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THE public health system in Australia is at an access crisis point because of severe and chronic underfunding, say experts, and fixing it will take a multipronged approach that brings prevention back into the national conversation.
These problems aren’t new and aren’t solely because of COVID-19, but the intensity of the past 2 years of the pandemic has exacerbated the situation. We continue to hear daily stories of ambulances ramping, emergency departments (EDs) at capacity, people not able to see their GP and not enough access for critical mental health services.
With a federal election 2 weeks away, the Public Health Association of Australia’s CEO, Adjunct Professor Terry Slevin, told InSight+ in an exclusive podcast that discussion about the long term future of Australia’s public health system has been conspicuous by its absence.
“There’s always been a challenge in the Australian political system with non-fixed 3-year terms, to turn the mind to long term thinking. [There’s] not an enormous political payoff for our political leaders, to think about 5-, 10-, 15- and 20-year plans. Their imperative is to get through the next election, to sell the policy that is popular now,” he said.
However, the public health system desperately needs that long term thinking. The Australian Medical Association (AMA) has been lobbying with the “Clear the hospital logjam” campaign. They’re hoping to engage either political party to promise a 50/50 hospital funding split with the states instead of the 45% the federal government currently provides.
“That is a call that’s been supported by all of the states, and it would go a long way,” Federal AMA President Dr Omar Khorshid told ABC News.
“It would actually add something like $20 billion into the health system, into the hospital system, over 4 years. And that’s enough to make a meaningful difference, to allow the states to invest in capacity and to make sure that hospitals are delivering on the health care needs, which we know are increasing.”
Part of the problem is that hospitals are full. But according to emergency physician and AMA Victoria representative Dr Simon Judkins, why they’re full is a more complex puzzle and comes down to workforce and resources.
“The reasons the hospitals are full is because [first] there’s a lot of bed closures, because there’s no staff. A lot of staff are off sick, and a lot of nursing staff have probably left the hospital system,” he explained.
Professor Slevin agreed that workforce was a big issue.
“Whether it’s in the aged care sector, whether it’s in the field of nursing, or a number of other areas, we’re coming to understand that having a reliable, well trained workforce in the public health sphere is increasingly important,” he said.
He said there needs to be effective leadership, but there also needs to be a workforce pipeline which doesn’t exist in most jurisdictions.
“We do have a model from which to draw on. New South Wales, for example, has had a public health officer training program in place for more than 30 years, and it’s served them very well,” he explained.
The other major issue was resources, both within the hospital and in the community, said Dr Judkins.
“You’ve got a large part of your beds that are supposed to be for acute patient care, that are full of patients who have passed that phase of their care and have nowhere else to go. They can’t go home, they can’t get into aged care, they can’t get a [National Disability Insurance Scheme] package. So they’re stuck in the hospital system,” he explained.
He said the cycle continues even when these people are in the community.
“We’re seeing more and more patients also presenting because of those things. When the level of care they need in the community increases, there isn’t the ability to escalate and get the resources in to actually care for that patient. So they end up in emergency departments,” he said.
They often try to see a GP, but for many people the waiting list is weeks long.
“It means that patients who would normally go to their GPs for things are waiting and waiting. And then they turn up to the ED and they need hospital admission,” Dr Judkins explained.
Professor Slevin said part of the resourcing problem was lack of funding.
“Most people are shocked to learn that currently, less than 2% of health expenditure goes into public and preventive health. So, if you think of an ounce of prevention being worth a pound of cure, we’re not even getting micrograms. That’s the fundamental problem,” he explained.
Dr Judkins agreed that, in the long term, we need to change the way we view health.
“We have a super specialised workforce. The majority of specialists are trained as proceduralists. They get paid to do procedures and make money out of doing procedures. We’re very much focused on that. We probably need to get the pendulum to swing back a lot more towards preventative care,” Dr Judkins said.
We saw from COVID-19 how important prevention is and experts say it should be a lesson for how we approach all areas of public health.
“Looking at mental health, we should make sure that people stay supported in their community. We look at homelessness, mental health, hospital [ED] presentations, they’re all linked. We should try to prevent that from happening by keeping people well, supported and in a secure home,” Dr Judkins explained.
Part of the problem was the health-wealth gap.
“If you have money and you can access dental care, and you can afford your medications, and you can access healthy food and health care literacy, then you’re going to live a lot longer in Australia. It’s sad that you have to have money to prevent yourself from getting unwell. But that’s the reality of our community,” he said.
If we want a better public health system, Dr Judkins said there’s one thing to think about when turning up at the polling booth.
“People need to think about not what’s best for them, but what’s best for the community. Ultimately, we’ll have a much better community if we all do that.”
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Health Education and Health Screening as Tools in Health Prevention
Certainly, two effective aspects of illness prevention, rather than the seemingly irrational term ‘health prevention’, are health education and health screening.
Health education can be used to teach people about adverse behaviours that lead to poor health and acute sickness. However, the emphasis placed on health education in Australia, and in other countries, is poorly lacking. Our health system is crisis-oriented as witnessed by the discussion on hospital efficiencies and deficiencies. ‘Ambulance ramping’ is a case in point.
For health education to be practical and effective it needs to be creditable, Further, it needs to be ‘toned’ to the audience to which it is addressed, Not always easy!
Prevention can also be addressed by health screening. The National Bowel Cancer Screening Programme is, arguably, ‘proof positive’ of health screening. Another example, indeed a fine example, of health screening was the National Anti-Tuberculosis Programme’ which no longer runs and which, incidentally, was Australia’s first national compulsory health screening programme. No doubt, modern drugs to defeat tuberculosis were one of the reasons for the start-up of this programme … knowing who had the disease was reason enough to commence pharmacotherapy. However, we need to keep in mind that we are now facing multi-drug resistance in our efforts to treat the tubercle bacilli. A great shame, Such is the story with many other diseases.
Health education helps to change those behaviours that lead to ill-health. Fortunately, we are addressing cigarette smoking and, to some extent, excessive alcohol intake through health education or, if you prefer, public awareness programmes. These are two behaviours that lead to a multitude of illnesses many of which are life-threatening and which lead to many hospital admissions. Further, we will be able to reduce the incidence and prevalence of rheumatic heart disease among our First Nations peoples if only we could introduce effective health education in this area although it needs mentioning that screening for this disease has somewhat improved recently.
I know of a few tertiary institutions across Australia that offer courses in ill-health prevention. That said, the issue of ill-health prevention is hardly mentioned or raised in many public health or health science courses.
Until health prevention is accorded the attention that it deserves we will see our hospitals working at breaking point and the general health of our populace deteriorate no matter how much money we throw at primary, secondary and tertiary level health care treatment.
I think the article is biased. The extreme demand for some specialists like Intensivist’s is borne out of need and primary care cannot prevent everything. The discussion should instead focus on what is required to scale up such complex services like intensive care. “Public health” – the dictatorial service without reason – on the other hand, needs to be held accountable for all their misgivings. These mistakes cannot be repeated. And they should never ever be able to hijack democracy under the pretext of precautionary principle. My humble 2 cents.
No amount of money will ever be enough. And health is just one of the inevitable lobby groups with an axe to grind.
How about we start by publishing the relative proportions of the health budget consumed by clinical care vs administrative churn, now, and say 30 years ago? The data must be out there.
Then maybe we could start reallocation of existing funding more effectively, before coming with begging bowl in an era when our grandchildren will already still be paying for our recent indulgences.