Govt under pressure as hospitals stumble

Mounting evidence that public hospitals are struggling to make headway in meeting key performance benchmarks is increasing the pressure on the Federal Government to agree on a permanent boost to funding as part of any overhaul of Commonwealth-State health arrangements.

Australian Institute of Health and Welfare figures show that the performance of public hospitals is slipping back as massive funding cuts announced in the 2014-15 Federal Budget begin to bite.

The proportion of urgent emergency department patients receiving treatment within the recommended time fell back in 2014-15 from 70 per cent to 68 per cent – brining to an end six years of continuous improvement and leaving performance well short of the target of 80 per cent, which was due to be reached two years ago.

The goal for all emergency department visits to be completed within four hours, which was meant to be achieved this year, has also been missed.

The results bear out warnings made by the AMA earlier this year that the Commonwealth’s funding cuts for hospitals would undermine the delivery of care.

Launching the AMA’s annual Public Hospital Report Card in April, President Professor Brian Owler said the Federal Government’s cuts – amounting to $57 billion in the next 10 years – were creating “a huge black hole in public hospital funding”.

“It’s the perfect storm for our public hospital system,” he said. “There’s no way that states and territories can even maintain their current frontline clinical services under that sort of funding regime, let alone build any capacity we actually need to address the shortfalls now.”

Health Minister Sussan Ley rejected the warnings at the time, but the latest evidence of declining performance are likely to make it increasingly difficult for the Government to win State backing for an overhaul of funding arrangements without more money on the table.

Late last week the nation’s leaders were due to discuss a proposal by South Australian Premier Jay Weatherill to increase the goods and services tax to 15 per cent, with the proceeds to go to the Commonwealth. In exchange, the states would be given a guaranteed slice of income tax revenue.

Weak growth in consumer spending has undermined the flow of revenue to the states from the GST, making it increasingly difficult for them to fund fast-growing demand for public hospital services.

Mr Weatherill said giving states a slice of the faster-growing income tax take would enable them to keep funding health.

The states have been ramping up the pressure on the Commonwealth over the impact of its spending cuts.

Queensland Health Minister Cameron Dick told a meeting of the nation’s health ministers last month that the Coalition Government’s cuts would slash $11.8 billion from the State’s hospital system. The Victorian Government has calculated it stands to lose $17.7, while New South Wales has figured a $16.5 billion loss, South Australia $4.6 billion, Western Australia $4.8 billion and Tasmania $1.1 billion.

The big cuts form a challenging backdrop for discussions of reform to Federal-State relations that include proposals for Commonwealth public hospital funding to be replaced by a “hospital benefit payment” that would follow individuals, similar to Medicare.

Government discussions of changes to the private health insurance industry have included reference to option two in the Reform of the Federation Discussion Paper, which proposes a Medicare-style payment for hospital services, regardless of whether they are provided in the public or private system.

Under the arrangement, the price of hospital procedures would be set by an independent body and the Commonwealth would pay a proportion. For patients in the public system, the states would be expected to make up the difference, while in private hospitals the gap would be covered either by insurers or the patients themselves.

States would retain responsibility and operational control of public hospitals, and would be able to commission services from the private sector, while the Commonwealth would discontinue the private health insurance rebate.

Adrian Rollins

Hospital doctors’ Opinions regarding educational Utility, public Sentiment and career Effects of Medical television Dramas: the HOUSE MD study

A career in medicine has long been considered an apprenticeship, with mentors providing guidance to their trainees. The word mentor finds its origins in Greek mythology. In Homer’s Odyssey, the confidant of king Odysseus, Mentor, was trusted to guide his son and oversee his education while Odysseus fought in the Trojan War.1

The modern practice of medicine, with an emphasis on shift work, has made the classical mentor–mentee relationship more challenging,2 but the modelling of one’s practice on observed social and clinical traits of a mentor or role model remains.3 Moreover, such exposures can be factors in students’ decisions to pursue a career in medicine and even in their subsequent choice of specialty.4

The eventual choice of role model is often a personal one and may not even involve one’s own supervising senior, although it is often based on clinical experiences.5 While knowledge and clinical competence have been cornerstones of role model selection, growing evidence suggests that factors relating to personality such as compassion, good communication and enthusiasm may in fact have more influence on the expanding minds of trainees.6 Further compounding this, in some educational situations, less than half of senior clinicians were subsequently identified as being excellent role models.7

While social interactions with parents, teachers or even peers may impact on personality, outlook and practice, other media such as literature and television (TV) have been demonstrated to be significant components of this role model hypothesis.8

Medical TV programs have grown in popularity from the 1960s onwards and are now considered a staple of primetime TV.9 It has only been in more recent years that the effects of these health and illness TV narratives have been studied in greater detail.

