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The Future of Health is in our hands: I–Health
Steven C. Boyages
Professor, University of Sydney, University of Western Sydney; Chief Executive, Sydney West Area
Health Service, Sydney NSW, Australia.
The Health system of any nation is unique. Whenever citizens have an opportunity to express their
democratic voice, health is always one of the major areas of policy debate. So it was so in Australia
in 2007, where a new Federal Labor Government was elected with one of its key policy mandates to
improve the health system. The newly elected government indicated that in part this could be
achieved through better Commonwealth State relations given a unique circumstance since
Federation where every elected parliament in Australia was now of the same political persuasion.
Since the election in late November, the usual set of experts has emerged to push their just add
water solution to the health system. There are those who argue for more money to health (Australia
spends just under 10% of GDP on health); there are those that propose to move all of health funding
to one layer of government (at present the states are responsible for health care delivery and the
Commonwealth government funds about 40% through a Health Care Agreement); there are those
that propose more health care workers, a better focus on patient safety and quality, and a greater
investment in technology and other infrastructure. In all of these proposals few focus on how to
improve the “system” of health as a whole and few proposals articulate a clear methodology for
implementation or what other industries term execution.
By any measure, Australia’s health system is one of the best in the world. It has a universal
insurance scheme Medicare that provides access for all. Childhood and maternal mortality are low,
life spans are rising, and the incidence of cancer and heart disease are falling. The major blot on the
copybook is the health status of its indigenous peoples, which is way below that of mainstream
communities. So you may ask what all the fuss is about. What are the challenges that face the
Australian health system?
The challenges may be divided into 3 categories, rising demand, constrained capacity, and
inadequate investment in infrastructure. These challenges are not unique to the health system and
have been addressed by the banking, mining, transport and retail industries, albeit not without pain
during the reform stage.
Rising demand can be explained by a combination of factors including a better‐informed community
as to the appropriate level of health care, a rising prevalence of risk factors associated with an
affluent society, and an increased burden of disease as a consequence of improved medical
interventions and longer life spans. This rise in demand is reflected in the number of people with
chronic and complex conditions attending our health services. In contradiction, our health system
was largely designed to address the needs of those with acute conditions and tends to struggle
where multiple connections are required in the patient journey.
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The disconnected patient journey is one manifestation of the constrained capacity of the Australian
health system. The patient and carer experience for those with chronic and complex conditions
continues to be poor and the debate to improve this experience is usually marred by professional
boundaries. If a parallel was made to the airline industry, it would be like travelling from Sydney to
London by way of 6 stops, not having a single ticket to your final destination and being offloaded on
at least 2 occasions and not knowing when and where to pick up the next aircraft at any of the
intervening waypoints. Waiting lists and waiting times in the emergency or planned domains of
health are other examples of a constrained system. Poor outcomes due to medical misadventure
also reduce the capacity of the system. Finally, workforce supply and structural constraints have
limited the flexibility of the health system to respond to the rising and changing nature of demand.
Infrastructure investment in health has largely been positioned into large buildings and large medical
equipment. By comparison capital reinvestment in community health centres has been poor.
Investment in information technology and management has been slow and stochastic. Finally,
investments in technologies that promote connectivity and facilitate health logistics are elementary.
So how do we address these challenges as a whole system? I have labelled the approach for future
health investment as I‐Health. The “I” stands for Investment in: International Exchange,
Infrastructure, Innovation and the Individual. The sequence of investment is not as crucial as to the
implementation of all of the elements.
Investment in addressing these health challenges should have an international focus given the
parallels that many health systems of the developed and even the developing world face. There are
only a finite number of ways forward. Yes, there are many sites and societies for professional
knowledge and development but there is no equivalent site such as Wikipedia for health investment.
There is an urgent need to develop an international marketplace for the currency exchange of ideas
and knowledge for health investment.
If I was to advise the new Health minister on Infrastructure I would strongly recommend an
investment in two areas; firstly connectivity across the different settings of care, and secondly the
development of a “common health operating system (HOS).” Laying down a common gauge railway
track will immediately improve communication of patient to provider, and amongst providers across
settings of care. Broadband connectivity of General Practice, Community Health Centres and
Hospitals should be achieved within 3 years. In parallel, the development of a HOS will allow the
portability and availability of health information at multiple points in the patient journey. A coalition
of industry, the professions, consumers and government should be formed to spearhead this
initiative. Both of these investments are essential to improve the logistics of health.
Innovation is the keystone to health. There is tremendous research in the understanding of disease
but much less emphasis and recognition for innovation in health care delivery. The latter has often
been termed health services research by academe or modernization and redesign by governments.
Other industries by comparison have made great strides in productivity through innovation in
understanding the service needs of customers and how the supply chain could be configured to
meet and exceed these needs. This approach is termed supply chain management or logistics. The
questions that have to be asked is how we learn from other industries and how we deploy these new
sciences to health; how we develop business intelligence tools that monitor the performance of the
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enterprise in real or near real time; and how we rapidly implement new models of care (improved
supply chain) that serve the needs and wants of our different patient and community groups.
No other industry is like health in the relationship of the consumer to the provider. The consumer in
health generally does not choose to be a consumer. Every consumer in health must be treated as an
individual. Treatment is determined by the intersection of the specific nature of the presenting
illness with the patient’s own understanding and previous experiences. The explosion of
information available through the internet has allowed consumers and carers to understand the
choices available. New developments in social networking software and the development of
personalized electronic health records will usher in a new era of patient centred health care.
We stand on the verge of a great era in health maintenance and health service delivery. The future
of health care is in our hands. The solutions proposed above will lead to a sustainable, flexible and
agile health system where the patient, ie the individual is at the center of care as an active