As a frontline clinician for 15 years, I have increasingly recognised the extent to which the current healthcare delivery model is broken and the extent to which fixing it has been delegated to non-clinical administrators and politicians.
It has become clear that the current system doesn't work for patients, who are often unable to access the quality care they require when they require it; for clinicians, who suffer from unprecedented levels of emotional and psychological distress; or for the country at large which faces the ongoing dilemma of how to fund such a complex and cumbersome system.
We are all stakeholders and we need urgent public discourse about how our healthcare system can be transformed.
We will not improve our struggling public healthcare system without courage, creativity, courage, and innovation. We must critically look at what the public system can afford and how it may financially incentivise appropriate and sustainable health behaviours.
In any given week, one can read media reports highlighting the national shortage of doctors, the unacceptable wait times for essential services, the increasing pressure on our hospital system, particularly our accident and emergency departments (AEDs), and worsening health outcomes between racial and socio-economic groups.
The analyses of these shortcomings always seem to end in the call for more government funding, but by now we must surely realise that increased funding alone will not fix them.
If we look at the current model as a mismatch between supply and demand we must examine ways to both increase our supply of qualified clinical providers while simultaneously looking at ways to decrease healthcare demand at the secondary (hospital and specialist) level and bolster access to high-quality preventative and primary care services.
With regard to the supply side, the current healthcare system is far too doctor-focused. It requires tremendous time and money to train a doctor workforce. When doctors finish training they often specialise in lucrative procedural skills such as colonoscopy or cataract extraction that utilise only a fraction of that training. From the day they are fully qualified, doctors are also free to practice as much as they like (and as much as the insurance industry will reimburse) in the private sector, thereby draining the public system of valuable capacity. DHBs are often forced to outsource essential services back to those same doctors in private, most of whom were trained at substantial government expense.
Do we need instead to consider training non-physician procedural specialists who will be far quicker and less expensive to train but who, given a limited scope of practice and sufficient supervision, may provide as high-quality care as their doctor counterparts? Do we also need to consider "bonding" doctors to the public system for as long as their training has been subsidised by the New Zealand taxpayer?
Do we need to regulate the fee-for-service model of reimbursement that makes private work so much more lucrative than public service for both doctors and nurses?
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On the demand side, we must look at how we currently fund primary versus secondary care and the extent to which the current funding model has created a perverse incentive to go directly to the hospital for non-urgent issues.
Why take time off from work and pay a significant fee to one's GP practice rather than go directly to an AED where wait times have been slashed due to ministerial mandates, where one will see a "specialist" and have any necessary ancillary testing done on site and for free?
One does not need to be a health economist nor a psychologist to understand why demand for hospital AED services have inexorably increased year upon year.
Instead of more doctors, do we need to train more nurse-level providers with prescriptive authority - or "nurse practitioners" - to bolster our preventive and primary care capacity, particularly in rural areas and areas of high socio-economic need?
Might putting more Māori and Pacifika nurse practitioners into the community, for example, redress some of the health inequities that the current system has in part created? Do we need to change financial incentives to guide health-seeking behaviour away from our overburdened hospitals and back into the community? Do we need to actively develop technology in the form of tele-medicine and tele-health? These are hard questions that will surely stir emotional debate but must be entertained.
We will not improve our struggling public healthcare system without courage, creativity, courage and innovation. We must honestly appraise the toll that the private industry takes on our valuable public resources. We must critically look at what the public system can afford and how it may financially incentivise appropriate and sustainable health behaviours.
Crisis creates opportunity to re-examine old beliefs and methods. We cannot afford to opt out of urgent discussions and decisions about the future of our healthcare system.
• Art Nahill is a general physician who has worked in both the US and, for the past 15 years, in New Zealand