A value-based odyssey in Australia

 

A value-based healthcare odyssey in Australia

I am freshly back in Wales having returned from a full immersion in the Australian healthcare system over the past few weeks. I have had the immense privilege of working with all parts of the system across 3 states and the federal government, talking to patients and consumers, clinicians, provider organisations, the primary health networks, policy leads, academics and politicians. Why go, you may well ask? As Australia increasingly moves towards a value-based approach supported by the Australian Healthcare and Hospital Association I had been asked by that organisation to give the keynote address at the VBHC Congress in Brisbane at the end of October. I have been struck by the similarity in approach to Value in Health in Australia to that of ours in Wales and much of the rest of Europe. Value in health is about striving to achieve the outcomes that matter to people and to promoting sustainability in healthcare systems around the world (finance, carbon, workforce). We are all facing the same challenges of rising costs, depleted and demoralised workforce, increased complexity and multi-morbidity in our patients, outdated system and care process design that fails to meet current need, and inequitable outcomes. Making progress against these challenges requires multiple systemic interventions through a collaborative approach. Collaboration was a theme that came up again and again at the Congress and afterwards – the need for a multi-professional approach to problem-solving in organisations and cross-sectoral collaboration to build better health in our communities irrespective of age, socio-economic status or ethnicity. This is espoused in legislation in Wales through the Wellbeing of Future Generations Act but there is still much to do to make this a reality.

Value-based healthcare, value in health, outcomes-focused healthcare – whatever we want to call it -  is not a methodology or a dogma. It is not quality improvement or cost effectiveness alone, though these things are a part of it and contribute to the overall picture of value for individuals and for society as a whole. Value-based healthcare is a cultural shift in mindset, a lens through which we can take a whole system view and begin to tackle some of our entrenched problems.

And so what are the multiple interventions and considerations that we have talked about in these past few weeks?

Prevention and supported self-management

Health has to be co-produced and healthcare is a contact sport. We will not improve health outcomes in our societies if we do not understand what patients and consumers need to be able to look after their own health, provide the core conditions for healthy living, and to be supported in managing chronic illness. Therefore a strong focus on prevention and investment in strategies for supported self-management is required. This is inexpensive but doesn’t happen by accident or automatically. We need to design it with our communities and be creative in our approaches. As more and more of us will live a long time with chronic conditions, benefiting from new treatments to extend life, we need to understand how to live our best lives when we are home. This is to maximise quality of life and reduce the incidence of acute exacerbations of illness requiring emergency intervention. It also supports reform of outdated models of outpatient care that are bad for patient experience, bad for workforce and consume more carbon. I met an inspirational group of people tackling really extreme challenges with creative and collaborative approaches to healthcare delivery when I visited Mount Isa, a remote mining town in NW Queensland which had just received the news of a forthcoming partial closure of the mine when I arrived. Many of the communities under the jurisdiction of the North West Queensland Primary Health Network have no routine access to a general practitioner and rely on periodic visits from the primary care team in the Royal Flying Doctor Service who do a sterling job in difficult circumstances. Lack of access to a GP in Australia also means lack of access to Medicare reimbursement and so people incur significant out of pocket costs. Care is fragmented, with no single healthcare provider holding a complete patient record. Prevalence of chronic diseases such as diabetes, hypertension and mental ill health are very high. Life expectancy for a person of aboriginal descent in the Western Corridor is 52 and it is 54 for white Australians living in this extremely remote location. Attempting to understand the vast distances involved here required me to re-calibrate my definition of rural healthcare. At the Congress, we heard powerful testimony on these inequalities from gynaecologist Alicia Veasey. This made a big impression on me.

To overcome these extreme challenges, the PHN in NW Queensland have devised an approach called Healthy Outback Communities which won an award at the Congress. Led by the wonderful Sandy, this is a framework of healthcare co-created with communities to both build health and manage chronic ill health in remote locations. I was struck by the creative ‘think outside the box’ solutions that they were considering. Here in this remote place, necessity has become the mother of invention. It has fostered collaboration between the Primary Health Network, Royal Flying Doctor Service and all other organisations delivering not for profit care in Queensland where under other circumstances competition between them for funding may have put them at odds. They were united in their common purpose to improve the situation in NW Queensland and were prepared to start with a blank sheet of paper.

 

Person-centred care alongside standardised pathways of care

One of the questions that came up quite a bit during the Congress and subsequent discussions was about the relationship between standardised pathways of care and a person-centred and more tailored approach.

Person-centred care has been described in a number of ways over the years but I think it is helpful to use the definition originally included in David Sackett’s definition of evidence-based medicine:

‘Evidence-based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research. The patient brings to the encounter his or her own personal preferences and unique concerns, expectations, and values.’

