Blame game ob­scures decades of ne­glect by all con­cerned

The Weekend Australian - Travel - - Health - STEPHEN LEEDER

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

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