Although their true purpose has been one of entertainment, much of their appeal is based on the perception that they are an accurate reflection of reality.10

It has been well accepted that TV can have an impact on society, increasing knowledge and influencing behaviour.11 TV medical dramas have also been shown to be of educational worth to patients12 and even doctors.13

However, they have occasionally come under criticism for unrealistic medical content, ranging from demonstration of intubation technique14 to cardiopulmonary resuscitation (CPR).15 Frequently, in CPR situations on TV compared with actual practice, there is a higher volume of trauma cases as an underlying aetiology. Further, these scenarios often show considerably younger patients than those seen in routine CPR and survival to discharge is much better than clinically encountered.16 Concerns that this may influence the attitudes of members of the public who watch these dramas for educational purposes remain.

More recently, there has been a growing emphasis on the use of these programs as educational resources.17 In particular, some of the established role model personality traits such as ethical astuteness, communication and empathy have been sufficiently demonstrated in these series to warrant use in undergraduate teaching videos.18 Although much of the learning that can be gleaned from observing the practices of TV doctors has focused on perceived softer undergraduate educational domains,19 their use in postgraduate settings is also increasing.20

TV is a medium through which many health care workers not only take their minds off work, but also reflect both consciously and unconsciously on experiences. Students and doctors do indeed watch these programs at least as often as the general public does and, when questioned, are quite positive regarding them.21 Although not yet demonstrated, watching these series may form an early part of any role modelling or identification with certain character traits that both trainee and established medical practitioners may have.

Methods

A structured questionnaire was distributed among doctors of all grades and specialties in three large teaching hospitals in Wales, United Kingdom (Morriston Hospital, Singleton Hospital and Princess of Wales Hospital) within the Abertawe Bro Morgannwg (ABM) University Health Board, to allow capture of data from a diverse range of specialties. These were disseminated through various different locations, including departmental meetings and on-call rooms.

Questions related to respondents’ gender, specialty and grade, whether they watched medical TV dramas and their opinions regarding them, and whether they identified with characters from these programs (and if so, who) or with a non-fictional doctor encountered during their clinical careers.

Hospital grades were summarised as consultant, specialist trainee (registrar), core trainee (resident medical officer [RMO]), and foundation doctor (intern). For simplification, specialties was separated into medical, surgical, acute (eg, accident and emergency, intensive care unit, etc) and non-acute (eg, pathology, radiology, etc), although note was made of individual subspecialty answers from within these broader categories.

Statistical analysis

A cumulative odds ordinal logistic regression with proportional odds was run to determine the effect of grade and specialty on the choice and frequency of viewing of medical TV dramas. Statistical significance was set at P < 0.05. Statistical calculations were performed using SPSS Statistics, version 21.0 (IBM).

Ethics approval

Ethics approval was granted by the ABM University Health Board Research and Development Joint Scientific Review Committee.

Results

Three hundred and seventy-two questionnaires were disseminated and 200 completed questionnaires were returned (response rate, 54%). Forty-six per cent of individuals completing questionnaires were women and 88% had graduated from a UK medical school. Grades and specialties of respondents are presented in Box 1.

How often do clinicians watch TV medical dramas?

One hundred and twenty-nine doctors (65%) surveyed admitted to watching TV medical dramas on more than one occasion and 14% considered themselves to be regular viewers; 15% of respondents felt that watching them as a school student positively influenced their decision to pursue a medical career.

Junior doctors were five times more likely to have watched these programs as medical students compared with more senior doctors (odds ratio [OR], 5.2; 95% CI, 2.5–10; P < 0.01). The ORs for RMOs and specialist trainees were 3.1 and 2.5, respectively, in relation to consultants (P < 0.05). Further, UK graduates were five times more likely to have watched these medical TV dramas as medical students compared with non-UK graduates (OR, 4.8; 95% CI, 2.4–9.6; P < 0.01).

The most commonly watched TV programs were Scrubs (49%), House MD (35%) and ER (21%). Most doctors who admitted to watching medical dramas did so for entertainment purposes (69%); 19% watched because there was nothing else on TV; 5% for insight into media perceptions of medical practice; and 8% for educational purposes.

Clinicians’ opinions regarding TV medical dramas

We asked individuals if they felt that TV medical dramas were educational, gave doctors a bad name, accurately showed the doctor–nurse relationship, and represented the spectrum of illnesses commonly encountered.

One hundred and three respondents (52%) felt that these shows displayed no educational value whatsoever, 52 (26%) were unsure, and 45 (23%) believed there were some educational benefits from watching them.

Evaluating the spectrum of illness represented in these dramas, 82% felt that those shown were unrealistic of daily practice. However, 20 respondents (10%) thought that they accurately portrayed reality. Most of these positive responses (16/20) were from junior doctors. No associations between the belief that medical dramas portrayed realistic life situations and specialty or frequency of viewing were observed.

Grade, specialty and country of qualification had no effect on whether a doctor believed that the programs represented current medical practice. Neither did current frequent watching or having been a regular viewer at undergraduate level.

Twenty-seven per cent of doctors surveyed felt that these programs gave doctors a bad name, although no significant differences were observed between any of the groups.

