John dwyer UNSW - Social Determinants of Health conference 2013
Real Health System Reform
will focus on Prevention and
Equity; major components of
the social determinants that
• Professor John Dwyer AO
• Emeritus Professor of Medicine UNSW
• Social determinants Conference 2013.
Workforce and Health Care
Genuine health care reform has stalled
Ignored during the recent Election
Politically “Done and Dusted”.
The system remains sickness and
hospital centric and provider focused.
• Structural inefficiencies and increasing
inequity produce poor health outcomes.
Workforce and Health Reform
• Our National (Public) Health System
needs to be driven by a clear vision of
what contemporary Australia needs and
• Need to agree on a detailed affordable
model of care and then focus clinical
education on the provision of the
professionals who can implement the
From Vision to Goal
• “Our health care system should be
charecterised by its resourcing of
strategies to prevent avoidable illness
and provide in a timely manner to those
who are ill, cost effective quality care
available on the basis of need not
personal financial wellbeing.
• In 2012 personal contributions
COAG’s love affair with
• Hospitals continue to struggle to provide
quality timely care with demand (3%
more sicker and older patients each
year) exceeding budget growth.
• Quality hospital care is only possible
with a reduced demand for hospital care
i.e. having fewer patients who need
Needed focus on Community
• Productivity Commission report: • 750,000 hospital admissions could be
avoided with a community intervention
in the three weeks prior to hospital
• So what are the structural and
ideological impediments to us
responding to all we have discussed?
Impediments to Reform
• The Three “Biggies”
• Vested interests, a provider rather than
patient focused system
• The wretched jurisdictional division of
• “Blame Game”, 9 DOH, MCLs, fractured
• No political leadership to take us on our
At the end of the road
• Australia’s health system in 2013
At the end of our reform
journey we find that ----• The Commonwealth has become the
single funder of our public health
• Australian Health Care Authority
• Regional Health Authorities
• Funding includes “needs” analysis
• Borders no longer a problem.
• RHAs contract with a series of providers
to to supply patient focused seamless
integrated hospital, community and
primary care services.
• Quality data are collected and
• Most importantly a new model of
Primary Care has been established
The organisation of Primary
• Medicare Locals have become PHOs
• Hub and spoke model established
• PHOs offer direct services to patients
but offer support services to affiliated
• “Secondary” services 23 hour wards.
• IT, CPD, Quality audit, Bulk buying etc.
Integrated Primary Care.
• What are the characteristics of our
Primary Care (Medicare supported)
• An emphasis on prevention and early
diagnosis. Patient enrolment.
• “Secondary Care”, acute care
• Management of C and C diseases by
• Community outreach
• Not neglecting the social determinants
of health but—
• No longer do people only visit a medical
practice when they are ill, they attend to
work with appropriate health
professionals I( Medicare funded teams)
to help themselves and their families
• Positive reports attracting doctors to PC
• Inter-professional learning implemented
• “Team learning to prepare for team
practice”. Silo mentality disappeared.
• Rural medical schools for genuine rural
students. Less dependent on OTDs.
• Medical education shortened, less
• Internship replaced by accelerated VT
• IPC and Community care reducing
• Planned surgery efficient and reliable.
• Abolition of PHI subsidy has had
• Mutually beneficial partnership between
public and private hospitals.
• Owned and run by States under
contract with RHA.
• “Role delineation” sees each hospital
having a specified service profile
• No longer islands in an ocean of health
• Universal electronic health record
How do we start the Journey?
• Community (voter) support for changes
• Convince Politicians to establish “proof
of concept” trials of these suggested
• As of today health reform is stymied and
any journey is circular and unrewarding.
• Health professionals and informed
consumers must present a clear readily
understandable and evidence based
vision for better, equitable and more
affordable health promotion and care in
• Health, Happiness and Productivity are