Like justice, medical specialist care delayed is care denied

Apr 27, 2023
Woman in hospital bed waiting for doctor. consultation in medic office treatment medication diagnosis expertise.

The statistics released by ABC journalist, Stephanie Dalzell on April 20, define a national disgrace and expose a massive hole in the once intact Medicare safety net.

The figures are as disturbing as they are worth reading in detail. Only four states release data: Victoria, Tasmania, South Australia and Queensland. As a sample, the average statewide waiting times in Victoria were over 15 months for hepatobiliary and pancreas, ENT, orthopaedics, plastic surgery, ophthalmology, dermatology, immunology, urology, rheumatology, and gynaecology. These are averages; the waiting times for the health services with the longest wait, across this huge disease spectrum, ranged from 2.9 to 9 years!

Such evidence describes people not just numbers. People mostly with serious health problems that the GP can’t sort out without help from a specialist. The referral to a hospital outpatient clinic is for several reasons but highest amongst them is an inability to afford the out-of-pocket expenses for private consultation or for procedures that may follow specialist assessment.

This breaches one of the most fundamental tenets of Medicare: that no Australian should be prevented from timely, essential healthcare due to the cost involved or fear of the cost involved.

The consequences are obvious. It is well established that a major factor in preventable death is delay in diagnosis. For many people, like justice, specialist care delayed is specialist care denied. And, just like barristers, medical specialists become increasingly, the doctors only rich people can afford.

Death, however, is just the extreme end of consequence. These statistics represent hundreds of thousands of Australians, if not millions, right now, suffering potentially preventable chronic pain, disability and reduced employment opportunity and quality of life, for a health problem that could be relieved, if not cured, by specialist consultation.

Often GPs are only asking for a single consultation, a definitive diagnosis and a shared management plan. As the statistics cited only include waiting time for first consultation, each number represents a failure of support to general practitioners as well as their patients.

Revealing these stark statistics now and the community concern they should provoke, is long overdue. They are the third stream of inequality that results from the Commonwealth’s underfunding of the state public hospital system. Ambulance ramping outside ED and long waiting times for elective surgery are regularly covered but this is an equal, if not a greater, cause of unequal healthcare opportunity. Until now, it has remained under the media radar.

Inequity of access to healthcare drives inequity of outcome. The difference between public and private care should be exactly the same as the difference between economy and business class air travel where all passengers start their journey at exactly the same time, with the same safety and technology and arrive together at the same destination. The only difference is comfort. For the first 20 years under Medicare, this analogy was more or less appropriate and something of which Australians could be justly proud.

How have we lost so much of the Medicare promise? Firstly, the current state is not due to Covid. Of course Covid made it worse but the waiting times were already unconscionable a decade before then. Ask any GP, or specialist, like me, working in an out-patient clinic.

The fundamental problem is twofold: a reduction in the proportionate support by the Commonwealth to the states’ public hospitals and the inability of both to bridge the jurisdictional divide. Public hospitals provide acute inpatient care whilst the Commonwealth is responsible for all healthcare delivered outside hospitals. In our ageing population, too many people with chronic complex problems fall between the cracks due to this divide. It is a system not fit for purpose in 2023.

When the Medicare agreement was struck in 1984, the Commonwealth agreed to pay 50% of the costs of the state public hospital system. During the Howard government years, this reached a nadir of 39%, the billions of dollars gained by the Commonwealth spent on tax rebate for private health insurance. With funds progressively tightening and the cost of acute in-hospital care rising, the states had no choice but to reduce funding to outpatient services. Much more could be written about this but space is tight.

Australians are well served by parallel public and private health systems as each controls the excesses of the other. But it needs a correct balance, currently tilted too far in favour of the private sector. Better funding for the public sector is needed to restore it.

Currently, the Commonwealth provides funding in the low 40% range. The ALP has for sometime supported paying 50% of the constantly increasing cost but have not yet committed to 50% of the base. In the current economic circumstance, the latter is not likely to occur soon.

But public hospital waiting times for gap-free, specialist consultation can be addressed now and at a reasonable and affordable cost. It requires funding for building more outpatient clinic space and the clinicians who would staff them, each cost reasonably easily calculated. The Commonwealth would have to provide the cost of both but the better model for employment of the staff would be with the state hospital to facilitate modern integrated and multidisciplinary models of care. The goal is to provide sufficient rate of consultation to bring waiting times down to the clinically appropriate period.

New clinic design would allow delivery of much needed modern models of care for severe chronic disease . They would not be built in the barn style of the last century. In clinics I visited in Sweden, no waiting area accommodates more than 15 people, for privacy; all are brightly furnished by you-know-what. Modern facilities should include a proportion of larger rooms for multidisciplinary consultation (more than one type of specialist and/or nurse specialists and allied health). Larger rooms are also used for teaching medical students and training young specialists skills that are poorly acquired in the inpatient wards. Space is allocated for clinical trial and clinical research staff, optimising the clinic’s contribution to future better care.

A key element is the appointment of clinical nurse specialists as complex care co-ordinators. When the UK NHS funded a national network of MS Nurses, the admissions to hospital for multiple sclerosis plummeted by a massive 97% ! It is not by chance that the Jane McGrath Foundation spends all of its funds on care co-ordinators.

Where possible, clinics would be developed off the hospital campus for patient convenience but most would not, as staffing would be difficult. In hospital, they may be co-located with a department’s day only ward and/or in patient beds. A mixture of all models would be developed by clinicians in partnership with health managers. The benefits go far beyond reducing waiting times.

The process could start this year with a trial in areas of greatest need; in Sydney, the southwest and west. Assessment would include process outcomes (rates and time to achieve waiting time goals) and cost per patient (discounted for estimated savings from avoided hospital admissions and time off work). Health outcomes are more difficult to measure but achievable, at least in part.

With the program evidence based, a rollout across the country could begin in this term of government.

In parallel, also during this term of government, the jurisdictional divide has to be permanently addressed through the creation of an Australian Health Reform Commission which would oversee the trial described above.

The Albanese government inherited this problem and now have an enhanced opportunity to tackle it with ALP governments in all mainland states and territories. The corollary of this is justified criticism if this challenge is ignored. An opportunity lost on their watch.

None of this is new territory to the ALP. Prior to the 2019 election, then shadow health minister Catherine King announced that, if in government, they would establish an Australian Health Reform Commission which “will initially focus on increasing access to public hospital specialists and addressing the rising burden of chronic disease in an ageing population”.

Good policy delayed, but please, not good policy denied, in 2023.


Editor’s note: This article was updated on April 28, 2023 to include reference to clinical nurse specialists as complex care co-ordinators.

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