Only 13% of respondents felt that medical dramas accurately portrayed the doctor–nurse relationship, most of whom were self-admitted non-regular viewers (P = 0.01) and general practitioners or GP trainees (19/25; P = 0.05).

Outcomes of watching TV medical dramas

Thirty per cent of foundation doctors (interns) and 25% of core trainees (RMOs) felt that watching medical TV programs may have affected their career choice (to any extent) compared with more senior doctors (18%).

Compared with consultants, the OR for interns considering that watching medical TV dramas had any effect on their subsequent career choices was 4.8 (95% CI, 1.6–13.7; P = 0.013); for RMOs and specialist trainees, the ORs were 2.5 (95% CI, 1.3–5.8) and 2.7 (95% CI, 1.3–5.8) respectively; P = 0.09 and 0.13).

Specialty and country of qualification did not influence doctors’ beliefs that watching medical dramas had an effect on their career choice.

Clinicians’ identification with doctors in TV medical dramas?

A total of 121 respondents (61%) role modelled aspects of their practice on another doctor (fictional and non-fictional).

Junior doctors, particularly interns and RMOs were more likely to find commonality in their practice with fictional TV characters compared with more senior doctors (OR, 2.7; 95% CI, 1.3–5.8; P = 0.008).

Consultants were most likely not to specify any role models and, if they did so, were more likely to identify themselves with non-fictional characters (32/55) compared with other doctors, particularly interns (4/49).

Medical doctors were more likely to identify themselves with a fictional TV character (OR, 3.2; 95% CI, 1.08–9.43; P = 0.035). This was followed by 19% of acute specialty doctors and 14% of surgical specialty doctors. Non-acute specialty doctors were least likely to identify themselves with a fictional TV doctor.

The top five most popular fictional role models are shown in Box 2. Leonard McCoy (Star Trek) and Quincy (Quincy ME) were the most popular choices among consultants; the majority of positive responders were anaesthetists and pathologists. A more varied response was seen among physicians and surgeons, but note was made of a peculiar popular choice: Dr Evil (from the Austin Powers film series, Box 3) was named by four trainees, all surgical (three orthopaedic and one general surgery).

Discussion

There is a known association between clinical role models in undergraduate medicine and career choice.22 Therefore, TV medical dramas could potentially influence doctors’ and students’ opinions and have been found to be a source of entertainment for both health care professionals as well as the wider public.23

Fictional doctors have evolved into television heroes and much of their appeal is their on-screen personality as well as, in some cases, their absolute prioritisation of scientific challenge over social relationships.24 Further, much of their appeal is their ability to navigate through difficult ethical dilemmas, to make decisions that are often perceived by clinical trainees as being positive ones.25

Although clinicians watching these programs appear to do so predominantly for entertainment purposes, we found that those who watch for educational reasons show that junior trainees exposed to this genre of TV entertainment are more influenced by these series than their more senior counterparts. Interestingly, all respondents who admitted to watching TV medical dramas for educational reasons watched House MD (Box 4), perhaps suggesting that they value its learning input.

In keeping with previous studies,14–16 most doctors felt that a large proportion of what was televised may not be a true representation of clinical practice; however, suggestions that more junior trainees believe this to be so could be explained by their relative lack of clinical experiences to date.

Identifying aspects of one’s practice with witnessed exposures has been a cornerstone of the role modelling theory, but data generated from this questionnaire-based study suggest some interesting differences between specialties. Doctors who answered negatively to currently viewing or having ever viewed this type of program were least likely to admit to having been influenced into a career in medicine on the basis of TV medical dramas, thus validating the data.

It is to be assumed that consultants may look on their past seniors as role models to identify commonality of practice but the high proportion of respondents among all grades who admitted to being influenced, at least in part, by medical TV dramas suggests a much higher effect than anticipated.

Further, differences between specialities — for example, medical doctors identifying more with TV doctors compared with their surgical peers — might be explained by the sizeable volume of medically themed programs as opposed to more surgical ones. It is plausible, however, that some of the core learning traits seen in physicianly specialties, particularly regarding difficult diagnostics and ethical dilemmas, strike a chord with this group of clinicians. Specific choice of TV doctor hero as a potential role model will require further evaluation. Motivations for the popular choice of a Star Trek character among anaesthetists may include an interest in futuristic technology. Likewise, the interesting preference for Dr Evil among some surgical trainees may be due to an interest in world and/or career domination, or it may be suggestive of professional ambition rather than a display of true megalomaniac traits.

While we may be some years from continuing medical education creditation obtained from Saturday evening viewing, this study does suggest that the current generation of junior doctors relies on medical TV dramas for entertainment and education in parallel. Further observation may show some interesting effects during career progression, particularly regarding the atypical answers we received to our questions about TV doctor identification.

