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THERE has never been a greater appetite for whole-of-health system reform.
In recent weeks, we have seen state health ministers agree that public hospitals are in crisis, pointing out that hundreds of acute hospital beds are occupied by people waiting for aged care or disability services.
The Australian Medical Association has joined the call, warning that patients are being harmed in clogged emergency departments (EDs) and in ambulances queued outside, recommending significant investment in primary and hospital care.
Reports from the Royal Commission into Victoria’s Mental Health System and the Productivity Commission into Mental Health have made it clear that large-scale redesign of mental health services is urgently required.
The media spotlight has been on ED overcrowding. Tragic stories accentuate the need for change. ED clinicians feel the impact of overcrowding every day — people treated on ambulance stretchers, in corridors, or in the waiting room; people waiting hours for diagnostic tests and procedures; people who come to hospital with poorly managed chronic or social conditions because there is nowhere else to go. Access block, where patients who are admitted and require an inpatient bed are delayed in the ED for 8 hours or more due to lack of hospital capacity, compromises all aspects of ED care.
Emergency physicians know that ED overcrowding is a sign of dysfunction across the broader health system. While we are constantly striving to improve the quality of emergency care, we highlight that most of the solutions to overcrowding lie outside the ED.
InSight+ recently published an article by Dr Simon Judkins describing the critical state of ED overcrowding across Australia. A poll attached to the article asked readers whether they agreed with the statement: “urgent reform is needed to support the acute care sector of Australian health care”. To date there have been 1160 responses, with only 11 disagreeing or strongly disagreeing. The results were overwhelming.
There is clear evidence that ED overcrowding is associated with preventable morbidity and mortality. Emergency physicians have spoken up about this for many years, but responses have been inadequate. The system has become increasingly overloaded, fragmented and dysfunctional. Factors causing ED overcrowding have an impact on everyone who is treated in or works in the health system. Addressing overcrowding is not just an issue for EDs, the problems and solutions are complex and shared. The time has come for all of us to work together to create a safer, fairer and more patient-focused health system.
Much of the problem lies in the way our health services are governed and funded. Community and primary care, including GPs and residential aged care facilities, are regulated by the federal government. Acute hospitals are managed by the states. Add in a heavily subsidised private hospital sector and opaque (and often confusing) health insurance products and it is no surprise that the acute health sector is a mess, with cost-shifting, duplication and excessive bureaucracy. Review of governance and finance arrangements to drive best-practice, health-promoting, collaborative care must be an urgent priority for reform.
The divide between federal and state governments is responsible for a persistent problem: patients waiting in acute hospitals for residential aged care beds, and a pervasive myth that EDs would not be crowded if only people visited their GP.
Blame and cost-shifting between levels of government must stop. We must also stop blaming patients for coming to the ED. People with simple health issues that could have been managed by their GP do not require a bed in the ED, complex diagnostic testing, or admission to an inpatient unit. So-called “GP-suitable patients” are categorically not the cause of hospital access block. We must better appreciate the cost and access barriers that drive people to seek acute treatment in an ED instead of primary care, and design and resource the health system differently.
COVID-19 has highlighted new risks of ED and hospital overcrowding. It is impossible to practise effective spatial distancing and infection control in an overloaded clinical environment. Redesign efforts in response to the pandemic have demonstrated that clinicians from diverse specialties and professions can work together with managers, patients and carers to rapidly implement collaborative and safety-focused solutions. We should harness this spirit of cooperation to build a “new normal” health system. It is disappointing to see clinicians slip back into old, disconnected ways when we should continue working together to drive innovation and excellence.
What would an improved system look like? From an ED perspective, it is all about access.
We need access to senior clinical decision making, with regular inpatient team ward rounds, clinics and consultations beyond office hours, seven days per week. We need access to skilled health care workers in adequate numbers to allow balanced rosters over extended hours, with access to leave, rest and education, supported by smooth and integrated training pathways.
We need timely access to diagnostic tests and results. We need access to information, including well designed digital systems that cross hospital–community–patient interfaces and consistent, evidence-based national clinical guidelines.
We need collegial access to health service managers to troubleshoot problems and find clinically focused solutions.