I think it is important to make this explicit link because over the last 25 years we have used evidence-based approaches to create multiple treatment guidelines, protocols and pathways of care. Standardising care processes in this way is useful and legitimate in raising quality standards and efficiency, 2 key components of value in health. It is also legitimate to monitor unwarranted variation against those pathways and reduce low value care (care that does not improve the outcome and is therefore of no value to the patient). But it is insufficient in tackling what matters to individuals and therefore we have a responsibility to ensure that we are tailoring that evidence to the goals and preferences of each individual. In Australia, I saw fantastic work in progress from oncologists Katharine See and Christobel Saunders in Melbourne who are using patient-reported outcomes to guide conversation about what matters to people living with cancer. There was also fantastic advocacy from Monique Bareham in the field of lymphoedema, an area where we have seen significant progress towards better outcomes led by Mel Thomas and the lymphoedema network.

 

 

Sustainability of healthcare systems

Unsurprisingly another key topic for discussion was the resourcing and sustainability of healthcare systems in the broadest sense – finance, workforce, carbon reduction, and so on.

We see a growing workforce crisis in healthcare professionals in Wales and this was also true in Australia. The impact of this may manifest itself in different ways but the ultimate result is that there is inequitable access to care for certain demographic groups or remote geographical regions. Particular emphasis needs to be placed on this issue to ensure that we can close the gap on health inequalities and funding models must support new approaches to tackle it, as we saw in Mount Isa.

We know in the developed world that we have a population with a very different set of needs than were present when our healthcare systems were designed. We have a growing burden of disease and long term ill health from chronic conditions and growing complexity through multi-morbidity. Even if we had all the money in the world we simply do not have the workforce to meet these supportive needs so we must think innovatively about new models of care and appropriate skill mix to maximise the capacity and impact of our healthcare professionals. Strong and cohesive clinical leadership is needed. There was much talk about achieving the correct balance between generalism and specialism in healthcare delivery. This is important because generalists hold the ring for a patient, support care navigation through a complex array of guidelines and pathways (sometimes competing), and guard against ‘too much medicine’. As we age in multimorbidity, this is something of a crisis.

Palliative care is important to outcome as intention to cure but often we find it difficult to broach this discussion with patients, especially in non-malignant disease. As Australia has now started implementing its legislation on Voluntary Assisted Dying, tackling this issue becomes even more pressing as, surely, everyone who opts for VAD as a choice should have had access to high quality palliative care services first.

And what about funding models? Who has the best system? The truth is that all healthcare systems are financially unsustainable in their current form. Beyond existential questions about what healthcare is for and how much we are willing to pay as a society and as individuals, there are differing perspectives on how best to pay for healthcare. We talked a lot about this in Australia and an in depth analysis is outside the scope of this initial reflection, but suffice to say that there is no perfect funding mechanism for healthcare and a range of approaches and incentives are likely to be needed if we are to tackle inequalities in health and sustainability on the broadest sense. Every model has a potential for unintended consequences but there is a general consensus that ‘fee for service’ does not guarantee outcome and therefore value, having a greater propensity also for driving low value care. In Australia, the consequences of current funding models mean that general practice is struggling, inequity is growing and patients are facing greater and greater out of pocket expenses. In Wales, general practice is struggling, hospitals are struggling and we are spreading an ever thinner layer of jam across our toast.

A theme that came up time and again was frustration about the need for longer funding cycles so that real change could be achieved along with more flexibility of funding mechanisms to support innovative new models of care. However, I sensed a real willingness politically in state and federal governments to try new ways of working.

 

 

Data and digital infrastructure

One of the key underpinning requirements for value-based healthcare is good data to drive our decision-making. This includes the collection and use in practice of patient-reported outcome measures but equally important is the triangulation of clinical outcome data points with costing and process data. Actionable information is important to everybody and so an attention to data issues and interoperability will always be a cornerstone of value-based healthcare. We also discussed the usability of digital systems from the perspective of patients and clinicians, given the importance of digital technologies in supporting new models of care and supported self-management strategies. In Australia, fragmentation of healthcare providers is a big barrier to getting a common view of outcome data across the states and support integration of care processes across the whole pathway but this is not an insurmountable barrier. Despite the existence of integrated health boards in Wales we see similar problems here. This is why strong policy drivers in the digital and data arena are critical with an adherence to nationally agreed data standards and data sharing agreements. In Melbourne I had the privilege of facilitating a session with the Primary Health Networks and Health Services Partnerships of Victoria where I saw a real will to collaborate and overcome these issues. Similarly in an academic/provider forum in the Australian Capital Territory in Canberra. I will watch their progress with interest.

In conclusion

And so here is a very brief summary of some of the issues that came up on my trip. I was struck by the fact that despite our very different contexts we are all facing the same challenges, albeit in different manifestations, and I look forward to taking aspects of this work forwards between our two systems.

I did not see a single spider (phew!) and I have completely recalibrated my definition of rural and remote healthcare…Powys is a metropolis.