Box 1 –
Grade and specialty of respondents (n = 200)

Grade and specialty

No. (%)

Grade

Intern

49 (24.5%)

Core trainee (RMO)

60 (30.0%)

Registrar (specialist trainee)

36 (18.0%)

Consultant

55 (27.5%)

Specialty

Medical

83 (41.5%)

Surgical

36 (18.0%)

Acute non-medical

27 (13.5%)

Non-acute

20 (10.0%)

GP or GP trainee

34 (17.0%)

RMO = resident medical officer.

Box 2 –
Most popular fictional television doctor role models

Rank

Doctor

Show

Alcohol gifts in medicine

Doctors commonly receive gifts of alcohol in professional settings, particularly after giving a talk. This article reflects our personal opinions of this practice. We want our colleagues to consider the symbolism of giving or receiving alcohol as a gift in a professional setting. This is not a promotion of abstinence.

Doctors should be aware of the preventable death and suffering caused by the harmful consumption of alcohol. Thirty per cent of emergency department attendances are alcohol related,1 and there are also personal health risks, mental health issues and social issues involved. Balanced against this, the health benefits of drinking alcohol are not clearly established.2 There is little to be said in favour of the promotion of alcohol, but consumption is a personal choice. In contrast, gift giving of alcohol in professional settings is a public statement.

Many professional bodies have policies on alcohol consumption, but we could find none — including the websites of the Royal Australasian College of Physicians, Royal Australasian College of Surgeons, and Royal Australian College of General Practitioners — with policies on giving alcohol as gifts. Health care professionals have a duty to promote health; as individuals and in our professional groups. The provision of alcohol as a gift would seem to be contrary to a basic tenet of medical practice, which is to promote health.

Alcohol consumption is an accepted part of Australian culture. Our impression is that no one has questioned the appropriateness of alcohol as a gift in the health professional setting. “Everyone drinks (alcohol)” is a frequently used phrase. This is not true as 20% of Australians do not consume alcohol.3 Therefore, the recipient of the alcohol gift could be pregnant, a recovering alcoholic or from a cultural or religious tradition that prohibits alcohol consumption. Others just do not consume alcohol. Giving alcohol as a gift in a professional setting is an ingrained habit, with little thought given to the choice of gift, consideration of the recipient or symbolic consequences of the act.

There are alternatives to giving alcohol as a gift. Giving a gift to someone who has taken the time to prepare and give a talk cannot compensate him or her adequately for his or her time, but it is a token of appreciation. So some thought on the part of the gift giver is in order. International speakers could have something from the country they are visiting and, similarly, someone from interstate could receive something particular to that state. If something particular cannot be identified, general gifts might include chocolates or flowers. Book or music vouchers are always valued. There are also charities that provide online gifts.

In summary, gift giving of alcohol in a professional setting is inappropriate in that it may be insensitive to the recipient and is a poor health promotion message. We call for professional health bodies to take a leadership role and develop policies to find appropriate alternatives to giving alcohol as a gift. We challenge health professionals to be more thoughtful in their choice of gifts in a professional setting.

Mental health services reach the tipping point in Australian acute hospitals

The OECD warns about Australia’s low psychiatric bed numbers

In April 2015, the federal government released the National Mental Health Commission (NMHC) report on the Australian mental health sector.1 Although the report contained many consensus-driven, consumer-oriented proposals, the media focused on the recommended shift of $1 billion from public acute-care hospitals over 5 years to expand community mental health programs including subacute beds.2

The NMHC schedule reduces mental health funding for acute hospitals progressively from the 2017–18 financial year (Box 1).1 Given that total funding was $1.4 billion in the 2012–13 financial year, the reallocation of at least $300 million in the final year of the schedule (2021–22) could reduce the number of acute-care hospital beds by 15%.

As an independent commission, the NMHC has encouraged debate about their report. In a recent article in the Journal, Professor Ian Hickie, an NMHC Commissioner, supported “shifting the emphasis” from acute hospitals to community-based services, and he urged the federal government to act.2 The NMHC chair, Professor Allan Fels, echoed these views in his National Press Club Address in August 2015.3 He criticised federal government expenditure on acute-care hospitals as “payment for failure” and argued that mental health problems should be treated earlier to “catch people before they fall”.

The NMHC report is not without its critics. Australian peak medical bodies suggested that the cuts to acute bed numbers could cost lives. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) argued that the NMHC report ignored the already excessive demand on Australia’s psychiatric wards and emergency departments (EDs).4 The Australian Medical Association (AMA) has also lobbied against acute bed closures, which can block admissions when the risks of suicide and aggression are higher.

These medical experts suggested that Australia’s mental health sector has reached the tipping point of high bed occupancy and extended ED waiting times. If this is correct, Australia needs to commission more acute psychiatric beds and maintain bed occupancy rates below 85%, in order to guarantee the safe functioning of acute hospitals.5

The debate around the public positions of the NMHC and peak medical bodies raises a series of important questions. Does Australia have too many acute psychiatric beds, and can the nation safely make savings by reducing future funding for acute hospitals? How would acute bed closures affect patient care?

