Pearls and Irritations

Australia’s public hospital system is having a hard time meeting the ever increasing demand for in-patient care.

Of course a pandemic associated with a sudden and large demand for admission, and often Intensive care, would strain any system, but even before Covid-19 placed huge stresses on hospitals, we were struggling to meet demand. The demand for residential aged care cannot be met. There are evidence based strategies to tackle both these problems but so far the election rhetoric contains no assurances that our politicians are planning to embrace them.

Today most of our public hospital beds are occupied by medical patients. This was not always so. In 1964 when I started working in the hospital system,40-50% of the admitted patients had surgical problems. Over the decades the tsunami of Australians developing chronic medical conditions has required more and more hospital admissions.

As a result the wait time for surgical services in public hospitals has grown longer and longer. This reality has seen many Australians, who struggle to pay for private health insurance, do so for fear the public hospital system will not be there for them when they need surgical help.

Our health system needs restructuring to better help Australians avoid those chronic diseases which are avoidable. We urgently need to provide better integrated primary and community health services for those who are ill to keep them out of hospital.

Many hospital admissions could be avoided with a timely intervention in the community in the three weeks before hospitalisation was unavoidable.

Today our health professionals are exposed to “Inter-professional learning” while at University. Students studying to be doctors, nurses, physiotherapists etc interact to prepare them for practising “Team Medicine” on graduation. They learn about the skills available from different professions and how to focus those skills to best help an individual with complex needs.

Frustratingly, they graduate into a health system that has yet embrace the concept.

Around the world numerous examples of the benefits of individuals enrolling in a “Medical Home” wherein a multidisciplinary team provides health education, continuity of care , early intervention when health problems begin and extension of care into community and home settings, has been demonstrated. It is so frustrating that we are so underutilising the skills of the modern nurse who can play a pivotal role in Medical Homes. Don’t we all accept this model, of care for our new cars!

We need Medicare to embrace the model and pay for the team. The cost savings from better health and reduced hospital admissions together with the resulting freeing up of some of the 11 billion dollars we spend on supporting private health insurance would more than pay for the program.

Frustratingly, but an example of the problem we have with Commonwealth / State health responsibilities, is the response to the initiative (which would reduce hospital admissions” from some bureaucrats in Canberra is, “Well that would help the States not the Commonwealth”!

These are the reforms we need to hear our would be leaders embrace. So far however health system reform has received scant attention.

One promise Labor made in 2019 and which I hope they will honour in 2022, is very relevant to our efforts to reduce the need for hospital care. Bill Shorten promised to re-introduce specialist run out-patient clinics in public hospitals. While I am embarrassed by some of the fees some specialist colleagues charge, even average costs see many who need to see a specialist not doing so.

Before financial pressures saw public hospitals axing this outpatient service, patients, students and research benefited enormously from the such clinics.

What is on offer, and is almost a good idea, is funding for 50 GP led emergency clinics attached to existing GP practices. They would be open from 8 am to 10 pm to treat minor emergencies. They would probably be better designated as “urgent care centres”. Labor talks of treating fractures, lacerations and medical problems that do not obviously need the resources of a hospital. The claim is that this would take pressure off hospitals while patients could avoid the long wait time in many hospital emergency departments.

While the latter claims is true the former is not. As discussed above its major emergencies and severe medical problems among those of us with chronic diseases that require hospital admission that strains our hospitals.

Even urgent care problems need experienced staff, readily available. It is not practical to have GPs with busy practices disrupt their booked patient schedule to treat an emergency. It’s also true that most GPs would not have treated the problems envisaged for many years, perhaps since their hospital internship.

Experience in other countries trying to achieve the above goals tells us that a far better model involves a “Hub and Spoke” arrangement. Imagine a geographic area which has lets say 35 GP practices. Centrally placed is a stand alone Acute Care Centre that services that area providing the services Labor is envisaging. The Hub may offer other services besides.

In some models Hubs have personnel with pharmaceutical expertise who interview representatives from drug companies and assess drug developments and provide recommendations back to GPs in this “Primary Care Network”. IT expertise, help with continuing professional development and the facilitation of the seamless integration of patient care from GPs, the Hub and local hospitals are features . There are numerous variations on this theme but networking in a patient focused way is the centrepiece.

I have sat, enviously, in the conference room of a “hub” in NZ for a lunch time meeting where some local GPs, staff of the Acute Care Centre and doctors and allied health professional from the local hospital, met to discuss better ways of helping their ‘frequent flyers’.

Contrast this with what we call “Primary Health Care Networks (PHNs) in Australia. of which we have 33 for the whole of the country. These organisations are primarily charged with helping GPs get for their patients, the non-medical care they need. There is but one PHN for all of Western Australia outside of Perth!

Both major parties are promising to reduce the cost of PBS prescriptions and that’s welcome. Far too many of us, struggling financially, chuck our doctors prescriptions in the bin.

But what are the crucial initiatives that are not even getting a mention?

Despite almost universal agreement among infectious disease specialists and epidemiologists that more animal to human infections are to be expected and exacerbated by climate change, calls for Australia to establish a Centre for Disease Control (CDC) to help us handle this reality and prepare for Covid-24, continue to fall on deaf government ears.

Much discussed in Pearls and Irritations is the need for dental care to be covered by Medicare. Poor oral health not only causes much suffering but costs us many millions of dollars as we treat the consequences. 26,000 people in NSW are on a waiting list for dental assessment at Sydney’s dental hospital.

Where is the discussion about the need for the Federal government to fund and manage more aged care residential facilities. Research demonstrates far superior care in government run centres. The lack of any reasonable profit margin in privately run homes is a major cause of the totally unacceptable standard of care that is so common.

Stalled are promised initiatives to move way from the ‘Fee for Service’ model for paying for primary care with its inbuilt perverse incentives for quantity to be more important than quality. Better remuneration for our GPs is a crucial issue. Only 15% of medical graduates express interest in being a ‘GP’. We need that figure to be 50% but the income disparities between GPs and ‘specialists’ (of course in reality GPs are specialists) is so great that a career in primary care is increasingly unattractive.

Then there is the crisis in rural based health care. The 33% of Australians who live in rural and remote settings produce 66% of the nations wealth and die, on average 4 years earlier than their city cousins. A detailed discussion is not possible herein but not much has changed, unfortunately, since my analysis in P&1 on December 4, 2017 “When will we seriously tackle the Inequity associated with the delivery of health services to rural and remote Australians?”

 Whether it be the AMA, the specialist medical societies, the consumer health forum, the Rural Doctors association, the College of Nursing etc etc, all agree that major structural reform of our health system is essential. Ten years of coalition government tells us that the LNP will not deliver the needed reforms. Labor might and certainly seem to better understand the imperatives. Perhaps a cluster of intelligent independent members of parliament might force reforms.

While we wait to see if any of the above issues surface in the last weeks of the electioneering, have a ‘flu’ shot. Stories of vaccine fatigue and slow uptake of influenza vaccination is an immediate concern.

Read more articles reflecting health reform needs here.

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