President’s Word November / December 2016
- On November 10, 2016
- NSW Doctor
Public hospital system under strain
The public hospital system is facing a number of challenges, which is impacting our ability to deliver high quality, safe care.
OUR PUBLIC hospitals are under pressure. Demand for emergency department treatment continues to grow at a rate that far outstrips population growth, and the main increase is in higher triage categories. The reasons for this are not clear to me. Is access to GPs increasingly difficult for patients, especially after hours? Or is access to specialists too expensive or too delayed for people to deal with serious illness at an earlier stage?
Both Governments are underestimating the impact of this ongoing growth, and the consequent implications for funding. The NSW Government has supported an ambitious hospital building program, which is welcome, but of course the biggest ongoing cost in health is the payment of the wages and entitlements of staff. This is devolved to the LHDs, who are under immense pressure to achieve a range of targets around elective surgery, emergency department performance, and budget. They are simply not in a position to be expansionary with staff hiring.
Our rural and regional colleagues are also doing it tough. There are too few GPs and inadequate access to specialists. In many places there are too few specialists on rosters providing acute care to patients. This is challenging and potentially unsafe for patients who risk being treated by doctors working unsafe hours, with insufficient support from larger referral centres which are always stretched for beds, especially in critical care areas.
When the system becomes overly focussed on the politically imperative performance indicators, like ED waiting times and elective surgery, there is a risk to its other key functions. Outpatient clinics are one example. For many patients across NSW, being seen in a public hospital outpatient clinic is the only affordable option to access specialist care. The coverage of specialties in outpatient departments across the system is patchy at best. The waiting times are usually unacceptably long. The quality of service provided is variable. The emergency department is the default.
We have seen two major incidents this year in the NSW public hospital system. One of these is now the subject of a parliamentary inquiry, that being the under-dosing of cancer patients with chemotherapy. One of the findings of Professor David Currow was that there had been inadequate use of multidisciplinary team care, and a lack of performance management of the senior clinician involved. This should raise awareness of the possibility that everyone, including administrators, are just so stressed providing clinical care and trying to reach unrealistic performance targets, that really important aspects of providing quality, safe care to patients are being overlooked.
The information management and technology systems available to us in public hospitals remain embarrassingly inadequate. In my private practice I am paperless. I prescribe electronically. I am switching to emailing patient letters to referring doctors. In my hospital practice, I still handwrite patient notes and prescriptions. If the paper file can’t be made available to me, I have no way of knowing what assessment and treatment I performed on a patient the last time I saw them, let alone what my colleagues have written down. The most junior doctors in the system have the least access to the technological tools that can make their care of patients safer. Audit and research are significantly hampered.
We still don’t have enough beds in the public hospital system. There is still a deliberate and sustained deception occurring that maintains there are enough beds because the occupancy data takes all beds, including cots, maternity beds, paediatric beds, etc into account. When the data looks at acute, overnight, adult beds available for medical and surgical patients, the figures are indeed much less reassuring. These, of course, are the patients that end up remaining in ED for unacceptably long periods of time, or being placed in inappropriate wards as outliers.
We should not be frightened to allow the government to explore new ways of doing things. An example of this is the proposal to allow private operators to redevelop some of our public hospitals. Now I have significant reservations about this, but I also accept that we can’t rely only on existing paradigms if we are going to upgrade and modernise our system.
AMA (NSW) has made a decision to wait and see what the government is proposing, and campaign for any proposals to ensure that public patients are provided with the same (if not better) care in these facilities as they receive in current public hospitals; that staff are not disadvantaged in any way by contractual arrangements; that teaching, training and research are embedded in the business of these hospitals; and that safety and quality systems are robust and remain under the management of the LHDs.
We have a lot to do in the NSW public hospital system to make it better for our patients, and our colleagues. Goodwill holds the system together, but it is a finite resource that must not be taken for granted. dr.