None of the “wicked’ problems in health – obesity, mental illness and suicide, chronic illness, ageing – will be solved with just hospitals, doctors, nurses and prescription pads. They all require resources beyond those provided by the health care system. That’s not news; there are very few health professionals who deny the impact of the social determinants of health on health outcomes and health care costs and the importance of linking into social services. The challenge is how to achieve this. In essence – how do we move the focus from general practice and primary care to primary health care? (There is a difference: see Primary care vs Primary health care: and who cares?)
Forty years after the world leaders and health experts at the 1978 International Conference on Primary Health Care endorsed the Alma-Ata Declaration (which identifies primary health care as the foundation for integrating health and social services and the cornerstone of sustainable and equitable health systems), delivering effective primary health care services remains an international dilemma for both developed and developing countries. These issues will top the agendas at two major upcoming conferences, the Global Conference on Primary Health Care in October in in Astana, Kazakhstan, and the 4th People’s Health Assembly in November in Savar, Bangladesh.
For Australia to move in this direction will require changes in how the health care and social care systems are structured, resourced and funded, an increased focus on public health and prevention, and – crucially – changes in attitudes and culture on the part of providers, funders and patients. Where are the exemplars of how this can be done?
In England a single government department and minister is now responsible for strategic leadership and funding for both health and social care. Integration of these services has been a policy goal of successive United Kingdom governments for over forty years, but overall progress has been patchy and limited. The take-out here is that simply bundling health and social services together under the same rubric does not make the sum greater than the parts. The Social Care Institute for Excellence has produced a report that outlines what an integrated health and social care should look like in 2020. Progress towards that goal is complicated by a fragmented regulatory landscape and the fact that for many years both the National Health Service and the care system have been funded at austerity levels. These are lessons Australia must recognise.
The Federally Qualified Community Health Centers in the United States provide an authentic model of primary health care. Their cost-effectiveness in addressing health inequalities in ways that are culturally sensitive, while simultaneously providing economic benefits for the surrounding communities, is backed by decades of data and analyses. In Australia the Aboriginal Community Controlled Health Services come closest to this model – and could do even better if resources were not so constrained. The ACCHS model has been found to be effective in improving the health of Indigenous peoples through providing quality health care, addressing the social determinants of health, and adding value to the broader health system.
What are the initial steps Australia must take? First, the data must be developed and presented to convince politicians, policy makers and stakeholders (especially those who currently zealously guard their professional turf) of the value of undertaking these reforms. At the same time, expectations should not be raised of immediate cost savings. Given the current levels of health disparities and unmet need for access to affordable medical and aged care, mental health and disability services, and care coordination, it will take time to see the return on investments, which is how these reforms must be regarded.
The US-based Commonwealth Fund has developed two Return on Investment (RoI) tools: one for assessing the risks and rewards of integrating social services with health care services and how these partnerships might be structured in an equitable way; and another for partnerships to address the Social Determinants of Health such as nutrition support, transportation, home modifications, housing, care management and legal, financial and social support counselling. Much of this work is underpinned by a 2014 paper Addressing patients’ social needs: an emerging business case for provider investment which explores the impact of social factors on health and health care costs. Australia has been a laggard in such modelling and evaluation, but these must become an essential part of health care reforms.
A second key issue to be addressed is the failure of successive governments to allocate the appropriate resources to public health and prevention. Australia currently spends less than 1.5 percent of all health spending (about $2 billion a year) on this. Yet there is clear Australian evidence (from the 2010 Assessing Cost Effectiveness in Prevention (ACE-Prevention) study) of the preventive health interventions that are cost-effective, reduce pressure on clinical services and help people live in good health for longer.
Thirdly, there is the issue of the necessary changes in perspectives and culture. A recent opinion piece in the Journal of the American Medical Association makes the case that the transition to primary health care requires a reworking and expansion of relationships within the health care system. It starts by putting the patient (the person, not the diagnosis) at the centre of care; this means using human and technological resources differently and will require health and social care teams in both primary and acute care. This will inevitably mean a flattening out of the predominant doctor-led team model. In particular, community health workers must be seen as a crucial link between communities and the primary health care system, providing a continuum across multiple points of care and having positions of trust based on their understanding of health challenges faced by individuals and communities.
At issue is how to ensure that clinicians both recognise and ensure a timely response to the social issues affecting the health and health outcomes of their patients. It is not the job of clinicians to address the need for safe housing, transportation, nutrition, protection from family or community violence, sanitation, criminal justice involvement or unemployment and poverty. But there must be the ability to make an instant referral to someone who can address these issues, and for the social system to be appropriately responsive.
Inevitably, that brings up the issues of incentives, barriers and facilitators and funding models. There is no one way to solve these difficult and contentious problems, but all solutions will require a shared long-term vision and leadership, backed by adequate funding and workforce, and communication and information-sharing across agencies.
Daunting and difficult as the task of transforming general practice into primary health care may be, it is necessary if Australia is to have a health system that is fit for purpose in the 21st century. There is no need to wait for ‘big bang’ reforms and restructures imposed from the top down – although ultimately these must come. Better that it starts from the bottom up and the lessons learned inform the system-wide changes.
The good news is process has already started, with innumerable small pockets of innovation around the nation that reflect local needs and local leadership and consequently have local ownership. For example, the health clinic at the Sydney Asylum Seekers Centre offers not just a wide range of health and health care services, but legal and financial support for accommodation, employment assistance and nutritional, educational and social support.
Examples such as these should serve as the basis for the way forward. They show that, even with current roadblocks such as the federal/state divide, Medicare reimbursements that are inadequate or lacking, and siloed medical and social services, successes can be achieved and bridges between health care and social care can be built.
Dr Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney. She has served as a senior policy advisor on health in the Australian Parliament, the US Congress and the Obama Administration.