Fairness the Key to Unlocking Health (2008 Young Writers Competition winner)

The draft report from the National Health and Hospitals Reform Commission (NHHRC) has certainly sparked debate about proposals ranging from a universal dental scheme to regional management of hospitals. While the final report is eagerly awaited, the diverse opinions on the draft are indicative of the challenges presented by the myriad of competing demands from an immensely complex system. It feels necessary to focus these fragmented discussions and articulate an overarching vision for reform that considers “health” in its broadest sense.

In 1948 the World Health Organization presciently defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Yet it is only recently that attempts have been made to widen the focus of our “illness system” from symptomatic treatment of disease to a more holistic approach. Certainly the adequate provision of acute care services is a pressing concern: the shortage of beds and rates of post-surgical infections are emblematic of the strain on our public hospitals. Ongoing reform must address the chronic underfunding and poor management, and focus on improving the quality of patient care.

Nevertheless it is in the community and not the hospital where additional resources can make the greatest difference. General practitioners are the lynchpins of our primary care system, and are best placed to combat the tide of chronic disease that threatens to impose an enormous burden on future generations. A disease such as diabetes can cause devastating blindness and kidney damage, and yet can be prevented if we employ proper nutrition and daily exercise to reduce our bulging waistlines. Unfortunately the current remuneration structure rewards the quantity rather than quality of patient consultations. The NHHRC draft report proposes a pay for performance system, and a scheme that rewards GPs for achievements such as immunisation coverage, reduction in smoking rates and patient education has already been successfully implemented in the United Kingdom. Our approach must balance flexibility for doctors and patients with aspirational benchmarks that should encourage healthier lifestyles.

Of course GPs are not the only players in the primary care landscape, and indeed people in rural and remote communities may have trouble accessing their services. In the context of such severe workforce shortages we must utilise the range of skills possessed by nurse practitioners and allied health workers to provide comprehensive and accessible care. The NHHRC has already signalled the broadening of the Medicare benefits scheme, although some medical practitioner groups have voiced fears about the threat of task substitution and compromised quality. The key to overcoming these professional turf wars is cooperation: there should be a specific Medicare item to reward multidisciplinary meetings to discuss and coordinate the care of patients.

A testament to this professional fragmentation is the ludicrous exclusion of dental care from the Medicare system. The lack of readily available public dental services is such that the state of teeth and gum health in some communities can only be described as third-world. Further the artificial barrier that has separated the management of teeth from the rest of the body is increasingly being challenged by new scientific evidence, with poor oral hygiene linked with the risk of heart disease. The Denticare model proposed by the NHHRC is based on a levy that funds a mixture of public and private services. Regardless of the funding arrangement any new system must ensure equity and access for all that has been so sorely lacking from previous dental care schemes.

We should not limit policy initiatives to the restrictive medical paradigm, as systems researchers are increasingly realising the power of the social determinants of health. Disease burden and life expectancy correlate astonishingly well with social circumstance, income and the level of educational achievement. The World Health Organisation recently released a landmark report that declared that social inequality as much as any single disease was the root cause of millions of avoidable deaths in the last 10 years. Tackling entrenched poverty, the lack of affordable housing and youth employment tangibly improves the well-being of our population, and the formulation of government policy must be integrated across domains of health, welfare and social services.

Amongst the most critical of these broader health domains is education. Convincing evidence shows that quality early childhood learning has multiplicative benefits that last well into the future. It is a travesty that government funded pre-school places are not provided for all children in Australia. Although various state governments are inching towards this goal, the federal government must coordinate these efforts to ensure coverage for all, including disadvantaged minorities and Indigenous children. For later years of schooling we must develop a robust health education strategy beyond the traditional message of “practice safe sex” and “say no to drugs”. The democratisation of health delivery, including ready access to hospital statistics and the myriad of resources on the web, has the potential to revolutionise the patient-doctor relationship. Tutorials on the biology of disease, the roles of health professionals, and reliable sources of medical information would verse students in health literacy and empower our future health consumers.

In addition to these social determinants, the environment can remarkably shape the health of communities and individuals. Flawed urban design in our outer suburbs encourages residents to drive to nearby destinations rather than walk or cycle, and contributes to inactivity and obesity. The blight of pollution has been curtailed by stronger environmental protection laws, but the spectre of climate change looms large. The consequences of rising temperatures range from higher rates of vector born diseases such as dengue fever to more kidney stones from dehydration. We must ensure that major planning proposals require environmental impact assessments that explicitly consider the health of the community. And we must all endeavour to combat the great challenge of climate change.

The media’s fixation on waiting lists and emergency rooms has distorted our perceptions of what we need from an integrated and efficient health system. My proposals may seem a disparate collection of ideas, but are not intended to be a comprehensive reform program - I’ll leave that to the NHHRC. They simply illustrate a holistic concept of health that encompasses acute and chronic disease, social factors such as education, and the environment. Our community and political leaders must embrace this broader definition if we are to achieve the aspiration to become the healthiest nation by 2020.
 
Shafqat Inam was the 2008 winner of the Young Writers Competition

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