COVID-19 brought a single, focused call for action in both Australia and New Zealand unlike many have ever seen in their lifetimes. 

While the two countries adopted different strategies – control in one and elimination in the other – the result was both countries developing and successfully implementing an integrated and cross-sector model of care, focusing on the overall health and wellbeing of the population. 

The population health approach during the pandemic took into account the health of everyone with a deliberate focus on specific cohorts of the population, including: the most vulnerable, the aged, those with chronic conditions, and the homeless. This drove the rapid adoption of key enablers such as telemedicine, the broader use of electronic medical records, and the deployment of other digital systems to communicate more effectively at scale and co-ordinate care. 

With the risk of hospitals being pushed beyond capacity, as was seen in some other countries, the Australian and New Zealand strategy sought to position hospitals as places of last resort in the views of the community, policy makers and the broader frontline workforce. 

In effect, the COVID-19 population health-based model had at its core both intra- and cross-sector collaboration. Historically, Australia and New Zealand’s healthcare systems have identified responsibility and accountability for population health as exclusively the domain of health, with limited true policy integration and approaches. COVID-19 led to a change in mindset and, importantly, a change in practice. 

The population health approach comprised four core principles with which most health policy makers and leaders at country, state or district level would agree: 

1. focusing on the most vulnerable and those with poorer health outcomes;
2. services orientated to supporting people to manage to live well in their own community and home;
3. hospitals identified as places of last resort; and
4. individual self-responsibility for health promotion and illness prevention. 

These four principles have been significantly tried and tested through COVID-19 in ways we have not seen before; moreover, they passed the challenge. 

This paper will consider the four principles and how they were deployed during the COVID-19 outbreak. The aim is to encourage policy makers, both at country and state level, to accelerate and enhance a broader population health-based model as the framework for establishing a “new norm” in healthcare in both Australia and New Zealand. 

The paper is based on discussions and interviews with senior health, social service and aged care leaders across Australia and New Zealand who are members of HardyGroup’s Executive Learning Set programme. This programme is designed to bring together top and emerging leaders from both countries, to strategise and resolve the complex challenges impacting their industries and organisations. 

Why accelerate and enhance a broader population health-based approach? 

It’s generally accepted that the key focus areas of any contemporary healthcare system is the simultaneous pursuit of improving a person’s experience of care, improving the health of populations, and reducing the per capita cost of healthcare. 

These key focus areas are priority for consideration in any change of direction in healthcare policy and were all tested, challenged and, to some extent, addressed in the short term during both countries’ response to COVID-19.

1. Addressing inequity and improving health outcomes 

Populations in rural and remote areas and populations of disadvantage often have reduced access to healthcare and experience poorer and inequitable health outcomes. This includes the original custodians of the land; the unemployed; the underemployed; the homeless; people with mental health and/or drug and alcohol issues; the aged; and those with chronic conditions. Supporting these key groups has never been adequately addressed in the way services are designed, who provides them, and the barriers to access. Through the first wave of COVID-19, these populations were recognised as most at risk and the system orientated more sharply towards them. Where do we take this now? 

2. Cost per capita 

Public hospitals and the healthcare systems more broadly in both Australia and New Zealand pre COVID-19 were under significant financial pressure. Almost all hospitals were struggling to come in on budget. In both Australia and New Zealand, we simply cannot afford to go back to the pre COVID-19 way of thinking, where building more is seen as better. Aside from the fact we simply cannot afford it, we have just demonstrated we can respond differently, faster, and sometimes better. Where do we take this now? 

3. Persons’ experience of care 

The healthcare system is continuously challenged with issues of staff attraction, workforce development and retention, and a plethora of workforce surveys that all too often describe intransigent behaviours such as bullying and harassment, not exclusively but often amplified in hospital settings. In public health systems, there is the additional experience of adjusting to new priorities within the political system as governments change. During COVID-19 we saw a determined and co-ordinated effort to deliver services in a different way, and closer to home wherever possible. To ensure hospitals were regarded as places of last resort. It undoubtedly changed the person’s experience, but it also led to reduced pressure in some parts of the service continuum. Where do we take this now? 

Towards a broader model of population health 

1. Focusing on the most vulnerable and those with poorer health outcomes

COVID-19 set out to support the most vulnerable in our communities: the original custodians of the land; the unemployed; the underemployed; the homeless; people with mental health and/or drug and alcohol issues; the aged; and those with chronic conditions. Prior to COVID-19, the recommendations of every major national review on vulnerable populations identified a fundamental lack of responsiveness to the needs of those most at risk of poorer health outcomes and those already with poorer health outcomes. 

