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Healthy Communities: A case for structural change in how we manage our health

Updated: Nov 2, 2023

Looking at our health system from an outsider’s perspective, governments wanting to reduce the unsustainable growth of health budgets should be looking at the strategic and structural impediments to better integration of primary health care, and human and community services.

Coming from a rural development background, and from outside the sector, provides a different perspective on the current effectiveness and future direction of our health system.

We know that our health system is failing rural and remote communities, and the declining numbers of GPs being produced by our medical and surgical education system is contributing to growing shortages of GPs in outer metropolitan and regional areas as well.

We also know that we have an epidemic of preventable disease that threatens to overwhelm our health system and budgets. Smoking, consumption of sugars, excessive use of drugs and alcohol, lack of physical activity and unemployment all combine to exacerbate rates of heart and respiratory diseases, poor mental health and other diseases like cancer.

We know that there are very effective place-based and community-level strategies to prevent disease and reduce the burden of poor health and injury.

On these things, everyone seems to agree.

The banning of the public display of tobacco products, combined with levies, has had a dramatic impact on smoking rates in Australia. Better regulation of airborne pollutants means we can now see the horizon on a sunny day and breathe cleaner air.

In the USA prohibiting the use of trans fats, and in the UK taxing sugar, aims to reduce obesity which contributes to heart disease and cancer.

Outlawing drink driving and the use of speed cameras has reduced avoidable disability due to motor vehicle accidents.

Chronic disease management plans have supported patients to better deal with their conditions and stay out of hospital.

What all these strategies and programs have in common, however, is that none of them have anything to do with our medical or surgical system. These are a product of the public health and primary health care system.

Despite our mature understanding of what is driving poor health, and how to reduce the burden of disease and injury, we continue to treat primary health care as a branch of our medical and surgical system.

The problem it seems to me is that we are trying to re-engineer a medical and surgical system designed more than a hundred years ago to treat disease to do something that it was not designed to do. In the process we have created structural impediments to delivering affordable and integrated solutions that reflect the contemporary health needs of communities and individuals.

We organise and lead health policies and strategies around emergency and acute episodic care when we should be organising and leading it around people and communities.

If I look at a town like Walgett, what would be the best approach to reducing the appalling burden of disease in this community?

A new hospital? No. Walgett has a relatively new hospital but the problems of poor housing, education and unemployment, which are driving poor health and other social challenges, remain.

In my view, we should be doing things like community-led regional economic development (stimulating job creation to remove people from the cycle of poverty), education (building health literacy and self-esteem), sports and recreation (lifting levels of physical activity), housing (making homes healthier places for children to grow), environment (addressing airborne pollutants), justice (diverting young people from crime), wellness planning (developing healthy lifestyle plans for every resident from birth that reflects their personal needs) and so forth.

In short, if we were designing a health system today we would drive every social, economic and infrastructure policy and decision in Walgett around the aim of reducing the incidence of preventable disease and other socioeconomic disadvantages - a ‘Health in All Policies’ approach.

But to achieve ‘Health in All Policies’ requires more than a Preventative Health Strategy designed around our existing disease-focussed system. It needs structural reform.

We need to recognise that hospitals exist to treat people when they get very sick or suffer serious injuries. The goal of for ‘Health in All Policies’ is to keep people out of hospital by working at an individual and community level before people get sick or suffer injury.

Addressing the causes of poor health (the social determinants) is the expertise of health generalists who work in and with communities.

That is why structural reform is necessary. The people who are involved in reducing poor health and hospitalisation - general practitioners, nurses, allied health, urban planners, human/community services professionals - should be working together around a common strategy enabling them to share expertise, resources and planning at a community-level.

Yet we lack the impetus to make the changes that are needed while we continue to see health through the prism of acute and emergency care.

Primary health care is a relatively new discipline compared to the medical and surgical sciences. Primary health care has grown in importance as we have come to realise that the reason people get sick, are unemployed or exposed to the criminal justice system is primarily influenced by the context in which they are born, live, work and grow.

But because primary health care grew out of our medical and surgical response system does not mean that this remains the best place for it today.

Operating within the hospital system has made primary health care the poor cousin as more public money flows into building new hospitals and treatments, while less money is allocated to general practice, and community development and care, hampering the efforts of our human and community care services to make change at a local level.

The next step in the evolution of primary health care is the integration of generalist health care with the human and community services disciplines.

That means recognising that primary health care plays a unique and different role relative to our hospitals and should be recognised as a distinct discipline with its own departmental structure, funding and strategy. Primary health care should be leading the State’s and Territory’s approach to addressing the social determinants of health.

Integrated care should be about more than whether a GP gets a discharge summary at the end of a patient’s visit to hospital. It should be about how primary health care works with human and community services to engage with communities, and develop plans and programs to address the cause of up to 80% of poor health and social disadvantage.

Recognising this, we also need to consider that our existing approach to the education and training of generalists, and the types of students we attract to work in this important discipline, is no longer appropriate and that generalism requires a different type of background, motivation, education and training.

General practitioners are health specialists, not disease specialists, and there is an argument that this should be better reflected in how we select, prepare and train generalist in the future. Some universities, such as James Cook, Charles Sturt, Western Sydney and Wollongong appear to have started down this road in their approach to generalist-specific education. We should be supporting and rewarding those universities, and their students, who have embraced the value of a generalist career pathway because these are the graduates we need to flatten the curve of avoidable disease.

Looking at our health system from an outsider’s perspective, governments wanting to reduce the unsustainable growth of health budgets should be looking at the strategic and structural impediments to better integration of primary health care, and human and community services.

To achieve real reform, we need to move beyond our attempts to re-engineer our medical and surgical system and recognise primary health care as a seperate discipline that should be playing a leadership role in the coordination of preventative health and community development measures at a local level.

We should also be looking to the remunerative structures that will attract the best and brightest to the critical work of reducing the burden of disease, rather than continuing to contribute to the escalating costs of treating disease which threatens to consume ever-increasing amounts of the State budget.

Rural and remote communities are the perfect place to explore new models of health and human development and care. Over the past four decades we have withdrawn all the elements that make rural hospitals, hospitals (maternity units, surgical wards etc). We have centralised many human and social services in large cities for administrative efficiency, coring out the layer of professionals required to create attractive places for people to live and work. There is an opportunity to start our journey of reconceptualising health and human care with a focus on integrated community development and wellbeing In rural and remote Australia.

For more information contact Mark Burdack, CEO of The Healthy Communities Foundation Australia (THCFA) on 0418974988.



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