Trying to identify just five top priorities in an area as complex and ethically fraught as health care is a tough challenge, but that was the task Australian Medicine set for seven of the nation’s leading health advocates and thinkers, including AMA President Dr Steve Hambleton, the nation’s Chief Medical Officer Professor Chris Baggoley, health policy expert Dr Lesley Russell and World Medical Association Council chair Dr Mukesh Haikerwal. Here they provide their thought-provoking and insightful responses.

AMA President Dr Steve Hambleton

1.  Make population health a cross-portfolio priority for all levels of government
Population health is not just about treating illness. It’s also about keeping people well, and all portfolios (Agriculture, Defence, Education, Employment, Environment, Finance, Foreign Affairs and Trade, Health, Immigration and Border Protection, Industry, Infrastructure and Regional Development, Social Services, Treasury etc) need to do their part to fight the threat of non-communicable diseases which stem from tobacco, alcohol, over-nutrition and under- exercise.

2. Continue the investment in closing the life expectancy gap between Aboriginal and Torres Strait Islander peoples and all Australians
All governments need to keep up the investment, but not just in the health portfolio. There is stark evidence that investing in the social determinants of health and a good education, starting at birth, are major predictors of health outcomes.

3. Fix e-health and the PCEHR
We must be able to talk to each other in the same language -general practice, hospitals (public and private), public outpatients, private specialists, aged and community care. Too often the right message just does not get through. Let’s get the (e) rail gauge right and use it.

4. Reduce unwarranted clinical variation
The fastest way to save health dollars and achieve better outcomes is to (as Professor Lord Ari Darzi advised at the 2012 AMA National Conference) “close the gap between what we know and what we do”.  We know we are doing a good job and are very cost effective. If we embrace the move of learned colleges toward clinical audit and self-reflection we can make best practice even better.

5. Invest in research
The human papillomavirus vaccine will save millions of lives. Research delivered and refined the place of statins, also saving millions of lives. We need new ways of treating infections, perhaps more antibiotics or better ways to use the ones we already have.

Professor Chris Baggoley, Australian Government Chief Medical Officer

It is not easy to nominate five priority areas for action, given that there are so many deserving areas that require our ongoing attention. Of course, in my role there are a number of areas where my direct involvement is needed to help made a difference.
Understanding that this list excludes other equally deserving priority areas, my list is:
1. Antimicrobial Resistance, where concerns we are facing a post antibiotic era are widely shared across the globe. Australia is taking a leading role: we have adopted a One Health approach, a safety and quality approach (via the National Standards), and we are increasing our surveillance of resistant microbes and antimicrobial usage.

2. Emerging Infectious Diseases. The appearance of avian influenza H7N9 in China in 2013, and the Middle East Respiratory Syndrome Coronavirus in 2012-13, has redoubled the focus of all areas of the health system to prepare to manage emerging infectious diseases, and this must remain a focus for 2014.

3. Immunisation coverage. Public interest in the benefits of high levels of childhood immunisation was a particular feature of 2013, especially following the National Health Performance Authority report breaking coverage down to Medicare Local and postcode areas. Vaccine-preventable diseases should be prevented, and our attention to this aspect of health care in all areas must remain a priority.

4. Dementia. While the first three areas are part of my daily work, this is not the case for dementia. Nonetheless, the case for research into the causes and prevention of dementia is apparent to all of us.

5. Improving the nation’s mental health. Much work is underway to improve our mental health. Improved community and professional understanding and reduction in stigma will assist sufferers of mental health illness to seek help, and assist their recovery.

Dr Lesley Russell, Visiting Fellow, Australian Primary Health Care Research Institute, Australian National University

National

1. Addressing health disparities

Prime among these is the need to Close the Gap on health disparities for Indigenous Australians, but we should not forget the disparities suffered by people with mental illness, people with disabilities, the homeless, and those who are isolated, both geographically and socially. These gaps will only be closed by a broader focus on the social determinants of health through a whole-of-government approach.

2. Changing the way we pay for healthcare services

It’s time to move away from fee-for-service to a financing system that is (1) focused on value rather than volume; (2) rewards improved health outcomes and cognitive services as much as procedures; (3) encourages effective teamwork and collaboration; and (4) recognises time dedicated to education, mentoring, research, essential paperwork and communication.

3. Reworking the healthcare workforce

If we are to address the health and healthcare needs of the 21st century in a country as large and diverse as Australia, then we need an appropriate workforce and a system that enables every healthcare profession to work to full scope of practice. That means widening who can prescribe and who can work independently. The new workforce must include more Aboriginal and Community Health Workers to assist with outreach, education, care coordination and cultural sensitivity.

International

4. Antibiotic resistance

The growing threat of multiple resistance requires a major international effort involving the agriculture, food and health sectors and an increased focus on research to deliver solutions and new antibiotics.

5. Climate change

Everyone’s way of life and even national security is under threat from climate change. Developed nations like Australia must show leadership in tackling both the causes and the impacts. In the absence of government action, communities must step in to lead the way.

