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Health reform – needed the world over

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Early this year, Australian Medicine readers will be aware, I attended the Chinese Medical Association’s annual meeting.

One of the lasting messages from that gathering was the need to build a better primary care workforce in China to tackle the growing epidemic of non-communicable diseases.

China is intent on training more than 200,000 new specialist general practitioners by 2020 – and they are probably the only country on earth who could do it!

I have just presented a paper on health reform at the first in a series of three focused annual conferences aimed at transformational change in Canadian healthcare, and in the last few days I attended the American Medical Association’s House of Delegates, who also recognise the need for health reform.

All of these countries realise that their health systems are designed for acute care. They were set up well to deal with acute problems.

We know in Australia that a well-trained specialist general practitioner can deal with 90 per cent of the problems that they face.

We have secondary and tertiary specialists who can be called in to get to the root of the problem.

Each of these countries is facing an ageing population, we are all experiencing an explosion in medical knowledge, accompanied by an increased ability to do more and more for our patients.

And we are all facing financial pressures arising from that very ability. 

We all are seeing our patients, on average, getting larger and larger, resulting in more and more chronic conditions such as diabetes, heart disease, renal failure, hypertension, coronary artery disease, heart failure and osteoarthritic joints that need replacing.

Treating this new population with multiple co-morbidities is what is driving up our health care costs.

The US is losing the cost race and is currently spending 18 per cent of its gross domestic product (GDP) on health, with another 30 million people about to be added to the bill through Obamacare.  Canada is spending 12 per cent of its GDP on health, with worse outcomes than Australia which – as we know – spends 9.3 per cent.

The Canadians at the conference noted that despite the fact that they could currently afford this spend they could not afford the future trajectory.

We all need a major reorganisation of our health systems to shift the focus to community-based, medically-led teams to manage chronic medical conditions. This will focus our increasingly limited resources on the inexpensive end of health care to delay hospitalisation or, in some cases, avoid it altogether.

Electronic medical records and electronic sharing of information is seen as way to enable community and team-based health care to operate efficiently.

Accurate sharing of information should also close the information gap between community, residential and inpatient care.

Australia is one step ahead of both Canada and the USA, now that we have settled on a communication standard for the transfer of information between software packages and different parts of the health system. They were quite surprised by the fact that despite more than 99 per cent of our general practitioners use electronic medical records, none of them can as yet talk to each other.

In Canada it has been impossible to date for the country to agree on a common ‘rail gauge’ for e-health, because most of the health care decisions are made at the provincial level. In the US, the House of Delegates of the AMA also recognised this, and voted to compel the software houses to facilitate interoperability.

On the same theme, at its Annual Representative meeting the British Medical Association passed a motion to facilitate the secure transfer of handover data between health care professionals, particularly between primary and secondary care colleagues.

In my talk in Canada, I also pointed out that Medicare in Australia had already begun the process of providing rebates for a structured approach to chronic disease management, with the Australian Medical Association and the Coordinated Veterans’ Care Program taking this one step further with longitudinal interactive approaches to chronic disease management.

Finally, medical associations internationally all share the view that only doctors can safely provide medical care, and that to avoid rising costs and fragmentation of health care, non-medical health care providers must work in medically-led health care teams.

Moves by pharmacists, optometrists, nurse practitioners and others to work outside of their scope of practice are happening worldwide, and all our international colleagues agree this should be vigorously resisted.