Crisis as opportunity: how COVID-19 will reshape the Australian health system

Background

2020 so far has been consumed by the global pandemic of COVID-19 and its devastating effect on healthcare systems worldwide. The Australian health system has yet to be truly tested by the pandemic but the prudent public health response has saved lives, protected healthcare capacity and continues to provide care to the most vulnerable Australians. No health system is perfect and, although Australia’s has some wonderful attributes that make it the envy of many countries, it faces a number of important challenges. Our paper explores what might be the impact of the COVID-19 crisis on reforming our health system for the long term, and we argue that ultimately positive reforms can occur.

The first challenge is poor integration. At a macro level, federal and state funding so often result in disconnected and competing health systems; for example, the arbitrary split between the funding of general practice and hospitals. (1) At a state level we see in Victoria for instance, hospital governance has been largely devolved to local health services, making centralised planning, IT integration and bulk purchasing decisions challenging. Within the tertiary sector we see specialties becoming ever-more siloed, with super-sub-specialised clinicians frequently working in isolation of one another, rather than with each other, leading to disjointed care.

The second challenge is the weighting of services towards treatment of acute illness rather than prevention or wellness promotion. There have been a number of attempts to prioritise prevention in Australia but the reality is that a disproportionate slice of health funding goes to acute care and favours proceduralists over non-proceduralists. Funding is often targeted towards short term projects rather than investment into longer term structural reforms in healthcare delivery. (2)

A third challenge is the monumental wastage and inefficiency of utilising healthcare resources in the Australian healthcare system, though to be fair this is a worldwide problem.

So, what have we learned when our health system is challenged by a global pandemic that has shaken our societal norms like never before? How will it impact the future of our health systems and allow reform to happen more rapidly than thought possible?

Necessity is the mother of invention

Health system reforms are typically arduous, frustrating processes with vested interests, risk-averse bureaucrats and general inertia preventing rapid change, even when changes seem eminently sensible. A remarkable characteristic of the COVID-19 response has been the sheer pace of reform, with major changes such as the expansion of telehealth, the creation of COVID-19 specific clinical services within hospitals (3), and unprecedented levels of cooperation between private and public hospitals, and state and federal governments. Innovation has flourished, from ventilation hoods (4) to 3D-printed medical parts to vaccine development.

We must now determine how we carry forward this “can-do” attitude to health reform when we emerge from the acute crisis. In reality the current paradigm of obtaining grants and ethics approval for research projects often stifles innovation. We must learn how to capitalise on the positive unintended consequences of this pandemic to reward and facilitate innovation. One promising new development is the Australian Academy of Science Rapid Research Information Forum (RRIF) which facilitates rapid and policy-relevant information sharing about COVID-19 within the Australian research and innovation sector. (5)

Flexibility is a strength

Inflexibility is unfortunately baked into many of our health system structures, exacerbated by our system of devolved governance, clinical and specialist siloing and separated lines of accountability of our public and private health systems, and segregated primary care and hospital systems. This inflexibility has been evident over decades, with reform held up by vested interests and often a culture of hostility between clinicians and health bureaucracy and between clinicians of different craft groups.  This has hampered governments’ capacity to coordinate an agile system-wide response.

Indeed, as we have discovered through the current crisis, a pandemic response requires a coordinated response. Individual hospitals each have to play their role as part of a larger plan, as does the public, for instance, by allowing electronic contact tracing through the CovidSafe app, even with significant community reservations about privacy.

Our health system has demonstrated flexibility in the rapid transitioning of public hospital outpatient clinics to telehealth models, but much work remains to do in this space. (6) We hope that a lasting legacy of the current crisis is that the flexibility to utilise communication technology during the COVID-19 response becomes “business as usual”.

Use resources wisely

In a crisis, resources are more precious than ever, and as health leaders, it behoves us to prioritise resource stewardship. Suddenly, a laissez-faire approach towards using resources becomes dangerous in a pandemic when potential shortages loom in personal protective equipment, ICU capacity and laboratory capability. As countries scramble to secure adequate equipment, the COVID-19 pandemic has been a salient reminder that health resources are indeed finite, even in wealthy countries.

