NSW Hospitals Under Pressure

The cracks are starting to show in the NSW health system.

The nitrous oxide mix up at Bankstown-Lidcombe Hospital combined with chemotherapy underdosing controversies are just two of the scandals that rocked the public’s confidence in the state’s health system.

A Fairfax poll shortly after those incidents revealed four in five people feared the health system wasn’t safe.

At the time, AMA (NSW) President, Professor Brad Frankum told the media, “people are very concerned about the public health system, and they should be.”

The systemic errors highlight the ongoing deficiencies that exist.

Despite a huge investment in hospital infrastructure and redevelopment, many hospitals across the State are struggling to meet increasing demand.

The latest figures from the Bureau of Health Information (BHI) indicate the system is under pressure. The report shows there have never been more patients admitted to hospital in a quarter, and emergency department presentations are at the highest level of any previous April to June quarter.

Year on year, these figures have increased. Since the BHI started recording data five years ago, NSW hospitals have seen a substantial increase – 130,000 extra patients in the first quarter of 2016, compared to the same time in 2011.

Despite the best efforts of staff, measures against performance targets like the four-hour rule in emergency departments continue to stagnate.

There are simply no more efficiencies to be found in the system, and hospital staff are just managing to hold the line.

Hospitals are not only seeing more patients, they are seeing sicker patients that require more complex treatment.

Approximately 81% of triage one patients and 59% of triage two patients needed admission to hospital in the first quarter of this year, and they are the two areas that had the biggest growth in numbers.

“We continue to see big jumps in the most urgent triage categories, while the proportion of lower urgency patients seen by NSW EDs continues to fall,” Prof Frankum said.

“The more complex care required for these sicker and more gravely injured patients takes time and requires the resources of our biggest hospitals – and when you look at the performance of our largest hospitals, most of them trail the state average.”

As a result, the average figures really hide the realities of much longer waits faced by thousands of our sickest patients who need the care that only larger hospitals can provide.

Given this perilous position, many health professionals are questioning how the system will cope once the State goes over the fiscal funding cliff come July 2017.

“Public hospital funding must remain a priority if hospitals are going to keep up with demand,” Prof Frankum said. “We are at a critical juncture, and we need to focus on properly resourcing our health system.

“Patients will face longer waiting times and poorer health outcomes unless the Government commits to appropriately funding our public hospital systems now and into the future.”

The Federal Government pushes the narrative that health spending is out of control. But the facts don’t support this.

Research from the Australian Institute of Health and Welfare (AIHW) reveals that growth in Australia’s spending on health remains slow.

The AIHW report, Health expenditure Australia 2014–15, (released in 2016) shows that $161.6 billion was spent on health goods and services in 2014–15. While this was $4.4 billion (2.8%) higher in real terms than in the previous year, it is the third consecutive year that growth was below the 10-year average of 4.6%.

AIHW figures also show that health inflation was less than general inflation by 0.77 from 2003/04 to 2013/14.

To put it in perspective – the 10-year average for health spending by the Federal Government is 9.12% of the GDP and Australia is below the OECD average on this benchmark.

Appropriate funding of hospitals is critical to performance of our health system, as is adequate resourcing and management. Without these components, tragic mistakes are inevitable as hospital staff are pushed to the limits of ability.

COMMENTS FROM THE FIELD

“Working in general practice in South West Sydney the difficulties of getting serious but low acuity patients being seen through OPD is mind boggling.

“There is no clear pathway to get in to some of the more specialised clinics without the patient having been seen in that hospital already. Sometimes what ends up needing to happen is for the patient to be sent to ED so that the inpatient team will see them and then they can have appropriate follow up through OPD.

“For many of the families (where the patient is a child) and individuals this is a costly, time-wasting process. Some of the services need hospital clinic management rather than community specialists. And if the patient cannot wait for any reason (family, mental health, work) then they often return to general practice and we are left with the same issue.

Adequate resourcing

Despite a huge investment in hospital infrastructure and redevelopment, many hospitals across the State are inadequately staffed and unable to meet increasing demands.

Wagga Wagga Rural Referral Hospital and Bega’s South East Regional Hospital are two examples.

In February 2016, Wagga Wagga Base Hospital (WWBH) morphed into the new Wagga Wagga Rural Referral Hospital (WWRRH). The new hospital is a $280 million facility that the region has been eagerly anticipating for well over 50 years. The building itself is quite architecturally stunning, with its river mosaic tile exterior and eye-catching views from the upper floors of the surrounding countryside.

However, within a month of opening, the previous WWBH problems with bed block have recurred. Doctors report that the ‘house full’ sign was seen fairly early after the hospital’s redevelopment and has occurred frequently in the first six months.

