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As part of Guardian Australia’s series on the decline of bulk billing, we asked six experts from different areas how to fix our healthcare system so that more people can access timely and affordable care.
1. Rethink the role of nurses
True equity of access in community and primary healthcare will only be achieved by the full deployment of nurses.
There are about 89,000 nurses, nurse practitioners (NPs) and midwives working in rural and remote, Indigenous, maternal, child, family and mental health across Australia.
Nurse practitioners – who have the ability to prescribe medications and write referrals, much like a GP – are well established and completely safe, and have proven to be over the past 20 years in the public sector in Australia. Yet they are constrained from working to their full scope by both protocols and funding models.
They do not fragment care, as some have suggested, nor are they in competition with other health professionals, because in many of these areas nobody else is there.
Privately practising nurse practitioners, mental health nurses and midwives in particular have demonstrated their ability to address the needs of under-served patients. But they need appropriate access and funding to enable prescribing, diagnostics and referrals so they can to be able to fully serve the communities for which they care.
2. Put more emphasis on preventive care
If the system is to be truly patient-centred, then the focus must be on patients’ needs – and specifically on affordable and timely access to preventive services, treatment and care.
Key areas for reform include workforce expansion, planning and incentives to encourage healthcare workers to under-served areas; and funding to facilitate teamwork and integrated care across community-based, acute and sub-acute services. These should recognise the costs of care management, which is currently unfunded.
There also needs to be bundled payments for the care of people with chronic and complex conditions, using patient-centred medical homes; and publicly funded specialist and allied health clinics – attached to hospitals where feasible – with minimal out-of-pocket costs.
But nothing important will happen unless and until there are significant changes in clinical cultures. Political and clinical leaders must work together to tackle these “wicked” problems.
3. Understand that poverty is a health issue
Primary healthcare in Australia is an impenetrable, unnecessarily complex and expensive system that fails to provide care and support for some of the most marginalised groups in society. The system entrenches inequality and provides interventions that fail to get to the cause.
Quality of care should not be dependent on where you live, where you are from and how much you earn, but that is in essence the basis of our system. Consecutive governments have failed to follow through on their promises for reform.
Addressing issues like poverty, secure employment and housing, access to education, discrimination and risk of violence are central to good health. Yet our system centres GPs above all, providing a very individualistic and highly medical approach to complex and intersecting issues. The system has such a narrow understanding of health.
There are some great initiatives where primary health is seen as a person-centred, collaborative approach between the client and a range of professionals. Tragically, it is still somewhat of a revolutionary idea that good health is more than physical health, and until we address this we will see little change.
4. Address disability competency
The health of people with disability is on average much worse than people without and they are more likely to have complex needs that necessitate a range of health and disability supports. Assistance to coordinate these supports is essential.
Improving the coordination of primary care through GP-led teams should be essential to reforms. People with disability are much more likely to be living in poverty than those without so are less able to pay for services. Data also shows that people with disability experience greater barriers to care than others.
Barriers come from poverty, but also inaccessibility of services. This does not just relate to physical accessibility, but communication accessibility and inclusive practice.
The disability royal commission showed that many health practitioners are not confident to work with people with disability because health curricula often leave disability competencies to chance. Reforms must therefore increase the disability competency of primary care physicians to improve health outcomes for people with disability.
5. Take mental health seriously
Mental health problems, including eating disorders, often manifest in self-harm and suicide. Although young people who self-harm do not necessarily mean to take their life, this behaviour can also be highly dangerous.
To reduce the physical, psychological, social and economic burden of eating disorders, self-harm and suicide, more effective interventions are urgently needed, These should incorporate users of health services and people with lived experience in the co-design of changes and national, regional and local implementation.
Funding models need to recognise and support multidisciplinary team-based care, including the distinct role of social workers, digital innovations, and the continued development of primary healthcare workforces in areas such as culturally safe care for Aboriginal and Torres Strait Islander people.
6. Improve access for Indigenous children
At present there is virtually no access to a range of essential primary healthcare services other than medical care for many Aboriginal and Torres Strait islander children.
These include dental care, which impact nutrition at a time when it is critical for growth, respiratory problems, recurrent pneumonia and heart disease – including rheumatic heart disease. It remains one of our nation’s great shames that this preventable disease of poverty continues in Aboriginal and Torres Strait islander communities.
Too many Aboriginal and Torres Strait islander children also enter school with untreated serious hearing disabilities and are subsequently categorised with behavioural problems.
In Aboriginal and Torres Strait Islander health we have always used a broader definition of health that includes social, emotional and cultural wellbeing of the whole community. It is critical to have trauma-informed, family-centred services that parents can trust and where there is a relationship and sense of safety. Community-controlled health services and Aboriginal health workers are crucial too.
Obstacles include financial barriers, travel costs and logistics and waiting times – a particular issue for busy parents with other kids at home and school.
There can also be less obvious barriers such as families not feeling culturally safe, feeling shamed during care visits, or fearing being judged a “bad parent” and the child being removed – which is an ever-present threat and fear for too many Aboriginal and Torres Strait Islander families.
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