Above all, we need streamlined patient flow in, through and out of acute hospitals, to ensure that patients requiring admission from the ED always have access to an adequately staffed appropriate inpatient bed, with public hospital bed capacity proportionate to the predicted population demand.
Of course, the majority of health care does not happen in hospitals. An improved health system must be centred on access to excellent, well resourced, primary and community-based care. We need access to GPs who are appropriately remunerated, connected and supported. We need after-hours access to subacute services, such as the “Safe Haven Café” for mental health care and child health clinics.
We need hospital-in-the-home models to support treatment of people in their usual environment, and timely and affordable access to medical specialist, dental and allied health care.
We need a residential aged care sector which is driven by care, not profit, with adequate numbers of registered nurses and around-the-clock access to contextualised medical advice.
We need health promotion, access to timely preventive measures, and better attention to improving the social determinants of health.
An effective health system requires all these components, across the full spectrum from individual to population level care. As clinicians, it can be difficult to see beyond our professional silos and it is tempting to advocate (and compete) for our own direct priorities, especially in times of budgetary constraint. A functional system requires balance and coordination. No single service or sector holds all the answers.
You are likely to be familiar with the National Emergency Access Target (NEAT), also known as “the 4-hour rule”, which was implemented across Australia in 2012. While intended to drive resourcing and capacity across the entire health system, the one-size-fits-all measure did not consider the needs of different patient streams, making it possible to hit the target and miss the point. It was easy for hospital executives to focus on patient movements in and out of the ED but not on resolving the fundamental problem: that the entire system was running over capacity. Evidence has shown that there are improvements in patient mortality and morbidity when we adopt a hospital-wide approach to patient flow through proper resourcing, staffing and hospital capacity. A more nuanced approach and a broader understanding of hospital access targets will be required as we move forward.
It is time for action on ED overcrowding and access block. Emergency physicians cannot do this alone. The problems are too complex, and solutions largely sit outside the ED. We need whole-of-system collaboration to drive meaningful change. Poor access to care threatens the health and safety of patients and clinicians. We have a shared responsibility to do better, including learning more about system-wide problems, redesigning our own processes and practice, and making more deliberate efforts to collaborate across professional and service boundaries to improve care.
The Australasian College for Emergency Medicine continues with significant advocacy on ED overcrowding and access block, calling for greater state, territory and federal government collaboration to alleviate significant pressures.
We ask that colleagues in other specialties and professions stand with us to advocate for change. Together, we must engage with decision makers and work towards a common goal: timely access to affordable, safe, and effective health care for all Australians.
Dr Simon Judkins is the Immediate Past President of the Australasian College for Emergency Medicine (ACEM).
Dr John Bonning is President of ACEM.
Dr Clare Skinner is President Elect of ACEM.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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It’s so good to see the number of positive comments here – clearly the issue is real and well-understood. What many here may not understand, if it has been a while since they worked in an ED, is that, while the workload continues to grow, under such constrained working conditions and resources, the expectations also continue to grow. ED clinicians are expected to take on the risk of patients that others want to pass on, do so in a timely way but also perform perfectly – or get crucified by both institutional managers and other-specialty colleagues if things go wrong (which they inevitably do under these circumstances).
I would ask everyone reading and commenting here to consider what they, personally, can do to avoid the increasing overload of EDs. Consider alternatives to ED for those patients who do not have an acute life-threatening issue. If you do refer them, explain the reason for the wait. If you are a community consultant wanting to bypass the admission process, please explain to your patient that it is not the ED’s choice that you have to wait in a queue, and think about finding a different solution.
Great article – if we have a government that struggles to cope with a pandemic – how are they going to plan a health system that works for normal times!!
This is a well written and researched article. With the population growth and changing demographics it is absolutely neccessary for the State and Federal Health departments to continue to monitor and review the Hospital system regularly (perhaps every 2 to 5 years) to update and modify hospitals to serve the needs of the people. It takes time and funding to build or extend a hospital and to staff the hospital properly to provide the health care needs of the population. To quote a very ancient Chinese philosopher ” Do not wait till your are thirsty before starting to dig a well”.