The OECD warning

The NMHC report’s recommended acute bed closures would begin from a low base by international standards. Australia is ranked 26th of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) for hospital psychiatric beds per 100 000 population (Box 2).6 In 2013, Australia had 29 fewer beds per 100 000 than the OECD average. Anglosphere countries such as Australia, Canada, the United States and New Zealand tended to have lower bed numbers than the wealthy European nations, with the United Kingdom showing a European influence by having 15 more beds per 100 000 than Australia.

The OECD warned that Australia’s low psychiatric bed numbers increased the risks of worsening symptoms before acute admission.6 These patient risks depended on the “tricky balance” between inpatient care, community services, primary mental health care, and social capital including cooperative networks of carers, extended families and neighbourhoods.

In Australia, the nation seeks to compensate for low acute bed numbers by funding numerous community mental health services.6 In these circumstances, community services must be able to assist patients during the acute phase of their illness either to avert admission or to help patients immediately after discharge.

As Australia’s acute bed occupancy rates are high and patients have a short average length of stay (LOS), patients are often discharged before pharmacotherapy is optimally effective (Australia’s average LOS is 17 days). The 30-day hospital unplanned readmission rate provides a measure of how well community services offset short LOS. In 2011, Australia had the third highest readmission rate among the OECD countries for patients diagnosed with schizophrenia with over 15% being readmitted to hospital within 30 days, and the fourth highest unplanned readmission rate of 15% for patients with bipolar disorder.7 Australia’s readmission rate was higher than that of the UK, where more acute beds allowed longer admissions (the UK average LOS was 30 days versus the Australian average of 17 days); this ensured adequate acute treatment in the UK, which was accompanied by lower readmission rates (5%–10%).7

There was a significant increase in UK readmission rates from 2006 to 2011, which corresponded with a period of acute bed closures.7 As Fels3 noted, the UK government was “trying to manage cutting back hospital spending” in mental health. While hospital psychiatric bed numbers remained considerably higher in the UK than in Australia, these spending cuts created debate. In 2011, distinguished community psychiatrist Professor Peter Tyrer contended that the closure of psychiatric beds had gone too far in the UK, and the risk of preventing admissions was becoming too great.8 He concluded that inpatient care had been “demonised” by community psychiatry advocates who had captured national policy, and he suggested that the UK needed new policies that recognised the unique value of inpatient care. His argument could equally well be applied to Australia.

Emergency demand

South Australian data provide evidence of the excessive mental health demand on acute hospitals. From July 2011, SA anticipated the NMHC report recommendations by transferring funding from acute hospitals to fund community subacute beds.9 Over this period, SA was the only state decommissioning recently mainstreamed acute beds; other states were increasing acute bed numbers consistent with population growth. By 2014, SA was 20% below the Australian average for non-veteran general adult acute hospital beds (for 18–65-year-olds), with double the average number of community beds.

It soon became apparent, however, that these subacute beds were not substituting for the decommissioned acute beds as intended.9 The central problem was risk management. The subacute units were built and staffed for patients at minimal risk of suicide and aggression. This meant that only patients with low-risk presentations could be referred from the community or acute hospitals to the subacute units. Before the subacute units, most of these patients would have been treated at home.

Hence, the SA psychiatric bed mix left a gap in acute care, which resulted in increasing average ED total visit times for mental health patients in metropolitan hospitals over 2011–2014 (Box 3). Average ED visit times peaked at 15.7 hours in October 2014. These average ED visit times reflected the extended periods that mental health patients waited for admission (33.5 hours for mental health patients on average versus 9.3 hours for non-mental health patients in 2014). Of particular concern, 2450 mental health patients waited more than 24 hours in busy and overstimulating ED environments during 2014 (representing 17.5% of the mental health presentations to SA hospital EDs).10

Responding to patient need and community concern, in December 2014, the SA government commissioned 20 beds in metropolitan hospitals to return the state to the national average. The government’s revised strategy targeted investment towards psychiatric short-stay units in acute hospitals (14 beds) allowing up to 48-hour admissions. Early signs were positive, especially in those hospitals with the short-stay beds. For instance, average ED visit times reduced from 12.3 hours in 2014 to 6.7 hours during 2015 following the opening of 8 short-stay psychiatry beds at Flinders Medical Centre in December 2014. The short-stay units provided a dedicated environment for acute presentations enabling improved ED flow, which regional subacute beds had been unable to achieve.

Conclusion

Australia’s low acute bed numbers can block access for mental health patients when the risks of suicide and aggression are higher. The OECD 30-day readmission rates and the SA experience suggest that these problems are not being offset by Australia’s numerous community mental health services, including the expansion of subacute beds in SA. Overall, the data support RANZCP and AMA concerns that Australian acute hospitals are facing excessive mental health demand.

