Reform needs to refocus on research
THE Rudd Government’s commitment to a major review of Australian health services, with a National Health and Hospitals Reform Commission, before resolving the long-term responsibility for hospitals, is welcomed.
The current structure, with shared responsibilities for funding of hospitals between Commonwealth and the States, was set in place with introduction of Medibank in 1975. Many issues have changed in the intervening 33 years, both in health services and community needs.
The current tangled and conflicting responsibilities for the sick elderly are not the answer. Health care for the aged needs case management crossing hospital, nursing home and community sectors. The Council of Australian Governments (COAG) sees diabetes and obesity as major challenges, but conflicting responsibilities need a rethink if headway is to be achieved. There are many emerging issues impacting on both hospital and primary care services and on prevention.
Initiatives have been taken related to safety and quality in hospitals, such as development of the Australian Council on Safety and Quality in Health Care and the National Institute of Clinical Studies, but to date these have had limited impact. Our national system, articulated through the Australian Health Care Agreements (AHCAs), has budgets, patient throughput figures and waiting lists as the primary drivers in hospitals management.
During the recent election campaign, states were criticised for poor management of hospitals, but we have no real evidence on which to assess quality of performance. In recent years, in the UK’s National Health Service (NHS) and many hospital services in the US, measures of hospital performance have become widely employed, with international benchmarks, such as those developed by the US Commonwealth Fund.
There is now clear evidence that quality of health care has significantly improved in the NHS since such measures have been used. Quality of performance of research-active (teaching) hospitals has been shown to be superior to that of non-teaching hospitals. There are many reasons for this, including attracting and retaining staff of high quality, commitment to innovation and to constant assessment of the quality of outcomes.
When major innovation in health services is becoming possible with discoveries in biomolecular medicine and with innovative use of information technology, we must ensure we have the capacity to respond. It is essential that we have, for the future, a basis for innovation and development in our national system.
In the UK this has been tackled with changes, culminating in the Cooksey Report of 2006, making research and development integral components of the function of all major hospitals. In the US, major university hospitals, since the Flexner Report of 1910, have had a commitment to research and have been the source of many major advances in medicine and surgery internationally over the past 40 years. In Australia, with a hospital system under financial stress and no measures of quality associated with funding or control, research has increasingly been seen as a cost, not relevant to performance of hospitals or of their CEOs. Incidents such as a miscarriage in an emergency department come to be used as a measure of hospital quality!
The absence of any major commitment to research and development in health services or of formal assessment of quality of outcomes has long-term health system.
We have strong medical research in Australia, but its presence as a necessary function of hospitals is in jeopardy. The situation is made worse when research funds, normally from NHMRC and major alternative bodies, pass primarily through universities or medical research institutes, which then receive Commonwealth research infrastructure funding. Hospitals, however, remain responsible for Human Research Ethics approval and all research related to patient care must be approved by the hospital — but there is no source of funding for administration and support of this function.
Translational research’’ is the means by which new methods to deliver health care emerge from advances in science and technology, but the incentive in managing hospitals is to minimise expenditure on activities not directly related to patient throughput, waiting lists and balanced budgets.
Appointment of hospital research directors and support staff are in jeopardy unless support of research and development becomes recognised as of major significance in the performance of hospitals, linked with appropriate funding. The commitment to continuing review of clinical outcomes for patients, so fundamental to applied clinical research, is also basic for data collection on quality of hospital performance.
Professor Sally Davies, director-general for research and development for the NHS, will be in Melbourne on 30 January 2008 in association with a review of the NHMRC. A national summit will be held at which CEOs of a number of major teaching hospitals around Australia will meet her to learn from British experience. It is proposed to develop a plan for support of the research function of major hospitals in Australia, which might then be incorporated in future AHCA arrangements. Professor David Penington AC was chairman of the Commonwealth Committee of Inquiry into Rights of Private Practice in Public Hospitals in 1984, which entailed reviewing the entire Australian public hospital system. He has since been vice-chancellor of the University of Melbourne.