Issue 47 / 9 December 2013

FEW doctors would think we can afford to provide all treatments that have been invented — let alone those still to be invented — for everyone who might benefit.

By “all treatments” I don’t mean those of uncertain or dubious benefit, but only those that can be shown to deliver a reasonable likelihood of significant improvement in the quality and/or quantity of life.

Across the therapeutic spectrum — from extreme neonatology to basic care of the elderly — demand and costs are rising more rapidly than revenue. Even a very rich nation like Australia cannot make the elderly live forever, nor can we ensure that every extremely premature baby will grow up to be self-sufficient or have all the necessary resources to lead a life of dignified disability.

We cannot continue on our current course without depriving other societal domains that are essential to the long-term wellbeing of our community, such as education, physical infrastructure, aged care, environmental protection, the arts and recreation, etc.

When we eventually do act we will realise that there are a limited number of ways to constrain the proportion of community resources expended on health care.

One is for funders to pay less for the things that are done.

The second, and perhaps the simplest, is to not do things that are of little or no benefit. We could also ensure that, when there is a choice, the less expensive options are used. This is primarily a task for doctors but everyone is responsible.

The third is to make sure that people do not have treatment that they do not want. This merely supports the right of people to make a choice not to start or persist with treatment that will not bring them sufficient benefit in terms of a quantity of a life of quality as they define it. This also requires community acceptance that individuals have the right to make such choices.

The challenge for health workers and community leaders is to communicate this right to patients in a way that supports them as they grapple with letting go of the hope of a prolonged life (families often find this very difficult) without being nihilistic.

Patients must also know that, in this context at least, they are not expected to forgo treatment for economic reasons — even though some might make such a personal economic choice spontaneously. Health workers also must accept that the rejection by patients of treatments they offer is not questioning their raison d’être.

The fourth approach is to encourage improvements in the efficiency of health care delivery — to continue offering the same treatments, but without peripheral activity that does not contribute to ensuring a positive outcome. Unfortunately, the complexity of modern health care means that this is not always possible without unforseen flow-on effects. Some so-called efficiencies may benefit one organisation by merely shifting the cost to another.

Ceaseless cost-cutting masquerading as “efficiency dividends” can be demoralising to health workers who often find they are unable to provide care to their own learned expectations and to the standards espoused by the employer imposing the cuts. Things can get even more difficult when cost-cutting measures are found to be insufficient.

One of the most difficult tasks is to limit access to some taxpayer-funded treatments of proven benefit. As a community we now have a general expectation that we are entitled to access new technologies as they are developed — as health workers we believe we should use them, and as patients we expect to receive them. No one wants to be the one to decide what not to do and who will not be offered it. Fortunately for clinicians who must advocate for the interests of their individual patients, decisions not to fund treatment belong to policymakers.

Inescapably, at some point we will realise that the long-term interests of our community as a whole are best met by restricting the allocation of resources to health care in the present to allow investment for the future.

While thoughtful medical practice, systemic support of the right to individual choice and improved efficiency can buy us some time they are unlikely to be sufficient.

Perhaps the complex ecology of gridlocked self-interest means that struggling health systems must collapse and fail before they can be rebuilt, and we will just have to watch while it happens.

Surely a better outcome would be to work towards spending only what we can afford. These are not simple issues and the process might begin with an open discussion of our community values and the goals of health care. The sooner we start that discussion the better.

 

Associate Professor Will Cairns is the director of the Townsville Palliative Care Service, Queensland.

4 thoughts on “Will Cairns: Hard choices

  1. Jane Andrews says:

    This is an important issue which Will Cairns has articulately set out. He omits however to comment on the large issue we have in declining to provide tests, treatments and consultations for the “worried well”. Unfortunately in ambulatory care – whether specialist or GP based – much of the work is sepnt on dealing with people who do not “need” to be there, but who have concerns, lower symptom thresholds and unrealistic expectations. Much of this is unable to be addressed by conventional medicine and probably needs counselling and education (and often anxiety management), but not referrals, tests or drugs.

    Until we directly deal with this “elephant in the room” we will find ourselves unable to better target medical resources to where they are most efficient. These people do need help – but should it be via a high tech, high costs, acure medical model, or can we – as a society – find a better way to do it?

  2. Sue Ieraci says:

    Jane Andrews is spot on! Much of what we do is driven by risk-aversion and unrealistic expectations. Too many tests are done in low prevalence populations ”just in case we miss something” – resulting in wild goose chases for false positives, and treatment for abnormal test results with no clinical impact. I agree that we, as a medical community, must resist the temptation to use ”the latest thing” because it is available – if the benefit is not worth the additional cost, we shouldn’t change what we do. The big gains in medicine were made last century – with antibiotics, vaccines, antihypertensives, antidiabetic medications, steroids, bronchodilators, basic antiplatelet agents. New therapies have diminishing returns for cost. The real catch is the human desire to continue improving – just like the latest smart phone (some of us excepted), we all want the latest anti-platelet drug and the latest PPI. Maybe the earlier one was good enough – but how is this decision made and who enforces it? Regulation is one thing, but it only needs a concerted campaign by a radio ”shock jock” on behalf of someone campaigning for a particular treatment and rational decisions go out the window.

  3. Kirsten Price says:

    Professor Cairns hits the nail on the head with his diagnosis of “gridlocked self interest”.  

    Health is an industry significantly pressured by cost, and all players are keen to cost-shift to another practitioner in order to ensure their own survival. This is absolutely unsustainable. Ultimately, the only way to ensure survival is to ensure  the health system remains viable.

    That means making sure that everything you do, as a practitioner,  adds value. If what you do is more costly to the system than the overall benefit to the patient (over the long term) then you are actually adding to the problem and ultimately ensuring your own demise.

     

  4. Malcolm Brown says:

    The Dutch have a high performing health system:

    http://www.euractiv.com/health/netherlands-best-healthcare-syst-news-532022

    Since 2006 they have had a system based on regulated competitive insurance choices with a basic safety net. The approach is similar to our workers compensation systems which are funded like other insurance through investment income as well as premiums. This is an attempt to get away from the need for constantly increasing demands on taxpayers, and although waiting lists have disappeared completely, their costs haven’t been contained yet, so more fine tuning is required. Well worth investigating however.

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