The issue is and will always be, is you can’t run a hospital for profit. Unfortunately that is the way in which we live in today society. People demand better services and instant access to health care. But the problem is that investors demand returns and profit. We have a multitude of professionals that are leaving in droves and theses are highly skilled professionals with years of experience that are willing to provide the training and support that or new and enthusiastic health care workers need.
Grest article and dealt well with the humanity of the people they come across. A bit disappointed at some of the negative comments wanting perfection. Really! Doing nothing to change things sure as he’ll isn’t working…..and I was a nurse when Noah was a boy so not an outsider
So the issue I have with this otherwise really very sensible set of policy prescriptions is that we’re adressing efficiency issues. Efficiency improvements, as I see it, are effectively a Parabolic curve of improvement approaching an unacheivable 100% efficient asymptote. Meanwhile, demand increases in an exponential way.
The reason demand increases exponentially is that each time we see a patient, fix them and send them back to the community, they come back with 1 more complexity. We deal with that, send them out, then come back a bit more complex: They spend less and less time out of hospital, returning more and more frequently until the eventually reach the end of what medical science can acheive, then we call in Pal care. That’s an exponential curve, especially when applied to a whole population, and then align that to a steady incremental increase on the number of available treatments.
Thought experiment: Its 2221 and we have the tech to treat every disease that ever existed. How do people die then? Simple: They aren’t seen in time, because the demand is too great, and they die in the waiting room because that’s the only place that it is structurally possible to die. All those treatments still cost money. In this thought experiment efficiency is irrelevant, because demand is infinite but resources are not.
That’s why i reckon every attempt to “Fix” this will merely kick the can down the road: More efficency -> more treatment -> more life extension -> more demand -> more access block. And the cost will eventually be what happened to the little girl in Perth – we can’t simply work harder/more efficiently to stop that from happening.
As a civilisation, we have to find a way to interrupt that cycle (Efficiency -> -> access block) which means one of those steps has to be interrupted – this means deliberately choosing less treatment, less treatment options, less life extension. Can we do it?
A significant omission of this article , is poor end of life identification , communication and management, so that patients bounce in and out of ED, with deterioration/ exacerbation that are part of end of life deterioration.
Medicine’s tendency to find more and more medications to put people on , more and more tests and procedures to do on people, with limited benefits or without the big picture for the patient taken into account.
Lack of Generalists – we are lucky in the regions to still have generalist physicians – I often prefer my elderly complex patients to be looked after by them rather than the gauntlet of public hospital outpatients – with its cumbersomeness and lack of continuity of care.
GP clinics providing their own 24 hr patient cover would improve the situation ( I worked in the last clinic to do so in in my suburb in 1994) but it became non-viable when we attracted too many patients from the Bulk Billing clinic which would not cover their patients after hours. That aside, the home visit fee was an insult ( can’t claim travel time like a lawyer !)
I suspect as long as Australia continues with this federal system, these issue will always be nigh impossible to fix. One does not see this ever changing, sadly. So, what to do, other than the feds take over all healthcare, raise taxes where feasible, add in a wealth tax, and fund the system properly at least. Then we might just see something like the utopian system outlined in the article emerge..?
Great article. Basic things like more hospice beds, rehab facilities, step down hospitals, good access to medical services in the aged care facilities will ease a lot of pressure from the mainstream larger hospitals.
Well said couldn’t agree more!
Agree that in an ideal world all those things would be done but then the issue has always remained re funding. Which means higher taxation’s. Also too many admins/ managerial people implementing unnecessary hurdles in healthcare and not enough docs/ nurses being employed who are actually keep the hospitals/ Primary health care going as most doing it overtime out of their goodwill and not getting remunerated accordingly.
Great article
My daughter is an ED registrar. Her story of completing a 10 hour shift, sleeping, then returning to work to find an octogenarian she had treated the night before still in ED waiting for a ward bed horrified me.
Profits for political mates the infinire-depth bureaucratic mess, the lack of a single state of the art IT system, are all inexcusable.
Fantastic article. Thanks.
Could not agree more. If one single good thing comes from COVID let it please be a focus on this topic.