On the 9th November, IFIC Australia hosted a symposium at NSW Parliament House examining international evidence and experience in the organisation, funding and evaluation of integrated care. Led by Dr Apostolos Tsiachristas (Oxford University), Dr Liz Schroeder (Macquarie University), and Dr Viktoria Stein (IFIC) the symposium explored trends and approaches in the organisation of care services to improve population health and sought to put the debate in the context of the Australian reality.
The workshop was designed in the light of the Australia Government’s Productivity Commission report that recommended the need for reforms aimed at achieving more integrated and person-centred health care focused on improving population health outcomes through high-quality and more cost-effective service provision. Specifically, this report highlighted that whilst Australia ranks pretty well on many measures in comparison to other health systems, it is beginning to fail due to the many structural impediments of the system including: the lack of focus on supporting people to live well, as opposed to treating illness and those in crisis; fragmented care services that hamper the ability to co-ordinate care and services around people’s needs, leading to unnecessary costs and poor user experiences; poor data integration; and increasing health inequalities that adversely impact on vulnerable populations such as older people who are living increasingly longer years in ill-health, those living in rural communities, in low-income households, and Indigenous Australians.
Another recent report by CSIRO on the Future of Health, summarised by Dr Schroeder, has similarly advocated for a significant shift from medicalised services treating illness towards health and wellbeing management. The report pointed to similar structural weaknesses in the care system in Australia and especially to financing mechanisms that are seen as increasingly unsustainable and that require reform. The action plan highlighted in the report focused on a number of key change elements including: empowering consumers; addressing health inequalities; unlocking the value of digitised data; and supporting integration of care, especially with other sectors outside of health.
During the workshop, the experts were clear that the challenges and issues facing Australia were very similar to other countries around the world. For example, Dr Stein demonstrated that care systems internationally have largely failed to place the person at the centre of care so that they may become empowered and active participants in their own care – for example, through health literacy and supported self-management – and that a democratic deficit exists in people’s ability to be involved in the care and treatment options they require and the investment decisions that would improve health within communities. This is despite good evidence that activated, person-centred and community-centric approaches that build on a wide range of assets have proven benefits, not least because they recognise that the health system itself can only contribute to about 10% of a person’s overall quality of life. Dr Stein argued that the future will require multi-sectoral partnerships working with and within local communities to meet emerging challenges.
In terms of funding and financing, Dr Tsiachristas picked up on the CSIRO report conclusions to outline how other care systems internationally have sought to move towards a blended payment model. This supports the idea that integrated care solutions dealing with complex problems need to gravitate towards a largely capitation-based model, but with incentive payments related to, for example: improving care access; achieving quality-based care; enabling better outcomes; and stimulating innovation. In the short term, Dr Tsiachristas suggested the need in Australia for experimenting with changes in activity-based funding in hospitals to a ‘payment by results’ framework that might stimulate new ways of thinking and operating. Partial capitation in primary care to stimulate – for example, the development of community-based services focusing on health promotion would be worthwhile. In the longer term, consideration might need to be given to the ability to bring federal and state budgets together to develop joint commissioning agencies that enable new alliances to be created that help to deliver services differently through networks and teams and which focus on outcomes. These long-term thoughts dovetail with the international movement for change towards the development of integrated care systems, alliances, and ‘accountable care’ models that seek to focus as much on improving population health outcomes as on the effectiveness of the care delivery process.
Like other care systems around the world, Australia is facing the need for transformational change whilst being simultaneously constrained by existing system characteristics and dynamics. There is no magic bullet solution and the way forward is likely to require a series of incremental steps that focus on key priority areas. Rather than focusing on the usual suspects (e.g. chronic illnesses such as diabetes or heart failure) these innovations may look towards tackling ‘wicked issues’ amongst the more vulnerable populations where need is greatest, costs in care are accelerating, and where more person-centred and integrated solutions are likely to have the most positive impact on population health. More urgently, the impression I have as an ‘outsider’ to the Australian system is that many managers and care professionals working in the system do not necessarily feel any compelling need for change, in part because they focus their accountability towards their own specific aspect of care delivery rather than looking at the whole picture. Yet, it is this collective responsibility for meeting people’s complex needs that will become ever more important in the future.
Dr Nick Goodwin is the CEO and co-founder of the International Foundation for Integrated Care (IFIC)