When ED waiting times and 30-day readmission rates are excessive, it is not possible to safely reduce acute hospital funding and close beds. Quite the opposite policy is required; more acute beds should be commissioned when mental health patients are waiting far longer for admission than medical or surgical patients, as occurred recently in SA. Clinical opinion suggests that these issues are not isolated to SA but are occurring in acute hospitals around the country. It is time for policy planners to reflect on the OECD warning, and urgently tackle this huge national problem.

The federal government convened an Expert Reference Group to provide a fresh perspective on the NMHC report. This presents Prime Minister Malcolm Turnbull and the government with an ideal opportunity to carefully evaluate mental health demand on acute hospitals, and to ensure adequate activity-based funding for acute psychiatric beds. This expenditure should not be regarded as “payment for failure”; it is a minimal investment in the compassionate care of mental health patients when they are most unwell, which is the standard required in every area of medicine in Australia.

Box 1 –
The National Mental Health Commission schedule for reducing acute hospital funding1

Financial year

Minimum reallocation ($ million)

2017–18

$100

2018–19

$150

2019–20

$200

2020–21

$250

2021–22

$300

Total

$1000

Box 2 –
Comparison of psychiatric bed numbers in Organisation for Economic Co-operation and Development (OECD) countries, 20116

1. In Japan, a high number of psychiatric care beds are used by long-stay patients. 2. In the Netherlands, psychiatric bed numbers include social care sector beds that may not be included as psychiatric beds in other countries. Source: OECD Health Statistics 2013. http://dx.doi.org/10.1787/health-data-en. Reproduced with permission from the OECD.

Box 3 –
Mean total visit times for mental health patients in the emergency departments (EDs) of South Australian metropolitan hospitals (2011–2015)10

Time period	Mean total ED visit time (hours)

July – December 2011	8.9
January – June 2012	8.4
July – December 2012	10.2
January – June 2013	10.2
July – December 2013	11.4
January – June 2014	12.3
July – December 2014	14.5
January – August 2015	11.5

Time to shut down the acute care conveyor belt?

A rapid response system may be an appropriate model for meeting the urgent need for more suitable care for patients at the end of life

Hospitals can be dangerous places where people can unexpectedly die. Hospitals can also be dangerous places because people are not allowed to die. When they eventually die, it can be a prolonged and demeaning experience.1,2

The population of the world is increasing. People are living longer. An increasing number of aged people are spending their last few days, weeks or months in acute hospitals,3 many of whom will die in intensive care units (ICUs).4 Almost a third of Americans will spend time in an ICU during the last month of their life.4 However, most people want to die at home, not in an acute care hospital.

Discussions around the end of life (EOL) are ubiquitous and the term can be interpreted in many different ways. For the purposes of this article, we limit the term EOL to older people with significant comorbidities who, based on existing evidence, have less than 1 year to live. If EOL care in acute hospitals is one of the largest contributors to health care costs and if our society does not want it, how did it happen and how can we manage EOL care more appropriately and in line with what people want?

The acute care conveyor belt

The current situation is akin to older people with illness being placed on a conveyor belt, beginning in the community and eventually taking them to an acute hospital and then possibly to an ICU. Dying and EOL care have slowly and almost imperceptibly become medicalised. As we have developed impressive ways of keeping people alive, it has become very difficult to exercise the choice to die naturally and not be surrounded by machines and well-meaning people.

When people suffer sudden injury or illness in the community, an ambulance is often called, whether the illness is potentially reversible or simply a minor deterioration in someone with only days to live. The conveyor belt operates largely because of uncertainty of the patient’s prognosis, the lack of practical and readily available alternatives, and the failure of people to have stated their wishes regarding EOL care. Even if people’s wishes are expressed clearly, uncertainty can be a barrier to those wishes being carried out. Patients with severe chronic diseases marked by acute exacerbations become used to the idea that the medical system can always rescue them from life-threatening deteriorations. Of course, rescue is sometimes possible, until it is not. Well-meaning clinicians may convince patients that there is a large, potentially reversible component to their deterioration and that they deserve every chance to leave hospital alive. As a result, the rate of emergency admissions to hospitals and ICUs is dramatically increasing.5–7 Many of these patients are in the last year of life.6 Once patients are in the emergency department, it is easier to admit them to hospital rather than to embark on the time-consuming task of discussing options with them and their caregivers and finding a more appropriate place of care.6

After admission to the hospital, patients are confronted with further pressures to keep them on the conveyor belt. Hospital medicine has become increasingly specialised and fragmented.8 Hospital specialists are experts in their own particular part of the patient’s clinical status. However, the population of patients in acute hospitals has changed and elderly patients rarely have single-organ problems.9 They are now older, with multiple comorbidities. The ability to diagnose dying patients or to identify patients at the EOL, or understand the bigger picture of the patient’s circumstances, is often overlooked by single-organ specialists.10 All in all, the management of the dying process is not done well in acute hospitals.1,2

The final step in this process is to an ICU, where drugs and machines can, in theory, prolong life, no matter what the ultimate prognosis is.

