Would you get into an aeroplane with a faulty navigation system?
In 2015, the OECD Health Care Quality Review of Australia baldly stated: “Australia’s health system is too complex for patients” because of fragmentation and poor coordination. This report also indicated that such systems are susceptible to medical errors. Navigating fragmented health systems burdens health consumers who access care from different healthcare providers in multiple locations. The concentration of specialist services in capital cities further burdens people who live in regional and remote Australia. Given that about 50% of Australians have at least one chronic condition, navigating multiple health services is a common problem.
… about 50% of Australians have at least one chronic condition
The very nature of our health system, with a mix of public and private funders, primary care, hospital services, aged care services, and allied health, mainly working independently of each other, is problematic, particularly for those of us living with chronic conditions who need more integrated care.
Information sharing and clear and complete cross-sector communication are key to effective navigation. When traveling on an aeroplane you expect that the navigation system is sophisticated, reliable, always connected and you as the passenger usually don’t have to worry about the pilot and crew having enough information to take you where you need to go and land safely. If we suspected that the navigation system would cut out once we left Australian borders, we would never fly overseas! Yet sharing health records across state borders is a significant impediment for people who have no choice but to access needed care in another state or territory.
…. sharing health records across state borders is a significant impediment for people who have no choice but to access needed care in another state or territory.
Communication and information sharing among clinicians still often happens by emailed letters or worse, posted or faxed letters or documentation. Even when electronic health records are available, separate data platforms make sharing information difficult. This is risky, and sometimes leads to care decision-making based on less than complete health information, repeated tests and investigations, with additional burden and cost for consumers, and for the health system. Although 22 million of us have MyHealth Record, it contains minimal, often outdated, information and is not easily accessed by all health providers, leaving the burden of responsibility on the health consumer to keep and share their health information.
Communication and information sharing among clinicians still often happens by emailed letters or worse, posted or faxed letters or documentation
In large representative surveys co-designed with Consumers Health Forum and including over 1000 Australians in 2018 and over 5000 in 2021, about 25% of people told us they had difficulties knowing which health services to access and to which health services they were entitled. This was higher (over 30%) among people with chronic health conditions. [1] Difficulties discussing health problems fully to ensure that health professionals understood all that was needed, were also reported more commonly by people with chronic conditions. This might lead to worsening health outcomes and repeated appointments or avoidable presentations to Emergency Departments.
25% of people told us they had difficulties knowing which health services to access and to which health services they were entitled
We need to support Australians to increase their health literacy, but we also need the health system to become more fit-for-purpose to deliver person-centred, integrated and coordinated care. Although the complexity of people’s medical problems and their multimorbidities are increasing, the length of the average GP consultation has remained at approximately 15 minutes for over 20 years. [2] A quarter of an hour is often not enough to fully engage and understand patient needs and preferences, nor to establish shared care plans and coordinate interdisciplinary care. The current Medicare rebate system de-incentivises long consultations with proportionately lower rebates for long consultations. Furthermore, interdisciplinary care could be better supported by appropriately rewarding for consultations that involve multiple providers, for example when a GP and a paediatrician see a child and family at the same time.
…. interdisciplinary care could be better supported by appropriately rewarding for consultations that involve multiple providers, for example when a GP and a paediatrician see a child and family at the same time.
Although excellent models that include care navigation and integration mechanisms have emerged, access to care coordinators is not the norm in our health system. Notable examples include the Kids Guided Personalised Service (KidsGPS) developed at the Sydney Children’s Hospitals Network that provides each family with access to a care coordinator, uses interdisciplinary teams and shared care plans (also shared with the family), telehealth, and appointment coordination. [3] Through Rural KidsGPS, this model of care is being implemented across rural NSW.
Another example is the newly established HeartConnect service at Macquarie University’s MQHealth that provides a rapid referral pathway from local GP practices to specialist cardiologists at MQHealth. Patients get appointments within days rather than weeks or months, and all needed tests are usually done on the same day, reducing the burden on patients whilst improving communication between GPs and specialist cardiologists.
The Western Sydney Integrated Care Program, another case example, includes care facilitators who help patients to navigate hospital services whilst closely linking with the GP. [4] The Western Sydney Health Collective also strives to provide patient-centred integrated care pathways and services.
These programs, and others, are showing promising results but they require long term support and investment from government to embed them into the very fabric of our health system rather than remaining “notable examples” of excellent care.
These programs, and others, are showing promising results but they require long term support and investment from government to embed them into the very fabric of our health system
The care navigator role is becoming established in the mainstream of health systems in the United Kingdom and Canada. The role of “care navigator” or ”care facilitator” is largely unrecognised in our healthcare system, although such functions are increasingly valued to support appropriate access to care, prevent complications and optimise care pathways.
