A 2015 international survey[i] completed by primary care doctors attempted to investigate how we care for older adults with multiple chronic conditions or with functional limitations. We often assume the Australian and New Zealand systems are similar due to the rapid exchange and closer working of our leaders and good ideas, but I would suggest that this report raises some unfortunate and perhaps unexpected differences when it comes to the care received by the most vulnerable living in these two nations. Of course if you’ve talked with a few Kiwi GPs who’ve worked here you won’t be at all surprised by some of this difference.
Key differences when it comes to the most vulnerable
Let’s be clear at the outset, any comparison of systems is complex and of limited value. For example, while New Zealand’s population and economy is smaller than Australia’s, they invest more in health per capita despite fewer doctors and fewer acute beds per head of population. However, their total population could be viewed as the equivalent of the state of Queensland while their economy is around half that of Queensland so there is a very strong pressure to do a lot with a little.
Of course, despite Australia’s larger and more diverse economy, we still have our own unique challenges that shouldn’t be underestimated. For instance, we have huge distances between health services for a more dispersed population along with the associated infrastructure challenges, and yes we at times face both Federal and State shortfalls when it comes to whole of sector collaboration and shared accountability–but what specifically is different for complex care I hear you ask? Well, this report shows that Australian GPs receive less essential communication when compared with NZ GPs, and that Australia’s care professionals may therefore be less able to coordinate complex care than even those in the USA.
Australian GPs receive less communication than NZ counterparts
For example, only 18% of the Australian GPs surveyed said that they are always notified when one of their patients is discharged from the hospital as compared with 31% in the US and 48% in NZ. This higher level of systems maturity overseas could be correlated with the fact that 65% of primary care practices in NZ also receive and review clinical outcomes data (60% of whom can benchmark or compare and learn from other leading peer practices) as compared with 35% here (and only 13% of our practices can benchmark with their peers), or 52% in the USA (37% of whom can benchmark with their peers).
Now when a vulnerable patient’s journey is further complicated, say by a diagnosis of mild to moderate depression, anxiety, or another mental illness, things can go from bad to worse pretty quickly and teams come to the fore. Of course the terms ‘transferred to…’ or ‘discharged from…’ look professional enough on patient records, reports or policy papers, but as I’m sure you know the actual experience can sometimes leave strong individuals feeling neglected at a very vulnerable time in their life. Some might not be surprised to hear, for example, that an Aboriginal patient was urgently transported to a large city from the outback and then later ‘discharged’ from the hospital to the city street dressed only in a thin hospital gown on a cool Friday night with no clothes, no money, no transport, and no friend to help. Perhaps you personally know of similar coordination examples.
‘Un-integrated care’ and ‘service provider skewed care’
Beneath these statistics are the real people sometimes left in these situations, despite the best of intentions, and let’s be clear that these patients would never refer to such treatment as ‘care’. Of course we prefer to hear about the many amazing examples of great care being provided daily in Australia and I’m not proposing more self-flagellation at all. Perhaps it is because of these examples of inconsistent care that we collect longer and longer lists of terms to distance ourselves from too lightly accepting them such as the need to focus on more quality care, pro-active care, person-centred care, or integrated care etc.?
However if we continue to adopt more and more adjectives to differentiate the good care we want to provide from the poor care or outcomes that those bad, selfish, incompetent, or untrained people don’t provide (or we collectively achieve), we could find ourselves more divided, confused[ii] and our community losing respect. Perhaps instead of resorting to distancing and shame we should develop more mechanisms to honestly discuss and practically learn from the more embarrassing instances of ‘un-integrated care’ or ‘service provider skewed care’ (implied by our other terms which inadvertently leave managers or clinicians with even more blame) so it becomes both unacceptable and extremely difficult for these events to occur again? Of course there are concepts such as fraud or professional negligence and I’m not referring to those, but I’m advocating for us to take collective responsibility that allows all people to consistently receive care from a local team of professionals who are passionate about both the care they provide as well as the care their peers, peer organisations, and interconnected planning and technical systems all enable.
Shared responsibility and greater trust
This also seems to align with the growing international view that many aspects of complex care can only be progressed through shared responsibility and greater trust and respect for each other as expressed in concepts such as ‘one team – one budget’. How can we learn from other coordination systems that seem to be well ahead of Australia? My view is we should stop relying on variable personality driven improvements (which only work until the ‘good’ clinician or unit manager or government leader etc. leaves) or politically driven improvements (election cycles do not sit well with long term change).
We need to stop blaming politicians and other groups and stop waiting for some guru to give us permission to improve things. I for one still prefer the healthcare system here (and in New Zealand) rather than most of the US models (despite their ‘islands of excellence’) so I hope this article stirs up our collective good will and competitive nature, as no Aussie I know likes to fall behind or lose. We can be world-leaders in real care coordination again. I believe there are people who seriously want to improve Australia’s complex care systems and I’m looking forward to meeting with you to discuss practical ways to achieve that together!
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[i] “2015 International Profiles of Health Care Systems” The Commonwealth Fund January 2016
[ii] One example of diverse interpretations for a single term is discussed in the ‘Health systems integration: state of the evidence’ report in the International Journal of Integrated Care 9(17), 1–11 where it was found there were 175 different definitions and concepts for the term ‘integrated care’ in use in 2009.