The conveyor belt is also maintained and oiled by those who make the decision about whether the value of further medical intervention is futile. The diagnosis of dying, as defined by the well worn tenet “medicine at this time has nothing more to offer”, has moved from being made by general practitioners in community settings to hospital-based specialists. Deaths in ICUs are rarely sudden and unexpected.11 They are usually orchestrated as a result of withdrawing and withholding treatment after it has been decided, together with the patient and his or her carers, that further medical intervention has nothing else to give. Often, the underlying “disease” or combination of medicalised problems is simply the end result of normal and expected ageing.

Even in the ICU, the decision to continue active management may not be appropriate, as many of the survivors of the ICU do not leave hospital alive and many survivors of intensive care die within 12 months of discharge.12 For the cohort that does survive and leave hospital, there is a high incidence of a severe decrease in quality of life and of symptoms similar to those of posttraumatic stress disorder.13,14 Even if patients at the EOL survive the hospital intervention, little may have been done to improve posthospital survival or quality of life. Apart from the failure of the hospital system to recognise when people are at the EOL, there are other drivers pushing them along the conveyor belt. Society is bombarded with daily reports of medical miracles.15 There is little honest discussion about ageing and dying. Physicians seem to be complicit in this. It is sobering to reflect on the finding that most patients with terminal cancer may not be aware that the palliative chemotherapy they receive is unlikely to be curative.16

Rapid response systems and end-of-life care

Rapid response systems (RRSs) were established as a patient safety system to improve patients’ outcomes in acute hospitals.17 Their key features are vital sign and observational abnormalities which identify seriously ill patients and, in turn, trigger an urgent response by an individual or team with the appropriate skills, knowledge and experience to deal with any hospital emergency.17

Initially, they were established to identify seriously ill patients with potentially preventable illnesses. However, an RRS will also identify patients who are predictably and normally dying.18 Up to a third of all RRS calls are for patients who require limitations of treatment as a result of being at the EOL.18 This has important implications. It tells us that acute hospitals do not necessarily recognise patients at the EOL.9 The rapid response team becomes the surrogate “dying” team. The poor prognosis of the patient then has to be brought to the attention of the admitting team. It does not seem acceptable that patients only become aware of their parlous state when they are so close to death. The inappropriate management of patients at the EOL not only largely contributes to the unsustainable cost of health care but it is also not in the interest of patients and their carers to be denied rational and personal choices based on the prognosis.

Another approach to patients at the end of life

Managing patients in acute hospitals who are at the EOL may benefit from an approach similar to that used in RRSs. This would require identification of the patient followed by an appropriate response. There are currently attempts to identify such patients.19 Whatever tool is developed must deal with uncertainty, which is an integral part of medicine. However, a prognostic tool would equip the patient and the caring physicians with information such as the possibility of dying within, say, months or a year. We would not consider withholding poor prognostic information from a 20-year-old patient with a terminal brain tumour. The estimate of exactly how long that patient had to live would be uncertain in terms of weeks, months or even years in some instances. However, the same honest discussions usually do not occur with aged, frail patients who have had multiple admissions to hospital and who may have a similar prognosis to that young patient with the brain tumour.

It is early days in predicting prognosis in frail older people, but there are features (such as weight loss, significant decrease in mobility, gait speed, increasing weakness and exhaustion) which may indicate that a person has a high probability of having less than 12 months to live.19 Once a patient is identified as being in an at-risk group, there would need to be an urgent and appropriate response. As with RRSs, the response to the seriously ill, deteriorating patient would need to involve a clinician with appropriate skills, knowledge and experience, as well as the time to carry out lengthy and complex discussions with the patient and his or her carers. Currently, most admitting teams do not have that level of training.18 Moreover, the home team is often busy caring for the more conventional aspects of medical care. One could argue that we need an extensive rethink of our undergraduate and postgraduate training in order to give every clinician, including attending doctors and nurses, the skills to appropriately manage EOL care. Alternatively, or until we undergo that radical retraining, a response could be in the form of someone specifically trained in EOL care such as a palliative care nurse.

The response would obviously begin with involvement of the patient and their carers. Discussions would then be centred on the patients’ wishes, such as whether they want to be continually admitted to acute hospitals or whether they would prefer more home and community-based care. It would be essential to involve GPs in continuing management plans. These choices and the patient’s condition may, of course, change with time.

Other responses could include the offer of palliative care, perhaps in parallel with continued active treatment. Choices would include how patients would like to spend their last few months. Where they would like to spend them? What sort of support do they have? And what support do they need?

During these discussions, there would also need to be close communication with others in the palliative care team as well as members of the admitting team.

Conclusion

The current medicalisation of dying can be compared with the medicalisation of birthing in the 1950s, when mothers’ legs were put up in stirrups, babies were delivered and removed from their mothers and put in a large room together with other babies, and mothers were only allowed to see their babies for feeding. And, of course, fathers were excluded from the process altogether. Perhaps there is hope that the baby boomers, who have changed the way society operates in many ways, will demand greater choice and involvement in the way that their dying is handled.