This has impacted significantly on the ability to transfer patients from outlying facilities in a timely manner and on elective surgery, with entire lists and many individual patients being cancelled at short notice.

This has exposed, somewhat earlier than expected, the warned about capacity issues of the new WWRRH. Surprisingly, this has not resulted in more than five of the eight operating theatres being regularly, fully staffed, nor the two, as yet unopened, interventional suites being commissioned. (The most recent advice from MLHD is that, with the change of radiology provider, the first angio suite will open in December 2016. However, staff report that in November there was still a lot of equipment uninstalled in boxes).

The innovative solution has been to pay local nearby private facilities for theatre time to accommodate cases that were not able to be done at WWRRH.

According to doctors, other mechanisms of surgical waiting list control have included:

• needing to transfer patients from the WWRRH to facilities in other towns, often under the care of different doctors
• returning patient’s Recommendation For Admission (RFA) forms with letters indicating that the WWRRH Booking Office could no longer guarantee admitting them within the time recommended on the RFA, and suggesting the patient either make a new appointment with the same VMO to again plan their admission or make an appointment with their GP to get a referral to a new VMO for that procedure.

According to doctors, WWRRH Administration have been keen to try and explain the above as merely “teething problems” while the facility has been “transitioning to new models of care” during a “busy winter”.

The latter was regularly a cause of ‘bed block in the old WWBH, so it is disconcerting that the new facility has not been able to overcome that impediment.

The South East Regional Hospital in Bega is also an impressive piece of infrastructure. However, it lacks many critical services that a base hospital needs.

AMA (NSW) President, Prof Brad Frankum said, “when the hospital came online, it wasn’t adequately resourced in terms of staff for a facility of its size.”

Medical staff are being asked to do too much with too little.

“A base hospital workload cannot be expected to be performed by a rural hospital-sized medical staff,” Prof Frankum said. “Trying to run it as a base hospital with the staffing levels of a rural one will not provide the health services that Bega needs.”

President of the Rural Doctors’ Association, Dr Emma Cunningham, said, “Strangely, while the hospital has local doctors it can call on, management often ships in temporary locums from Canberra and Sydney.

“Meanwhile, when it does utilise local doctors, it does not provide them with the support they would receive at a base hospital-sized facility.”

AMA (NSW) has been advocating for the hospital to employ the right number of doctors, with the right training and the right support to ensure a stable workforce.

“Just having a new, larger hospital is not enough,” Prof Frankum said. “You need to staff it appropriately and you need to ensure that it has the facilities to provide the additional services of a base hospital.

“Without that, it’s just a bigger building.”

PPP – size matters

In September, the Baird Government announced it is inviting expressions of interest from private healthcare operators to run and redevelop five regional hospitals across NSW.

Using the same model that is currently in place for the Northern Beaches Hospital, the State Government is seeking to implement Public Private Partnerships (PPPs) for Bowral, Maitland, Shellharbour and Wyong. (The State also proposed a PPP hospital for Goulburn, however the plan has already been scrapped due to local opposition.)More than $1 billion was committed in the last State election to upgrade the regional facilities.

Health Minister Jillian Skinner stated that the government is pursuing PPPs as it allows for the creation of larger, more advanced hospitals, with extra services for these communities.

Current permanent staff would be offered two-year guaranteed contracts, if their equivalent position exists within the new structure. Those who leave will be offered a guarantee of two years’ employment in the public system.

There are several concerns with the privatisation of public hospitals.

Two decades ago, NSW first trialled a private operation model with the Port Macquarie Base Hospital, which it ended up buying back.

At the Northern Beaches Hospital, which is scheduled to open in 2018, the State Government will pay Healthscope to treat public patients alongside private patients.

While Labor’s Shadow Minister for Health, Walt Secord suggests that we could see the creation of a two-tier health system in NSW, Minister Skinner insists public patients would continue to receive free quality care.

The socio-economic demographic of Sydney’s Northern Beaches, however, is quite different than the regional areas now under consideration for PPP hospitals.

Regardless of how Maitland Hospital is funded, there are additional concerns that current plans are not in line with the community’s growth trajectory.

According to Prof Frankum, “Doctors at the hospital have been alarmed for some time about the way the Government has approached the redevelopment. They know they need a bigger facility than is currently planned to cope with the growing and ageing population.”

Maitland hospital supports nine other hospitals, including Kurri Kurri, Scone, Muswellbrook, Cessnock, and Singleton.

Despite concerns with these models, and particular concerns for the Maitland Hospital, AMA (NSW) is realistic that these regions need better hospitals – and these funding arrangements may expedite the process of getting satisfactory healthcare facilities in place.   dr.

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