It is true to say that even before the pandemic, calls had been growing to reduce the environmental footprint of healthcare provision. (7) On a day to day level, questions have been raised about the proliferation of single-use items, with the increased cost and significant environmental footprint compared with reusable items. (8) At the same time, programs such as Evolve and Choosing Wisely (9) have been calling on clinicians and consumers to be more cognisant of not only the burgeoning waste in healthcare, but also potential harms of unnecessary investigations and treatments.

Quality of Life

The pandemic has prompted a difficult but overdue community dialogue on how choices in healthcare should be directed towards improving quality of life, not merely extending it. The pandemic has been a time for great reflection by the profession about what constitutes quality of life and how we sensibly allocate finite health resources. We hope these meaningful conversations will continue between clinicians, patients, families and the broader society about our values and what ought to be the goals of our health system.

Prevention is better than Cure  

A defining lesson of the COVID-19 pandemic is that there are great rewards for implementing strong measures early, for detecting, isolating and contact tracing infected people as rapidly as possible. Though less dramatic, this same lesson also applies well to countries around the world tackling the noncommunicable diseases; chronic diseases such as diabetes, heart disease, smoking-related illnesses and cancers. Getting in early on these conditions through primary and secondary prevention is highly cost-effective and increases the duration and quality of life at a population level. COVID-19 reminds us that the greatest impact on public health is the prevention of disease through population health measures, and we should be focussing more on spending there, rather than just on more tertiary facilities. And of course, the ancient, humble and cheap public health recommendation about hand washing is having its time in the sun, as promotion of hand hygiene throughout the global community is a key strategy in reducing COVID-19 spread.

Social Determinants of Health

 This pandemic has highlighted the fragility of health care provision and the importance of the social determinants of health has never been more evident. COVID-19 has reminded us of the vulnerabilities of our ageing populations, not just from the biological impacts of the virus, but also from the risks of social isolation, socioeconomic vulnerability and concurrent chronic diseases.

We see vulnerable populations in Australia; the homeless, those with disability, those residing in residential facilities and, of course, Indigenous Australians (11) being again in the spotlight as we recognise the impacts COVID-19 will have if it runs though these communities. And in the US, data tells us about the impact of race as a determination of outcome, with African-American (10) and Hispanic populations disproportionately impacted. COVID-19 plays out through the lens of socioeconomic determinants.

Think in Systems

COVID-19 has emphasised the value of systems thinking, to achieve the best outcomes in public health. Key lessons of a systems thinking approach (13) include that small changes can have disproportionate impacts, and we have seen that play out, for example with inadequate quarantine of cruise ship arrivals with COVID-19 infected passengers. Systems thinking also reminds us that a purely linear thinking approach to understanding our health system will fall short and that we need to recognise the complex (not just complicated) nature and unpredictable behaviour of health systems when planning for future crises.

One area where we could better apply systems thinking is the way in which we fund health services, and the balance between public and private funding. The ongoing concerns about the viability of private health insurance, the roles of profiteering by multinational health insurance providers, the reliance of payee contributions and government subsidies to prop up a model which is ultimately answerable to its shareholders is ultimately a complex system question. (14) The temporary successful merging of both systems that occurred during the pandemic opens the possibility of more symbiotic cooperation between public and private.

 Mental health care of our health workforce is essential

 As the weight of providing healthcare during the pandemic fell upon the shoulders of our medical workforce, Australian policy makers had the good insight to be proactive in providing support for the mental health of those front-line health professionals. The Beyond Blue National Mental Health Survey of Doctors and Medical Students had highlighted some 7 years ago that amongst the medical profession there are higher rates of psychological distress and also suicidal thoughts than in the general public, though stigma and concerns about being reported remain barriers to doctors seeking care. So, another lesson from this pandemic time is to support doctors’ mental health proactively as an integral part of supporting workforce capacity.

