From virtual hospitals to FaceTimed GP visits, innovations that have sprung up in response to coronavirus could transform a sector notoriously resistant to reform.

by Melissa Sweet

Last year, when plans were being developed to establish a “virtual hospital” in central Sydney, some clinicians were not convinced about the merits of using digital technologies to care for people in their homes.

“Now, everybody is on board,” says Dr Teresa Anderson, chief executive of the Sydney Local Health District. “There is not one clinical department across the district that is not providing care virtually.”

What a difference a pandemic makes. Although RPA Virtual Hospital was well into development when news broke from Wuhan in January, pandemic preparations meant it was scaled up far quicker than had been envisaged.

Anderson says RPA Virtual Hospital opened on 3 February with just six nurses. It now has more than 30 nurses, as well as medical and allied health teams, and 600 registered patients. Operating out of Royal Prince Alfred Hospital campus, it functions in many ways like a regular hospital, with a clinical handover, ward rounds, multidisciplinary team meetings and its own governance structures.

The virtual hospital is part of a wider suite of innovations developed at breakneck speed during the pandemic response, which include providing care in rented hotel and apartment accommodation to Covid-19 patients and others in quarantine, thus freeing up hospital beds.

By 28 April, 422 coronavirus patients had been registered for care with RPA Virtual Hospital, 348 of whom have been discharged.

Anderson says the success of the virtual hospital has encouraged wider uptake of the approach. “Every department in our district has now been looking at how they can provide outpatient services more effectively, using telemedicine not just for patients in rural and remote areas, but also for those who live locally,” she says. She expects the virtual transformation to continue post-coronavirus, and is particularly excited by the potential in antenatal care.

The health sector has a long history of resisting reform, but RPA Virtual Hospital is an example of the pandemic driving innovations that otherwise may have taken years, if not decades, of incremental changes. Importantly, the developments are not only about policies, programs or technologies, but also reflect new relationships and ways of working that cross sectors and systems, helping to break down some of the longstanding silos that have held back innovation.

Anderson has learned a great deal from working with new partners in the community and non-health agencies over the past three months. “When you have something like a pandemic that impacts across the whole system and impacts on the way in which we can deliver our business as usual, it actually makes us think about things differently,” she says.

The virtual hospital model brings benefits for wider population health as well as patients, she adds, including through reducing health services’ carbon footprint. Staff at the Sydney Local Health District have done more than 14,000 hours of video conferencing since Covid-19 began, contributing to reduced travel, air pollution and greenhouse gas emissions.

Dr Forbes McGain, an anaesthetist and intensive care physician in Melbourne who has a PhD in sustainable healthcare, is also watching the pandemic’s impact on healthcare’s greenhouse gas emissions, saying it has created a “mountain of waste” of single-use gloves and gowns. He sees the pandemic creating an opportunity for radical change in two related areas – the development of local manufacturing to meet healthcare supply chain needs, and the manufacture of reusable gowns.

This would be an example of more environmentally sustainable practices increasing the resilience and security of healthcare systems while also boosting local employment. The pandemic has highlighted a “real opportunity for much more interaction between manufacturing and medicine”, he says.

Covid-19 has also exposed the absurdity of Australia’s health funding arrangements, especially in historically underfunded areas that have been central to the pandemic response. Whether public health and prevention and the social determinants of health will benefit from increased investment in the longer term remains to be seen.

At a time of crisis, the business model for another vital pandemic workforce – primary healthcare – has also been found wanting. Many providers relying on fee-for-service income have struggled to remain afloat, with some laying off staff or closing their doors. Of more than 1,000 nurses who responded to an Australian Primary Health Care Nurses Association poll about the impact of Covid-19 on their employment, almost one-third said their paid hours had been reduced, and 7% had lost their jobs.

Covid-19 has also underscored, yet again, the case for reforming the massively subsidised private health insurance industry, which looks set to make a windfall from a slowdown in elective surgery and other services. The pandemic has also brought into sharp focus the imperative for reforms to reduce the waste and harms caused by low-value care (interventions that provide no or minimal benefits) across public and private sectors.

