Thursday, August 4, 2016

Reframing Primary Health Care for Older Australians


HCCA funds places at key events for our members to attend and participate in policy discussions. The most recent event was the COTA annual policy forum. This is a report from three of our members who attended. 

COTA Australia held their annual national policy forum at the National Press Club on 21 July 2016.
It was an impressive line up of front line policy drivers in the field of primary health care for older Australians, a scenario that gets little traction in the media apart from the supposed impending “tsunami of silver haired” Australians coming to an already overstretched health care sector. Probably the key point to come from the conference was that the numbers didn’t represent an impending catastrophe, but that should be looked at differently, with the societal response to older people needing reframing and older Australians respected because of their contributions to society and their human rights.  

Ian Yates, the CEO of COTA Australia, noted that in a recent survey of their constituents, older people nominated heath as their top issue of concern, a change from the previous top issue of the economy. Health will now be a strategic priority for COTA.

Highlights of the forum were key note presentations from Dr John Beard, Director of the WHO Ageing and the Lifecourse Programme and Prof Diane Gibson, Dean of the Faculty of Health at University of Canberra.

Dr Beard highlighted issues from the recent WHO World Report on Ageing and Health (http://www.who.int/ageing/publications/world-report-2015/en/):

·         Healthy ageing requires an understanding of capacity and environment starting from high capacity where the needs are to help identify and prevent disease onset and adopt appropriate health behaviours; declining capacity where the focus shifts to slow decline often with multiple chronic conditions where prevention becomes important with things like resistance and balance training, and disabled public transport is provided; and finally significant loss of capacity with extensive needs and support;

·         The pressing need is for us to realign the health system to shift from an emphasis on acute care for the individual to care for multiple chronic conditions with better measuring and monitoring;

·         The costs of health care for the ageing need to be seen as an investment in the health system. Better health means long acquired skills and knowledge are maintained with the ensuing benefit to society;

·         Older people need a supportive community NOT always more funding. We need to harness volunteers to work with them within their homes and communities;

·         The term “successful ageing” comes from a US Calvinist perspective and implies there is also ‘failed’ ageing, a better approach would be to emphasis wellbeing “living long, living well”.

Professor Gibson’s research includes the health of older people with delirium and dementia in acute care settings. She began her talk on health care as a human right by detailing a harrowing story of how her mother took 5 days to die in hospital following a fall down a flight of stairs. She detailed other examples of how older people are often stereotyped by the health profession. She gave examples of how the health system treats older people differently and the ignorant assumptions behind them: failing to understand that withholding treatment leads to poorer quality of life, the hostile stereotypes about sexuality and appearance, and the lack of evidence based medicine, for example, with few chemotherapy trials done for the over 70s and rarely including women.

In the panel session on Primary Healthcare – Living Long Living Well, Dr Cathy Mead, President of COTA Victoria, emphasised the need to focus on the broader understanding of primary health care as encompassing the WHO's Declaration of Alma Ata (WHO 1978): “Socially appropriate, universally accessible, scientifically sound first level care provided by a suitably trained workforce supported by integrated referral systems and in a way that gives priority to those in most need, maximises community and individual self-reliance and participation and involves collaboration with other sectors. It includes health promotion, illness prevention, care of the sick, advocacy and community development.”  She reiterated that it is crucial to step back from clinical care to a broader public health view and adopt a rights based approach that integrates social and health care. There is inadequate investment in prevention (1.5% of health expenditure) and she asserted that there is even ageism in how this is spent.

Dr Stephen Duckett from the Grattan Institute, gave two presentations, the first about better ways of supporting older people with chronic conditions to self- manage, with a focus on how multiple levels of systems and support can provide care for that individual. He insisted that the person needs to be at the centre of the care system, rather than the GP, and that critical enablers could be supplements to fee for service arrangements such as blended payments. The Grattan Institute publication, The Perils of Place, is also a valuable read about how hospitalisation rates for diabetes, tooth decay and other conditions that should be treatable or manageable out of hospital, show how Australia’s primary healthcare system is consistently failing some communities (https://grattan.edu.au/report/perils-of-place-identifying-hotspots-of-health-inequality/).

Stephen Duckett’s second presentation provocatively asked ‘Can the Health System Afford All These Old People?” And of course the answer was yes! An ageing population is not driving health expenditure and the ‘panic’ about ‘sustainability of the health system is a distraction – we must look at the benefits of health expenditure as well as the costs. The basis of his presentation can be found on The Conversation website: (http://theconversation.com/dont-just-blame-older-australians-for-increased-hospital-demand-62622).

Two other panel discussions covered:
·         Gaps in Access and Affordability in Primary Healthcare, with presentations on Mental Health (Dr Roderick McKay, NSW Institute of Psychiatry), Oral Health (Dr Jane Hartford, University of Adelaide) and Preventative Health (Rosemary Calder, Director of the Australian Health Policy Collaboration).
·         Models of Primary Health Care – What Do Older Australians Need?  The presentation from Dr Steve Hambleton on Outcomes of the Primary Health Care Review and Leanne Wells, Consumers’ Health Forum, on Consumer Focus and Control.

The facilitator Peter Mares summed up the forum with a list of the main points as he heard them:
·              primary healthcare must have the citizen at the centre of circles of care;
·              as we get older we have more teeth than previous generations but more gum disease;
·     better PHC is intrinsically linked better management of chronic conditions, patient engagement and agency and better coordination between systems;
·              more PHC, less hospitalisations;
·             why are we not getting there – increasingly complex systems;
·            Commonwealth/state division of responsibility – states must invest in PHC and preventative health care;
·           misinformation and myths (‘ageism’) about older people seen as a burden and a cost where less value is put on an older life, with no apparent economic importance;
·         BUT we are living longer and are healthier, as a society have plenty of time to adjust and contribute to greater civic leadership and community building.

Sue Andrews, Ros Lawson and Russell McGowan

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