as a Visiting Fellow at the Menzies Centre for Health Policy.

While professional lobby groups have a long and successful track record of arguing for more dollars to “fix” health system woes, Lewis says that when money is tight, real reform is more likely.

“You are more likely to get a lot of change with less money than more money,” he said.

As an example, he described how the Veterans Health Administration in the US underwent radical change very quickly, which took it “from worst to first”.

Between 1995 and 1999, the VHA dramatically improved clinical care, while closing 55% of its acute hospital beds (more than 28,000 of them), increasing the number of patients treated by 24%, increasing ambulatory care — and reducing staffing by 12%. The changes happened after the organisation got a leader, Ken Kaiser, “who had a mandate to rip the thing apart and put it back together again”.

Lewis also argues that reducing professional power and clinical autonomy, and redirecting the system’s focus towards the public’s needs are other key factors for successful change. His example: the Southcentral Foundation Alaskan Native Health Centre was completely redesigned so that it operated on the “turf and terms” of its native clientele, who also ran the organisation’s board.

The reforms led to less emergency, specialty, hospital and primary care — and improved health outcomes and improved patient and staff satisfaction.

The underlying philosophy driving the change was that health should be a service, not a product.

“There is no such thing as a non compliant customer, all there is is bad service that doesn’t meet their needs,” says Lewis. (For more detail of how the Alaskan service changed see here.)

Lewis argues that major barriers to transformational change include a widespread belief in incrementalism — that it is dangerous to change rapidly — along with the power of interest groups with a stake in the status quo.

“Abandonment of a transformative vision often signals capitulation to vested interests,” he said.

However, the cost of not changing health systems — in human suffering as well as dollars — is immense, he said.

Lewis also presented a series of findings suggesting that increasing health spending or the numbers of doctors and other health professionals is unlikely to lead to better health for populations like ours. Many countries, such as Cuba, achieve relatively good life expectancy with a universal health care system and relatively modest spending on health.

The presentation of these results led to a typically direct outburst from the editor of the Medical Journal of Australia, who wondered whether all those calling for more doctors and nurses were in fact “bullshit artists”. The answer, according to Lewis, is that we only need more if we keep on doing “the same things in the same ways”.

Lewis also argued that the private health sector cannot contribute to worthwhile reform because it is so focused on providing high volume, procedurally oriented, low risk care that it skews the system, drives up costs and fails the most needy, complex patients.

It’s a shame that Australia’s health ministers and their ministerial colleagues weren’t at the seminar. They would have heard that another critical factor for achieving meaningful health reform is political will.

The thought I took away is that if Australia doesn’t manage to achieve a better, fairer health system in coming years — with all the reform huff and puff now underway — then a large part of the blame should be shouldered by the powerful professional groups, whether medical, nursing, psychology, pharmacy or others from the allied health sphere.

Health ministers come and go, but the power of the professions seems to last forever.

Peter Fray

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Peter Fray
Editor-in-chief of Crikey

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