During COVID-19, many of the recommendations contained in several earlier reports were either initially or partially addressed. Such reports include: the Royal Commission into Aged Care Quality and Safety; the Productivity Commission reports, including those on rising inequality, and on deep and persistent disadvantage in Australia; He Ara Oranga – the New Zealand Government Inquiry into Mental Health and Addiction; and the draft report on Australian Mental Health Care, which also addressed the issue of homelessness. 

Aged care: The policy during COVID-19, that nursing home residents should not be sent to hospital emergency departments, resulted in many instances of new models of care and treatment, including palliative care in place. The health system, particularly hospitals and the primary care sectors, responded to the needs of nursing homes by providing additional nursing, allied health and medical staff where needed. The question now is what should our future responses to age-in-place healthcare look like? What can we learn here as a more meaningful alternative to overcrowded emergency departments, elderly people on wards for long periods, and the resultant expensive model to which we have grown accustomed? 

Mental health, addiction and homelessness: Both Australia and New Zealand increased resourcing and services in this key area and expanded collaboration with community and non-government organisation (NGO) groups and private-sector providers. Extra resourcing was also provided for primary health organisations (PHOs) and primary health networks (PHNs) to increase capacity in their geographic areas and to boost online and phone services. Suddenly, being homeless was not acceptable and addressed in a variety of ways we had not seen before. How do we capitalise on what we learnt? What do we need to do now to reduce duplication and improve co-ordination to ensure timely access for anyone requiring assistance? 

Biosecurity legislation protecting Aboriginal settlements: Discussions were had with Aboriginal elders on the most appropriate way of achieving social distancing and protective measures while, at the same time, safe and effective service provision. The decision was taken to effectively close the borders to protect and support these vulnerable and often remote communities. In some parts of New Zealand, Maori communities took carriage of things and established vetting points to dissuade non-local travellers from entering their rohe (community). Vulnerable communities, particularly those in remote settings, often have limited access to digital technology and reliable internet connectivity. In future, how do we ensure the tyranny of distance is reduced or, better still, removed through smart technology and the means to use it? 

2. Services orientated to supporting people in their own community and home 

There are remarkable success stories with telemedicine and remote monitoring previously resisted but rapidly deployed during COVID-19. Support in the home has advanced to include monitoring vital signs of patients 24/7 and is being trialled across the health services. The basics of the virtual hospital are being deployed involving connectivity to a central monitoring station and a process of increasing specialist services if required, with the intended aim of reducing hospital emergency admissions and facilitating early discharge planning. Telemedicine and remote monitoring provided rural communities with greater access to healthcare. They received the benefit of requiring less face-to-face specialist visits, less wait and travel time, and less inconvenience. Telehealth is working well for outpatients and community services, and the question is how far it can be extended? Evaluation of these programmes requires consideration of patient education to enable them to feel empowered to self-manage. This will result in more conditions that can be managed in the patient’s home. The success of telehealth is bringing with it the opportunity for a single waitlist management platform and improved patient co-ordination via e-health. Questions need to be asked such as what is the role of hospital outpatient departments in future? How do we strengthen the relationship between public hospital outpatient clinics and primary care services? With this success, there is no strong leap of the imagination required to consider a single waitlist platform for elective surgery waiting lists. 

3. Hospital as a place of last resort 

Public hospitals during the pandemic were, in most cases, seen as places of last resort. Elective surgery and non-acute care functions were cancelled and new respect for the role of general practitioners (GPs) and the broader community and NGO sector emerged within part of the healthcare system. 

Pre COVID-19, some health services in Australia had well-intentioned plans in place resulting from joint planning between PHNs, GPs and the local hospitals. Given the architecture of the New Zealand healthcare system, where the district health boards fund their local PHOs, integrated pandemic plans were largely already in place. Did they work in the way they were intended across both countries given COVID-19 was a new phenomenon? 

Primary and community care providers were acknowledged by many in the hospital part of the healthcare sector as having played an important role in keeping their constituents up to date, and new alliances developed between hospitals, specialists and GPs. Things like community COVID-19 testing clinics and caring for patients at home resulted in a new understanding of each other’s capabilities and the criticality of partnering differently. 

One question this raises is who does what going forward and should specialty clinics be provided in general practices or in broader community health centres? Another is the role of private hospitals. During the pandemic most only serviced privately insured patients yet wanted to take on a greater role. Many governments also wanted them to or at least wanted them to be ready to. What is the win-win to be found here in future? 

4. Individual self-responsibility for health promotion and illness prevention 

COVID-19 has ushered in the concept of individual responsibility with far greater clarity. We’ve all been told to take responsibility to wash our hands frequently, social distance, and isolate ourselves from everyone including the ones we love. To our great surprise, we largely listened and, better still, we actually did it. 