We seem to have lost the ability to be honest with society about the limitations of modern medicine and to recognise that people will inevitably age and die badly. Currently, many patients at the EOL are placed on a conveyor belt where futile treatment and less than full disclosure have replaced genuine and appropriate care for patients and their carers.

[Editorial] Postacute stroke care: same standards as acute care?

The Sentinel Stroke National Audit Programme (SSNAP), led by the Royal College of Physicians, has released the first comprehensive audit into 604 of 756 postacute stroke care services throughout the UK. Although vast improvements have been achieved in acute stroke care in recent years, progress in postacute care for long-term rehabilitation has been left behind in comparison.

[Editorial] Primary care is a team sport

Physicians are often called the gatekeepers of primary care, describing the providers at the front lines who orchestrate the steps in the cascade of care. Primary care is the first stop to connect patients—especially those with complex health needs, such as multiple chronic illnesses—with other necessary services, including specialists, after hours or home care, and social services. But a rising number of patients at risk for chronic diseases, an ageing population, and life-prolonging medical interventions have added new financial and capacity stresses on primary care systems, with primary care physicians making decisions from an increasingly challenging position.

Hospitals get just $1 more

The Federal Government spent just an extra $1 for each man, woman and child in the country on hospital funding in 2013-14 as it screwed down hard on its health budget.

As the nation’s leaders meet for the last Council of Australian Governments meeting of the year, figures compiled by the Australian Institute of Health and Welfare show that Commonwealth funding for hospitals reached $892 per person in 2013-14, which was a $132 increase from a decade earlier but just $1 more than in 2012-13.

The miserly increase has contributed to a big shift in the burden of hospital funding from the Commonwealth to the other levels of government.

In the 10 years to 2013-14, spending by the states, territories and local governments on hospitals grew at virtually double the rate of the Federal Government.

Over that time, they expended an extra $10.3 billion on hospitals, after inflation – a 69 per cent increase.

During the same period, the Commonwealth’s contribution grew by just $5.7 billion – a 38 per cent increase.

The result provides a sobering backdrop to the tax reform debate.

Weak growth in GST revenues in recent years has intensified the strain of health spending on State and Territory budgets, driving calls by premiers and chief ministers for access to a more dynamic revenue base. One proposal has been to push the GST to 15 per cent and direct the funds to the Commonwealth. In return, the states and territories would get a share of income tax revenue.

But the Commonwealth flagged it is not interested in increasing the GST and is instead pressuring the states to change their own tax mix.

At the same the Federal Government has been paring back on hospital funding, it has been pulling back on its share of primary health spending, which dropped to 36.7 per cent in 2013-14 from 37.3 per cent the previous year.

Instead, it has picked up its spending on other health goods and services, particularly referred medical services, and to a lesser extent research and health administration.

In the 10 years to 2013-14, Commonwealth spending on these services jumped from $11.6 billion to $19.3 billion – including $12.2 billion on referred medical services alone.

Indicating the increasing importance of this type of spending, in 2003-04, it was 8.4 percentage points lower than Commonwealth spending on hospitals. Ten years later, it was just 2.3 percentage points lower.

The figures underline AMA concerns that the Commonwealth is dumping an increasing share of the health funding burden onto the states and territories, intensifying the strain on public hospitals, which have already reported a downturn in performance.

The Commonwealth’s backsliding on primary health funding also lends weight to fears that the reviews it has initiated into primary care, particularly the MBS Review, are being driven by a cost-cutting agenda.

Adrian Rollins

[Correspondence] Tackling preventable diseases in Yemen

The health-care system in Yemen has deteriorated since the start of the war in March, 2015. Impairment exists at all levels of health services; from improper function of health-care facilities to a shortage of basic and life-saving needs, such as drugs, water, and fuel. This continuous, unresolved crisis has led to a rise in preventable diseases and other health problems, such as infectious diseases, malnutrition, diarrhoea, and unnecessary organ loss.1,2

Health expenditure Australia 2013–14: analysis by sector

This report extends the analysis presented in Health expenditure Australia 2013–14 to further explore expenditure on particular categories of health goods and services. In 2013–14, $58.8 billion was spent on hospitals in Australia, $54.7 billion on primary health care and $32.0 billion on other health goods and services. A further $9.1 billion was spent on capital expenditure. Unreferred medical services attracted the highest share of primary health care funding in 2013–14, at 19.3%. This is different to earlier in the decade, when benefit-paid pharmaceuticals attracted the most spending from 2008–09 to 2011–12. Growth in expenditure on benefit-paid pharmaceuticals slowed in the last 3 years compared with the rest of the decade. This slower growth in expenditure was in contrast to a steady increase in the number of prescriptions dispensed over the same period.