Blame game obscures decades of neglect by all concerned
YEARS of neglect of the public health system have created an overgrown variant of Jurassic Park: federal political aspirants with or without an interest in health pushing through the undergrowth with minimal skill and effort can have lots of fun if properly armed. They can shoot at almost anything and score a direct hit. Your hospital not running well? Sell it to John Howard for $1. Alternatively, privatise it. Emergency Department down at heel? Appoint a community board to run a lamington drive for a new defibrillator. Blame the states. Blame the Commonwealth.
These ‘‘ let’s go hunting’’ games obscure the failure in recent decades in Australia to invest in public hospitals commensurate with population growth, despite the fact that many high-tech and expensive services are provided by them — and them alone. And the willingness of all parties to engage in the quick fix means that no-one has been bold enough to tackle the reforms in hospital funding and services that are required to reflect the healthcare needs of the 21st century.
Our governments and the private sector have done nicely from this underinvestment. Shifting public money to the private sector via the health insurance subsidy has suited business, and several medical specialities have profited. The Commonwealth feels justified in subsequently limiting its investment in public hospitals and aged care and, until very recently, the states have been able to happily save as more medical services are done in the private sector.
Let’s look further at the effect of these health policies — these ‘‘ how to cut the costs of health services by cutting the services’’ policies — on emergency care.
To operate an effective emergency department in a public hospital first requires skilled staff. At present, there are insufficient trained emergency physicians, and locums, junior and overseas-trained doctors are recruited to fill gaps. They are not happy, feel undervalued, ignored and abused. The failure at both policy and managerial levels to resolve this problem must be shared among bureaucrats, physicians, hospital managers, and academic training institutions.
Problems like these happen when there is no political leadership interested in health and no vision beyond the electoral cycle. Superior recruitment strategies, changed attitudes to remuneration for emergency physicians, and enlightened management practices are required. An aspiring federal politician might well bend his or her mind as to how to meet such a requirement. Discussion with those providing the services is the place to begin.
The second missing piece in emergency service provision is enough beds. Public hospital bed availability has been decreasing. The growth in private emergency departments has not kept pace with the relative increase in private sector beds. Thus, proportionally, an ever-increasing load has been placed on public emergency departments at the same time as public bed availability has been falling.
Studies have shown that ‘‘ access block’’ occurs once hospital occupancy rates exceed 85 per cent, but large city hospitals in Australia commonly operate with occupancy rates over 95 per cent. The arithmetic is simple and political leadership could use it to solve the problem of emergency care. Integrating hospital care with well-resourced community services would improve the quality of life of older patients and probably halve their need for hospital admissions.
Public concern about emergency services has taken the lid off broader worries in the community. It is hard as a patient or a citizen to know who it is that you should turn to when wishing to express concern about health care. Tony Abbott has proposed ways of increasing accountability of hospitals to their communities for their services. Fair enough.
Certainly there is a perception that, in seeking political control over health services and to cut down on public complaints, states have reduced the extent to which the community can call the service to account, especially at the local level.
However, times have changed. Thirty or 40 years ago when high-tech specialisation was uncommon, most hospitals had their own board. But hospitals can no longer operate as individual entities, unconnected to other hospitals and to an integrated system of services and care.
Greater specialisation (with fewer hospitals being able any longer to offer all services) led to the formation of area health services or their equivalent in most states. They had boards that replaced those of individual hospitals — an often unpopular move but one that many observers claim improved health services.
In Victoria, for example, networks that link various health services have boards, and these oversee how well services are provided on behalf of the whole community. Perhaps this is the best example in Australia at present at finding a balance between bureaucratic efficiency and community accountability.
Unfortunately, to move back to the situation where every hospital has its own board invites a return to disintegrated service provision, and ignores the fact that highly specialised health services are nowadays provided not in every hospital, but at regional, state and sometimes even national centres of excellence. It also seems certain to ensure that less well-off areas, less able to advocate and raise funds, will have poorer services, thus doing nothing to resolve the growing problem of inequity in health care in Australia. This proposed solution to the problem of lack of accountability comes from the age of the dinosaur.
There is plenty for the thoughtful federal political aspirant to discuss and to propose in relation to the nation’s health. Not least is how to provide integrated hospital care and care in the community. Put down your weapons, please, look around, think, and lead. Professor Stephen Leeder is director of the the Australian Health Policy Institute and codirector of the Menzies Centre for Health Policy at the University of Sydney