Professor Stephen Leeder, Professor of Public Health and Community Medicine, University of Sydney

1. National data collection and evaluation – the collection of national hospital safety and quality data is critical to monitoring the use of drugs and controlling the rise of drug-resistant infections. Information is also needed to track progress in preventive health, such as in addressing obesity. Repeated surveys, done by the same people using the same survey instruments, are needed to judge our progress.

2. We need to tell the story of what we are achieving in health care for the tens of billions we invest in it. The community who pays deserves to hear. Health Ministers need to enunciate what the goal of providing health care is, backed by stories that illustrate what is achieved every day in caring for people. These stories are needed to keep compassion alive in our democracy.  “Look where my Medicare tax dollar goes!” would be a great thing to boast about, and would enable ordinary taxpayers to see that their tax contributes to something of immense social value.

3. Fixing IT. We are 20 years behind best practice. We can see what it looks like in the US. It requires a huge investment, but the pay-off in quality is immense.

Martin Laverty, Chief Executive Officer, Catholic Health Australia

1. Causes of ill health need to constantly inform both health policy and practice. Two-thirds of Australians are overweight, 16 per cent of Australians smoke, and 13 per cent drink at levels of risk. Implementing Senate recommendations on social determinants of health would revive efforts to prevent Australians, particularly the most disadvantaged, from suffering avoidable chronic illness.

2. Coordination of health services around a person’s unique needs must become more of a priority, to improve patient outcomes and reduce waisted expenditure. Ideally, any person with an ongoing health complaint would have a health plan worked out and appropriately managed to focus on right treatment in the right place, ongoing medication management, avoidance of duplicated service, and prevention of further disease.

3. Health workforce constraints and industrial barriers still haven’t been resolved to ensure Australia will have enough medical, nursing, and allied health staff to meet Australia’s growing and ageing population. Role redesign of who does what in the health system remains essential, but as a nation we’re no closer to being able to solve workforce constraints because of entrenched industrial perspectives.

4. Consumer choice underpins the new National Disability Insurance Scheme, and is being introduced into home care for the aged. Better choice in health and aged care also needs attention, so that competition and contestability can drive improvements in financial and clinical outcomes.

5. End of life care needs the entire community’s attention. Health professionals and health consumers need to give new consideration to talking about, determining, and then implementing future care plans. Pastoral care for those in the final stages of life, indeed for any person dealing with significant illness, needs elevation as a priority for health and aged care providers.

Dr Mukesh Haikerwal, Chair of Council, World Medical Association, former AMA President

With a new federal administration in place, a fiscal Armageddon heralded and the health settings for Australia being less favourable, the usual troupe of kite-fliers have been showing their wares in the ‘silly season’. What I think we need is to secure the fundamentals and enhance and support sensible collaborative work practices.

1. Support more care out of hospital – don’t penalise quality holistic care in general practice.

Embed the notion of general practice as the bedrock, not only of primary health care and all out of hospital care, but also for health care delivery across the nation. The costs of the same care out of hospital, when appropriate, are a fraction of the cost in hospital.

2. Enhance hospitals and support the care provided there, and stop perverse penalties.

Support the existing hospital infrastructure that is struggling with the burden of increased demand and expectation from patients and from governments, which absurdly see them penalised for trying their hardest to cope with this. There needs to be a move from blame to re-setting costs and targets based on realistic care need evaluations, allowing for inevitable variation.

3. Embolden and formalise clinical leadership in health in a meaningful way.

Use clinical Senates – groups of cognisant, focussed individuals suggesting and supporting innovation in health care delivery. Enhance their work by trialling and evaluating changing concepts before whole-of-system adjustments, so that unforeseen consequences are outed and adjusted for in real situations with real doctors treating real patients.

4. Use e-health and telehealth logically in clinically safe and acceptable forms over and above the PCEHR, especially secure messaging delivery and web-based videoconferencing.  

Use innovative technologies in health (e-health and telemedicine) for clinical purposes, with clinical needs and drivers at the forefront. We do have potential technology to support and enhance (but not replace) trusted, proven good clinical methods. This is over and above, but could include, the PCEHR. Secure email to connect information is the key element.

5. Innovate with translational research in real clinical situations, proving concepts before rolling them out.

In care settings, sequential work across disciplines and health care establishments, with clinical participants nutting out how to best to innovate. Use just one set of agreed best practice guidelines that promote translational research that have been promulgated to, and agreed by, relevant medical groups. Make sure the economics and medicine are understood: it may cost more to implement in the beginning, but it will save on costs down the track.

Dr Brian Morton, Chair, AMA Council of General Practice

1. End of life care – There is an expectation that modern medical technology and care will extend life, but at what cost to the quality of life? The preparation of an Advanced Care Directive when competent will bridge this gap.

2. Lifestyle health issues – The genesis of many health issues are related to poor lifestyle choices which then require medical solutions. We need brave governments to implement public health interventions to de-medicalise preventive management.

3. Obesity – a whole-of-community response is required to manage the obesity “epidemic”, including responsible marketing and labelling of foods, appropriate food helping sizes, ready access to exercise programs, dietetic advice and legislative recognition that obesity is a risk factor for multiple chronic diseases.

4. Prostate cancer – A rational evidence-based and consensus approach is needed regarding screening and management.

5. Alcohol – A multifactorial societal approach is fundamental to alcohol management.