Australia’s Health

System:

Opportunities and

Challenges26 October 2015

Rosemary Calder AMDirector

The challenges we know well: chronic

diseases

• The predominant causes of illness, premature mortality and health system utilisation

• High personal, family and community costs

• Reduce workforce participation and productivity for the individual and for their primary carer

• Have a major adverse impact on Australia’s economic prosperity with significant direct and indirect costs

• ‘If chronic disease was eliminated, the full-time workforce and hence productivity could increase by 10%’ (Business Council of Australia, 2011)

The risk factors we know well

• Shared amongst several chronic diseases

• Huge cost savings when addressing these 6:

Smoking

High risk alcohol use

Physical inactivity

Obesity

Inadequate diet

Intimate partner violence

1981 Australia becomes a signatory to the Health for All by the Year 2000 Agreement

1985 Better Health Commission established

1986 Better Health Commission and Looking forward to better health report

1986 WHO Health For All 2nd international conference

1988 Health for All Committee release Health for all Australians report

1993 Goals and targets for Australia’s Health in the Year 2000 and beyond released

1994 AHMAC release Better Health Outcomes for Australians report

1996 National Health Priority Areas agreed by Australian health ministers

1997 First report on National Health Priority Areas

2006 Australian Better Health Initiative

2008 National Partnership Agreement on Preventive Health and establishment of the

National Preventative Health Taskforce

2009 Australia: The healthiest Country by 2020 released

2011 Australian National Preventive Health Agency (ANPHA) established

2014 ANPHA closed and its functions transferred to the Department of Health

2014 Commonwealth pulls out of National Healthcare Agreements

2014 National Diabetes Strategy due

1981 Australia becomes a signatory to the Health for All by the Year 2000 Agreement

1985 Better Health Commission established

1986 Better Health Commission and Looking forward to better health report

1986 WHO Health For All 2nd international conference

1988 Health for All Committee release Health for all Australians report

1993 Goals and targets for Australia’s Health in the Year 2000 and beyond released

1994 AHMAC release Better Health Outcomes for Australians report

1996 National Health Priority Areas agreed by Australian health ministers

1997 First report on National Health Priority Areas

2006 Australian Better Health Initiative

2008 National Partnership Agreement on Preventive Health and establishment of the

National Preventative Health Taskforce

2009 Australia: The healthiest Country by 2020 released

2011 Australian National Preventive Health Agency (ANPHA) established

2014 Commonwealth terminates National Healthcare Agreements

2014 ANPHA closed and its functions transferred to the Department of Health

2014 National Diabetes Strategy due

Australian population health initiatives

Yet, against this backdrop, the prevalence and

burden of chronic diseases has continued to rise

1.0

1.5

2.0

2.5

3.0

3.5

4.0Diabetes Mellitus%

2

4

6

8

10

12

14Mental and Behavioural Problems%

Workforce participationIncreasing chronic disease is associated with decreasing workforce participation

Health ‘system’ costs

• The proportion of health expenditure devoted to hospital care in Australia increased from 38% in 2003 to 40.4% in 2011.

• Other like countries-Canada, Germany, Netherlands, spend less on hospital care

• Australia makes a relatively low investment in public health

• Life expectancy is increasing, but so too is the burden and prevalence of chronic diseases.

Australian health system structure & funding

Health system development

Re-engineering is needed to build an effective ‘system’

• Primary care

• Integrated care

• Funding

• E-health

• Acute care

Whose responsibility?

Historically, Australian governments have

not been required to answer for their

performance in relation to prevention of

chronic diseases.

There is no regular reporting against

national chronic disease prevention

targets, and indeed, there are no agreed

targets.

Accountability Framework

International

Comparisons

From the OECD

Australian National Preventive

Health Agency (ANPHA). State of

Preventive Health 2013. Report to

the Australian Government Minister

for Health. Canberra; ANPHA, 2013

Voluntary global targets for prevention and

control of noncommunicable diseases by 2025

AHPC Baseline report

Looks at the publicly available Australian data relevant to the 25x25:

• Identifies gaps

• Outlines trends where possible

0

2

4

6

8

10

12

2001 2004-05 2007-08 2011-12 2015-16 2019-20 2023-24

% P

rop

ort

ion

Year

Prevalence of Hypertensive Disease (age 18+)

18+ (Age-standardised)

2010 Baseline

WHO Target

9.0%

6.8%

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

2001 2004-05 2007-08 2011-12 2015-16 2019-20 2023-24

% P

rop

ort

ion

Year

Prevalence of Diabetes Mellitus (age 18+)

All Ages (Age-standardised)

2010 Baseline and WHO Target

3.8%

Examples of effective and cost-effective interventions

that have been implemented successfully in other

countries include:

• Salt reduction in the United Kingdom

• Taxation on sugar-sweetened beverages in Mexico,

Denmark, Finland, Hungary, France

• Early detection (Integrated health check (Diabetes,

Chronic Kidney Disease, Cardiovascular Disease))

Q:What are other countries doing that we are not?