“The days of public subsidy for private healthcare without proper scrutiny are over,” says Dr Sebastian Rosenberg, a mental health researcher with appointments at Australian National University and the University of Sydney. “We have to really think carefully about the best way to use all our valuable health resources because in times of crisis, whether it’s a pandemic or an individual crisis, it’s the public health system that responds.”

When the federal government announced a sweeping expansion of telehealth services – to ensure ongoing access to care during lockdown, to reduce healthcare workers’ and patients’ exposure to infection, and to support the sustainability of health and medical practices – it was described as “the most far-reaching change for general practice in a generation”.

‘You are beamed into their home’

GPs and other doctors, nurses, midwives and allied health providers have been able to claim Medicare Benefits Schedule (MBS) telehealth items for services provided by phone or video to all Australians, and not only those in designated areas or fields as was the case previously. By 20 April, more than three million patients had used these services.

These temporary arrangements are due to end on 30 September, and the health minister Greg Hunt has flagged his support for their continuation, although many questions are yet to be answered about the rollout and impact of these services.

Dr Chris Bollen, a GP in Adelaide who cares for many elderly people living in their own homes, has spent much time recently teaching patients to use FaceTime and other digital platforms. He is excited by the potential for telehealth to help support older people to live independently, and more generally to improve access to care, and to drive more proactive engagement with patients, especially those with chronic health conditions.

Bollen also sees advantages for clinicians. “We have lots more people saying ‘thank you’,” he says. “You are beamed into their home, their lounge. It is a privilege – seeing their smiling faces, rather than in the waiting room where you are running late. I go home at the end of the day after seeing lots of complex patients but am much less stressed because I don’t have waiting room pressure.”

Bollen also works as a consultant with medical practices around Australia, and says many are realising the benefits of this way of working. He expects it may also encourage more to support the concept of patients enrolling with a specific practice, to enable more systematic and safer management of their care.

 We are a conservative profession. This is an opportunity to shift our mental model.Dr Chris Bollen

“Clinical decisions via telehealth are safer for the person if the GP has access to the enrolled person’s medical record, current and past medical history, medication list, allergies and recent results,” says Bollen.

He stresses the importance of retaining the new telehealth arrangements. “We are a conservative profession,” he says. “This is an opportunity to shift our mental model. The pandemic has allowed us to do that. We are shifting peoples’ thinking, which allows more people to think about innovation, what else can we do?”

Peta Rutherford, CEO of the Rural Doctors Association of Australia, says the pandemic has forced many GPs and specialists who weren’t previously interested in telehealth to step into the space, enabling them to develop a better understanding of its potential and overcome their reservations. She believes there is “a huge opportunity going forward” to increase rural communities’ access to specialist services via telehealth, for cancer treatment and other services.

At Cohealth, a community health organisation in Melbourne, chief executive Nicole Bartholomeusz is also keen to see the measures continue. She has been surprised by the strong demand for telehealth consultations, especially as her organisation looks after many people dealing with poverty and complex, chronic health issues. Patient engagement with the alcohol and other drug counselling service has increased significantly since it moved to telehealth delivery, she says.

The pandemic has also sped up a long-awaited shift to electronic prescribing, and Tasmanian pharmacist Shane Jackson is enthusiastic about the benefits, including “a wave of patient empowerment”. But he stresses the need to better support people who are not digitally literate so they do not miss out.

Jackson also hopes the pandemic upheaval will create opportunities for expanding the scope of practice of pharmacists, so they work alongside doctors in diverse settings, including aged care, primary care are hospitals, doing more prescribing.

Rethinking the funding model

Leanne Wells, CEO of the Consumers Health Forum of Australia, is hopeful the government will continue the telehealth measures. “The genie is out of the bottle,” she says. “It is very difficult to introduce something that people and clinicians really like and then take it completely off the table.”

