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With leadership from the federal health department, we must urgently align on these critical capabilities, and the coherent implementation plan, so we can deliver sustainable national systemic performance improvements.

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Australia needs to reinvent how the health ecosystem manages chronic diseases. This has the potential to reduce up to 30% of avoidable hospitalisations, improve patient satisfaction, increase Quality Adjusted Life Years (QALY), reduce clinician burnout, and significantly enhance the sustainability of Australia’s healthcare system.

The current situation

On most measures, Australia has a fantastic healthcare system.  For example, patient surveys suggest Australia ranks higher than most OECD nations in primary care metrics including experience, quality, trust, and patient-centeredness.  However, like most countries, we struggle with the significant burden of chronic disease. 

Moreover, poor management of chronic disease is contributing to immense pressure on the public health system including increasing emergency department (ED) presentations, and a high burden of preventable hospitalisations. 

The current situation can be summarised by some startling statistics:

• 49.9% of Australians have at least one chronic condition. 
• “Multi-morbidity” is a serious challenge.  For example, 50% of Australians over 65 years have two or more chronic conditions (e.g. 84.8% of people with heart disease have another disease). Despairingly, 28.4% of all people living in areas of most disadvantage have two or more chronic conditions.
• 37% of visits to the ED are attributed to people suffering from chronic illnesses.
• 778,000 cases, representing ~6.2% of all hospital admissions in 2024, have been classified as potentially preventable.  Of these potentially preventable hospitalisations ~44% are due to chronic conditions, costing A$3.5 billion in 2024.

For patients with chronic and complex disease, and their families and carers, the daily burden can be immense.  There are issues such as ineffective care planning, with many patients not having aGP care plan, and for those with a plan, they are not accessible to other clinicians (e.g. ED or allied health clinicians).

Over time, after visiting various clinicians, a number of versions of a care plan may exist, which frequently result in fragmented and contradictory care plans that contribute to communication issues that ultimately lead to patient health issues.  Poorly coordinated care plans and insufficient patient “health literacy” impact effective delivery of care plan tasks.

Patients often do not recognise early warning signs, misinterpret symptoms, and delay accessing care.  Furthermore, patients do not always adhere to all care plan actions (e.g. appointments not scheduled, poor adherence to medications).  There is a significant lack of insight in the system, and risks are often not detected. Early indicators are not measured or patients are not aware of or insufficiently act on changes in key indicators. As such, significant “gaps in care” emerge over time.  

These rising “gaps in care” and changes in comorbidities (including mental health illness such as depression and/or anxiety) and changes in socioeconomic issues (e.g. inability to meet the rising costs of care) can put enormous pressure on patients and families. Social isolation and lack of sufficient support does exist, especially for older cohorts. 

Patients often delay in accessing care.  Consequently, there can be a range of unmet needs and the exacerbation of problems may frequently lead to ED visits and high rates of potentially preventable hospitalisations.  These can be incredibly difficult times for patients, families, carers, clinicians and the system as a whole.

“Heart failure is not a new problem, and the health system must do better to manage it. The high rate of hospitalisations for COPD is unacceptable, and we must implement the strategies we know can improve the health of people with this condition”

Australian Commission on Safety and Quality in Health Care (ACSQHC). The Fourth Australian Atlas of Healthcare Variation (2021)

Relative to the OECD average, Australia is not performing as well as it should regarding preventable hospitalisations, with Australia considerably higher than the OECD average (i.e. preventable hospitalisations in Australia is 606 per 100,000 people with the OECD average being 473 per 100,000 people).

Unfortunately, Australia invests less in prevention compared to most OECD nations.  The spend in 2022 was 3.1% of total health expenditure. Of 33 OECD countries, Australia ranked 27^th in terms of percentage of overall spending on prevention, placing us in the bottom quartile.

Fortunately, there is intent to improve this concerning situation. For example, the federal government’s National Preventive Health Strategy 2021-2030 aims to lift spending on prevention to 5% of total health expenditure by 2030.

The detailed plan for uplifting spending on prevention is yet to be fully defined. 

What should be the focus areas to deliver the best Return on Investment for this increased spend?  We need a detailed plan based on a rethink of how we detect and act on risk, how we better educate Australians, and how we enable the system (including clinicians) to intervene before a manageable condition becomes an acute issue. 

Preventive health has two pillars: primary and secondary prevention. Reimagining both is essential. However, this paper focuses on secondary prevention – otherwise known as early intervention for people with chronic disease. 

Reinventing care for early intervention

With significant technology advancements, especially with respect to data and analytics, we must reinvent our models of care to help improve outcomes for Australians with chronic disease.

The future of healthcare is incredibly exciting. The system and the typical patient journeys will look significantly different to what we have today. We will have system and patient level intelligence that makes healthcare safer, more proactive, and more resilient.  Healthcare will become more predictive than reactive.  The future will be defined by intelligent systems that connect data and operational workflows underpinned by AI models, with human decision‑makers to enable real‑world action and better outcomes for patients. 

How will the future look for patients with chronic diseases?

Firstly, there will be dynamic shared care planning.

For patients in need, the integrated care plan will be routinely developed and accessible to other clinicians in the multi-disciplinary care team. “Good practice” care pathways across clinical and organisational silos will provide the personalised guide for patient care. Where appropriate, patients will be assigned a clinician to assist the patient with service navigation and health coaching to promote better health and wellness, and actions to help avoid unnecessary hospitalisation. Where appropriate, agentic solutions will fill the void where human based services are not available or economically viable.

Patients will have more confidence in their integrated plan of care, and the self-management tasks will be automated and routinely much easier to abide by (e.g. medication adherence). The health system will seamlessly assist patients with tasks via digital tools and reminders. There will always be strong clinical oversight, but less effort as the workflow and tasks will be automated and helpful reminders will enable the right care at the right time.

There will be early detection of “gaps in care” and proactive outreach to patients when required. Data and analytics will assist with anticipating patient needs, organising touchpoints with the health system, and recommending actions before problems become critical.  Care teams will receive proactive notification of high-risk patients. Members of the care team will make data driven and context-aware decisions at every stage of care.  Patients will experience far fewer bottlenecks and delays, and as a result fewer unexpected hospital admissions. 

Consequently, there will be less pressure on hospitals associated with overwhelming patient demand, and reduced costs to serve.

With the reinvention of the health ecosystem for patients with chronic diseases, we have the potential to reduce up to 30% of avoidable hospitalisations, improve patient satisfaction and quality adjusted life years, reduce clinician burnout, and significantly enhance the sustainability of Australia’s healthcare system. 

There are strong global and local case studies which highlight the capabilities required to deliver on this vision. With leadership from the federal health department, we must urgently align on these critical capabilities, and the coherent implementation plan, so we can deliver sustainable national systemic performance improvements.

Dr Travis Grant is managing director – Health, Accenture ANZ

This document is part one of two articles. Part two will consist of “evidence-based” critical capabilities, including roles, technology and advanced analytics, required to deliver improvement in systemic performance. Part 2 will be published in June before “The Great Prevention Pivot”. Tickets to this event are available HERE.