Counter Productivity

The shape of healthcare in Australia is set to evolve over the next decade. As doctors-in-training, we are likely to find our eventual roles quite different from the ones we trained for. Changes to come could well be a positive – inflexible minds cling to the status quo and healthcare definitely has some domains that need work, including (but not limited to) waste, waiting times, and work hours. Nevertheless, JMOs and DITs should be paying keen attention to plans for the healthcare system we will inherit.

Last October, Federal Treasurer Scott Morrison released a five-year productivity blueprint entitled Shifting the Dial. This plan targets health as an area for potential savings in the hundreds of millions. Mr Morrison’s stated motivation isn’t care of the populace but rather economic productivity. Australians, whilst having some of the best health outcomes globally, spend an average of 10 years in poor health before death, one of the longest periods of disability of any developed country. The Treasurer has realised that that’s a lot of lost work hours.

In a nutshell, Mr Morrison’s suggested plan is to save money and increase general productivity through better chronic disease management using existing inpatient funds for community programs. This will require better integration between GPs and hospitals. The change will be led by primary health networks rather than health authorities and “social entrepreneurs…the not-for-profit sector, community groups, local governments, health insurers and businesses, [and] businesses contributing as corporate citizens”. ‘Low value’ interventions will be defunded (of concern for women’s health this seems to include hysterectomies) and payments will be outcomes based, rather than activity based.

This sounds intelligent enough, it makes sense that money is spent in ways that are objectively effective. As the doctors who write discharge summaries, JMOs probably have a better understanding of activity-based funding than many more senior clinicians (given that we try to fit the most ICD10 codes possible in a readable sentence).

However, I worry that between the lines in this proposal is a tougher situation for doctors trying to do the gold standard for their patients. A scenario in which doctors are (potentially) financially penalised for outcomes the Government doesn’t feel look good on paper will not necessarily benefit patients. In fact, such a model could potentially increase disparity between rich and poor areas. Hospitals treating higher rates of smoking and obesity, for example, would get less money despite greater need. The inner city where people smoke less, weigh less, and live longer would get a bigger slice of the pie for, apparently, better data. Inbuilt injustice like that may make those of us doing our training now reluctant to take up positions in the areas of greatest need. Another suggestion in Shifting the Dial with this potential is allowing patient satisfaction to be a factor in budget decisions. Addressing every point of the proposal is outside of my scope, but my point is all of this needs serious examination for feasibility and potential impact by stakeholders such as DITs in the public health system.

DITs spend huge amounts of time, money, and personal effort on vocational training. Moving the goal posts over the next five to seven years when it comes to key performance indicators and funding may not inherently be a bad thing, but it will certainly impact on DITs massively as we develop into specialists. A system that privatises, forces competition and penalises doctors could see us regretting all our efforts. JMOs are the first to want improved productivity, reduced waste, and to be paid fairly for hours worked. After all, pressure is greatest at the bottom of the pyramid when investigations are slow, beds are blocked, and patients are unhappy. We must remain informed and aware of the shifting landscape around us and keep up the pressure for training doctors to be seen as stakeholders in the management of our healthcare system. Our futures depend on it and we want to make sure that the wellbeing of both our patients (and also ourselves) is the primary consideration over bureaucratic bottom line thinking.