Conclusion

This global health care crisis which has spread across 188 countries and regions is not over; we are far away from seeing the impacts this will have on the future of Australian and international healthcare. Despite medical advances, the fragile pyramid of healthcare provision is at risk if we don’t get the fundamentals right. This pandemic period reminds us that our health systems have evolved over time not so much as a coherent “system”, rather as sequential improvisations over time with mixed models of funding, poor integration, inconsistent governance, environmentally unsustainable practices and ultimately inequities in access and care. COVID-19 has laid bare these inadequacies.

If positives result from this pandemic, it will be a change in how we, as health care providers at all levels, from policy makers to individual practitioners, view our roles in care delivery. Crises like these will recur, with an increasingly crowded and interconnected planet and with increasing divisions between those who can afford care and those who cannot. The lesson to learn is that healthcare is a human right; we need to agree that this is the fundamental principle for the Australian healthcare system and we use this common focus to reform our systems as we emerge from COVID-19.

References

1. Maddocks I. Silo mentality bad for our patients [Internet]. 2016 [cited 2020 Jun 4]. Available from: https://insightplus.mja.com.au/2016/41/silo-mentality-bad-for-our-patients/
2. Australia: The Healthiest Country by 2020 - National Preventative Health Strategy - Overview [Internet]. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0022/424426/nphs-overview.pdf
3. Rojek AM, Dutch M, Camilleri D, Gardiner E, Smith E, Marshall C, et al. Early clinical response to a high consequence infectious disease outbreak: insights from COVID‐19. Med J Aust. 2020 Jun;212(10):447.
4. Researchers design ventilation hoods for hospital beds to help contain COVID-19 spread [Internet]. 2020. Available from: https://about.unimelb.edu.au/newsroom/news/2020/april/researchers-design-ventilation-hoods-for-hospital-beds-to-help-contain-covid-19-spread
5. Australian Academy of Science Rapid Research Information Forum [Internet]. [cited 2020 Jun 4]. Available from: https://www.science.org.au/covid19/rapid-research-information-forum
6. Duckett S. Outpatient clinics: a policy renovator’s opportunity. 2020 May 18 [cited 2020 Mar 6]; Available from: https://croakey.org/outpatient-clinics-a-policy-renovators-opportunity/
7. McGain F, Blashki GA, Moon KP, Armstrong FM. Mandating sustainability in Australian hospitals. Med J Aust. 2009 Jun;190(12):719–20.
8. Sutton M. Single-use metalware a “big cost” for Australian hospitals as waste levels increase. 2020 May 25 [cited 2020 Mar 6]; Available from: https://www.abc.net.au/news/2020-05-25/surgical-metalware-thrown-out-by-hospitals-at-increasing-levels/12278400
9. Choosing Wisely Australia [Internet]. [cited 2020 Jun 4]. Available from: https://www.choosingwisely.org.au
10. Ray R. Why are Blacks dying at higher rates from COVID-19? [Internet]. 2020 [cited 2020 Jul 6]. Available from: https://www.brookings.edu/blog/fixgov/2020/04/09/why-are-blacks-dying-at-higher-rates-from-covid-19/
11. Indigenous Australians, Australian Institute of Health and Welfare [Internet]. [cited 2020 Jun 3]. Available from: https://www.aihw.gov.au/reports-data/population-groups/indigenous-australians/overview
12. Scharff X. Why the Coronavirus Outbreak Could Hit Women Hardest. Time Magazine [Internet]. 2020 Mar 12 [cited 2020 Apr 6]; Available from: https://time.com/5801897/women-affected-covid-19/
13. Peters DH. The application of systems thinking in health: why use systems thinking? Health Res Policy Syst. 2014 Aug 26;12:51.
14. Duckett S, Nemet K. The history and purposes of private health insurance [Internet]. 2019 Jul [cited 2020 Apr 6]. Available from: https://grattan.edu.au/wp-content/uploads/2019/07/918-The-history-and-purposes-of-private-health-insurance.pdf