In part, self-responsibility is about having the education and the tools to take on the task to achieve the gain. This extended to staff within the health system as well; for example, in respect of their mental health and wellbeing. The mental health of first responders and frontline staff during COVID-19 across Australia and New Zealand was impacted by fear of the unknown and what they were seeing reported in other countries such as the US, England and Italy. Most health services across Australia and New Zealand did provide mental health support for staff by telehealth, including mobile apps, online resources and virtual peer support. Importantly, staff developed plans that factored in that they might be in it for the long haul. Their wellness plans related to exercise, sleep, eating properly, and how to switch off at home. 

We all learnt a little more about the criticality of mental health and wellbeing and the importance of tuning in to our body’s response to stress. Where do we take this now and how do we sustain our collective learnings about the importance of self-responsibility during COVID-19? 

Two key imperatives of a post COVID-19 broader population health model 

1. Consider how services are funded 

Health policy makers in Australia and New Zealand have a goal for all the population to access the right care, in the right place, at the right time. Invariably, what we do not tend to do well is explain to the population how healthcare and services are funded. 

The pre COVID-19 models of care are focused heavily on the hospital and acute sector. It is where most of the money goes. Financial incentives are geared towards the provision of specialist care in public sector hospitals, where specialists also have a right to private practice. In Australia prior to COVID-19, telehealth programmes have been discussed and piloted for at least 20 years with minimal success. A key barrier was the lack of financial incentives to change the model of care. 

Telehealth programmes were achieved with simplicity as soon as health providers were paid to treat patients in the home and in the community rather than in the hospital outpatient setting. On 13 March 2020, the Commonwealth introduced new temporary MBS telehealth items for out-of-hospital patients. The temporary MBS telehealth items allow people to access essential Medicare-funded health services in their homes. Clinicians previously concerned with the broader use of telemedicine suddenly became advocates for it. 

Certainly, in an Australian context, for telemedicine and remote monitoring to succeed it will require the continuation of the MBS telehealth items. But, more broadly, we need to have an honest conversation about how we fund services and who provides them. We talk constantly about orientating the system towards the primary and community care end of the continuum but are we making much headway? 

2. Redefining health as an intra- and cross-sector collaborative initiative

A new driver in healthcare, one that showed its importance during COVID-19, was the redefining of health as both an intra- as well as cross-sector collaborative initiative. 

Integrated and co-ordinated service provision between frontline services such as first responders, GPs, pharmacy and other primary care providers, NGOs, and hospitals included intra collaboration, or simply getting their own house in order. However, health has also benefitted from the advantages of collaborating with different sectors, other government departments, schools, police, local government, the aged care sector, the private sector, and community groups. 

Cross-sector collaboration was evident in addressing the issue of mental health and wellbeing. With COVID-19, many people’s mental health was either at risk or directly impacted by facing and dealing with the unknown. This was recognised as beyond the responsibility and capacity of funded mental health services. This is where a more multisectoral approach to population health took effect. 

Health also saw the direct benefits of industry collaboration with non-traditional partners. If the number of people with COVID-19 requiring treatment grew exponentially, our health systems would not have been able to protect staff owing to shortages of personal protective equipment (PPE). We were very fortunate that this did not happen given the benefit gained in obtaining supplies from private-sector manufacturers, the construction industry, and so forth. Multidisciplinary teamwork across industry sectors also resulted in the rapid expansion of new technology as seen by four new prototypes of ventilators. 

Longer term, this population health approach of far broader intersectoral collaboration will establish a framework to address more of the social, environmental, cultural, physical and social determinants of health. Yes, it’s hard work, but do we really need a second or third wave to realise it’s worth the effort? 

Conclusion 

Containing or eliminating COVID-19 brought with it a great sense of urgency and laser-like focus across countries Australia and New Zealand. This generated throughout the pandemic many examples of what can be achieved in both countries under a broader population health-based model of care. 

The four guiding principles outlined in this document help illustrate the roadmap to addressing the challenges we’re all facing in healthcare. 

Financial savings can be achieved with a shift in focus away from hospitals and building towards developing a more balanced and broader service continuum. Taking pressure off the hospital system can also serve to enhance staff attraction and retention, as well as wellbeing. 

The long-standing issues of health inequity can be better addressed with a more determined focus on health promotion, early intervention, and services delivered in the right way by the right provider in the right place. We can also go so much further than we have on public health initiatives with real impact and the management of conditions in the community, with the use of telemedicine and digital systems that until now we have resisted. 

Most importantly, redefining health and the broader concept of community wellbeing, based on what we have learnt and are still learning in responding to COVID-19, may be the watershed moment we need to let go of old ways of thinking. 

Was it not Winston Churchill who famously said: “Never let a good crisis go to waste?” Why should we?

About the author

Based primarily in Australia, Dr Liz Paslawsky PhD, MHA coaches CEOs and executives in Integrative Leadership. She is visiting professor of the Ukrainian Catholic University, in Lviv, Ukraine. She is also a consultant to SALUS Global Knowledge Exchange.