A: Plenty

‘Achieving realistic targets in the prevention of

behavioural risk factors has implications beyond

health and is a core outcome for the whole of

government…As the report highlights, we are all

beneficiaries when it comes to reducing the

prevalence of these six behavioural risk factors’

- Cadilhac et al., 2009, The health and economic benefits of reducing disease risk

factors, Melbourne: Deakin University & National Stroke Research Institute.

Australia needs to act on prevention

AHPC National Targets & Indicators Work

• Seven working groups (morbidity/high risk, alcohol, physical inactivity, salt, tobacco, diabetes & obesity, mental illness

• Starting with, but not limited to, the WHO 25 x 25 and WHO Global Mental Health Plan T&I

• Selecting indicators based on criteria from AIHW

• Each group will produce a short report, and these will form the basis for a larger report

• Forum in Melbourne on November 25

“It is not that there is not enough data, not

enough information and not enough knowledge

as a basis for addressing the prevention and

control of NCD. The problem has been how to

raise the issue to a high enough level in the

political agenda and maintain it there, as

without that there will be no material progress.”

Sir George Alleyne, 2011

Prevention

This is not novel -

In the words of John Lennon, Imagine

It is 1965: For the first time, the number of annual road deaths in Australia

exceeds 3,000 people. There has been a 50 per cent increase over the past

decade associated with rising rates of car ownership. In the United States

(US), Ralph Nader does not publish his ground-breaking book, Unsafe at any

speed. The concept of designing in safety does not come into existence and

the car industry of the future does not invest in head restraints, airbags and

crumple zones.

It is 1969: The Royal Australasian College of Surgeons does not establish a

Road Trauma Committee. Road deaths and injuries are viewed as inevitable

‘accidents’, rather than as a preventable public health problem. Orthopaedic

surgeons have instead pioneered new approaches to treating the victims of

road accidents. There is a severe shortage of orthopaedic surgeons.

In the words of John Lennon, imagine

It is 1987: The Victorian Government does not establish the Transport

Accident Commission. Innovative road safety educational campaigns (If

you drink then drive, you’re a bloody idiot; Don’t fool yourself, speed kills;

and Knock off five) are not created. ….

It is 2001: Reduced speed limits for roads near schools are not introduced.

Governments argue that parents and children need to take responsibility

for their behaviours and not put themselves in danger.

It is 2014: The number of road deaths and injuries has kept pace with

population growth and car ownership. Every public and private hospital

now has its own road trauma ward and most communities have

rehabilitation hospitals. Shares in private sector companies that provide

wheelchairs, aids and appliances represent blue chip investments.

Policies in an

interconnected

network

Source: Hawkes C, Smith TG, Jewell J, et al. Smart food policies for obesity prevention. Lancet 2015

Primary Health Networks: the

challenge

• PHNs have replaced Medicare Locals that were only a few years old

• Other reviews will affect primary care directly or indirectly (MBS Review; Primary Health Care Advisory Group; Mental Health Review).

• PHNs need the opportunity to get established and serve their populations for a period of at least several years. Constant organisational change is in nobody’s interest.

• For the health system to perform well, strong and stable partnerships are needed across different parts of the system.

PHNs & chronic diseases: the

opportunity

Better prevention and management of chronic

diseases is essential

We should invest early, prior to the onset of illness,

and before health services are needed

Risk factors for chronic disease, such as obesity, are

at high levels and increasing

PHNs will have commissioning capacity – the

opportunity to build partnerships and focus

Integrated care & chronic diseases

• The challenges in prevention of avertable chronic

diseases and their impacts:

‘system’ capacity for effective management of

multiple chronic conditions over time and across

disciplines

‘system’ needs to be easy to access and use

equity of access using risk factors

promotion of self-management by consumers

What is integrated care?

• macro level: providers deliver integrated care across all services to the population they serve

• meso level : providers deliver integrated care for a particular group of consumers with the same disease or condition

• micro level: providers deliver integrated care for individual service users and their carers through care coordination and other approaches

The King’s Fund 2011

PHNs: the opportunities

• Improved care coordination and a focus on those at

risk of poor health outcomes are explicitly part of

PHN objectives

• High needs groups and high users of the system

• Meso integration: use of care pathways

• Micro integration: Integrated care service models,

care coordination

PHNs: the opportunities

Macro level integration:

• collaborative leadership and influence

• State/territory approaches

• Coordinated approach to population health analysis

and planning

• Potential links of PHN KPIs and population health

indicators

A Population Health System

Integrated Care

Coordination of care services for defined groups of people, including

people with multimorbidities

Population Health

Improving health across whole population via

multiple interventions

across system

Individual Care Management

Care for sick people or at risk of becoming sick

and requiring services

Health Improvement is Everyone’s Business

Using all service contacts with patients

and citizens in all settings, i.e. schools and workplaces to undertake health

promotion

Populations

Unit of

Intervention

Individuals

Care Services Focus of Intervention Health Improvement

Primary and integrated care – our

opportunity and challenge

The cornerstone of an effective health system