The role of “care navigator” or ”care facilitator” is largely unrecognised in our healthcare system, although such functions are increasingly valued to support appropriate access to care,
Increasingly, social prescribing programs are being adopted, where a care navigator works with an individual to determine needs and to link them with services in the community. [5] This approach recognises that to maintain wellbeing, not all care needs to be delivered by a doctor or health professional. Such programs also reduce burden on medical services.
Our research has shown that although most people are confident that they would get care of high quality if they were to become seriously ill, over 40% of people with chronic conditions in the 2018 survey were not confident that they could afford needed care. [1] Over 50% of people with chronic conditions skipped doses of prescribed medicines and almost 15% did not see a doctor when needed because of cost. Our just-released survey in 2021 of over 5000 Australians, showed similar results and a recent report from the Grattan Institute also highlights the growing out of pocket costs paid by Australian Health consumers and how to rein these in. [6]
Improving health system navigation, no matter how sophisticated, will mean little if people who need it most, can’t afford to access it. [7] We urge Australian health consumers to continue their strong advocacy for a more integrated, affordable, accessible and equitable health care system.
About the authors
Associate Professor Yvonne Zurynski, is Associate Professor, Health Systems Sustainability, leading the activities of the central coordinating unit of the NHMRC Partnership Centre for Health Systems Sustainability, at the Australian Institute of Health Innovation. She is a health services and systems researcher who conducts research for real world impact – her research has informed the development of clinical guidelines, the co-design and implementation of new models of care and informed national policy for rare chronic and complex diseases. She involves health consumers in her research as equal partners and is currently working on national projects with Consumers Health Forum of Australia and Rare Voices Australia. She is passionate about engaging health consumers in research and policy development.
Dr Louise Ellis is a Senior Research Fellow at the Australian Institute of Health Innovation, Macquarie University. She is co-lead of the Complex Systems Research Stream and Senior Research Fellow within the NHMRC Partnership Centre for Health System Sustainability. Dr Ellis has a clinical background as a registered Psychologist (>10 years), and is highly regarded for her research on complex systems and implementation science. She has particular expertise in mental health systems, safety culture and learning health systems.
Professor Jeffrey Braithwaite, is Founding Director of the Australian Institute of Health Innovation and Director of the Centre for Healthcare Resilience and Implementation Science and Professor of Health Systems Research at Macquarie University. He is Chief Investigator, NHMRC Partnership Centre for Health System Sustainability. Professor Braithwaite is a leading health services and systems researcher and implementation scientist with an international reputation for his work investigating and contributing to systems improvement. He has particular expertise in the culture and structure of acute settings, leadership, management and change in health sector organisations, quality and safety in healthcare, accreditation and surveying processes in the international context and the restructuring of health services.
References
1. Zurynski, Y., Ansell, J., Ellis, L.A., Pomare, C., Smith, C.L., Holt, J., Root, J., Gillespie, J., Wells, L. and Braithwaite, J. (2020), Accessible and affordable healthcare? Views of Australians with and without chronic conditions. Intern Med J, 51: 1060-1067. https://doi.org/10.1111/imj.15172
2. Irving G, Neves AL, Dambha-Miller H, et. al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open 2017;7:e017902. https://doi.org/10.1136/bmjopen-2017-017902
3. Breen C., Altman L., Ging J. et al. Significant reductions in tertiary hospital encounters and less travel for families after implementation of Paediatric Care Coordination in Australia. BMC Health Serv Res 18, 751 (2018). https://doi.org/10.1186/s12913-018-3553-4
4. Trankle S.A., Usherwood, T., Abbott, P. et al. Integrating health care in Australia: a qualitative evaluation. BMC Health Serv Res 19, 954 (2019). https://doi.org/10.1186/s12913-019-4780-z
5. Wells L, Morgan M, Zurynski Y. Social Prescribing Roundtable Report, November 2019. Available from: https://chf.org.au/publications/social-prescribing-roundtable-report
6. Duckett, S., Stobart, A., Lin, L., (March 2022). How to rein in rising health costs. The Conversation Media Group Ltd. Available from: https://grattan.edu.au/news/how-to-rein-in-rising-health-costs/
7. Duckett, S., Stobart, A., and Lin, L. (2022). Not so universal: How to reduce out-of-pocket healthcare payments. Grattan Institute. ISBN: 978-0-6452739-7-7 Available from: https://grattan.edu.au/wp-content/uploads/2022/03/Not-so-universal-how-to-reduce-out-of-pocket-healthcare-payments-Grattan-Report.pdf