Wells also hopes that wider primary healthcare reform will be a legacy of the pandemic. “We’ve been talking about primary healthcare reform for 15 to 20 years and reform has been going at glacial pace,” she says. “We’ve got to stop the incrementalism.”

Wells wants to see a blended funding model and universal voluntary enrolment of patients – recommendations that date back to a 2009 report by the National Health and Hospitals Reform Commission, A Healthier Future for All Australians. This report envisaged voluntary patient enrolment with a “healthcare home” to coordinate access to multidisciplinary care, with primary healthcare supported by a mix of fee-for-service, grants to support multidisciplinary clinical services and care coordination, outcomes payments to reward good performance, and episodic or bundled payments.

The report notes that “the use of episodic payments would create greater freedom for primary healthcare services to take a long-term, whole person and population health perspective that moves away from funding on the basis of single consultations or visits – an approach that can better meet the needs of people with chronic and complex conditions”.

Eleven years later, progress towards healthcare homes and related primary healthcare reform is widely judged to have been disappointing, with Grattan Institute researchers memorably describing the sector as “a renovator’s delight” because of the limited, piecemeal extent of reforms.

It’s a reminder there have been many missed opportunities to better equip the primary healthcare sector for dealing with an acute crisis like Covid-19.

‘It’s about respecting Aboriginal leadership’

It became clear early in the pandemic that Aboriginal Community Controlled Health Organisations (ACCHOs) were ahead of the mainstream health sector in responding to communities’ concerns with relevant local messaging and an urgency motivated by a lived and historic knowledge of the impact of infectious diseases.

In the remote Western Australian town of Broome, Kimberley Aboriginal Medical Services (KAMS) has developed a reputation as a source of reliable information for all local residents, according to chief operating officer Rob McPhee. The Kimberley has had 18 Covid-19 cases, all of whom have recovered, he adds.

Unimpeded by layers of government bureaucracy that slow and constrain information sharing, McPhee says ACCHOs can be more agile in getting information out quickly and are better placed to understand local culture, context and needs. The way KAMS shared information and resources transparently helped to build trust with other services, as well as the wider community, and he expects these positive connections to endure with benefits into the future.

It is also important to understand that it has been a community rather than a health sector response in the Kimberley, he says, with health services working closely with a range of other agencies, organisations and communities.

“Our relationships will be stronger,” he says. “I think there is more trust between us; people have seen the value of our sector.”

 Aboriginal community-controlled organisations have the capability and skills to respond to the health needs of our community.Rob McPhee

KAMS was also quick to adopt telehealth, for medical, mental health and social and emotional wellbeing services, and the uptake from clinicians and patients has been enthusiastic. McPhee is now looking forward to expanding its use much more widely in remote communities.

McPhee hopes the strong national leadership from the National Aboriginal Community Controlled Health Organisation (NACCHO), together with on-the-ground responses from local ACCHOs, will lead to a wider respect and acknowledgement for the sector.

“It’s about respecting Aboriginal leadership and the fact that Aboriginal community-controlled organisations have the capability and skills to respond to the health needs of our community.” He hopes this translates into needs-based funding with governance processes that support self-determination, rather than channelling funding for ACCHOs via Primary Health Networks and other third parties.

Indeed, the holistic work of the ACCHO sector, in addressing the cultural and social determinants of health at a local level, also sets an example for reform of the wider primary healthcare sector, which so often continues to entrench top-down, medicalised approaches.

As has been observed around the world, McPhee says the pandemic has brought home the importance for health of a liveable income, food security and proper housing – the social determinants of health.

While it is too early to know whether pandemic disruption will bring opportunities to address these determinants more effectively by promoting health in all policies, Dr Teresa Anderson is optimistic some of the positive lessons for healthcare will carry forward.

“In disasters and critical situations, human beings are incredible, everyone pulls together,” she says. “There has been the most amazing goodwill. I don’t think we will go back to business as usual; there have been so many positive learnings at a challenging time.”

• Melissa Sweet is a public health journalist and managing editor of Croakey Health Media

Details of the additional telehealth items are on the MBS website: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home