Squeezed to the last drop

“How there have not been more deaths in the waiting room is beyond me.”

Late last year, AMA (NSW) put out a call to members asking two simple questions:

• Over the past few years, what effects have the ongoing increase in demand for treatment had on you, your patients, and the medical and health staff around you?
• Is the pressure of demand worse in recent years?

The anonymous responses that flooded back sounded more like cries for help, than submissions.

“You walk into the emergency department, take a deep breath and hope that you keep your head above water till the end of the shift.”

“I see my kids very little – I picked them up from childcare less than five times over a one-year period I always know when I get in to work, but I truly never know when I will get out.”

“At times, the ‘greatest good for the greatest number’ is required because better care for one will compromise care for others. This is the essence of the definition of ‘triage’ which is a term first used in the Napoleonic era of war. It is a battlefield term and unfortunately our workplace feels consistently like a battlefield.”

Hospital emergency departments are being swamped by increasing numbers of patients across Australia. Data from the Australian Institute of Health and Welfare (AIHW) shows a dramatic increase in emergency room presentations – up 25% between the first quarter of 2016 and the same period in 2012.

The increased demand is having a devastating effect on the ability of medical professionals to cope.

“In the past 12 months, nearly every day sees my ED operating in ‘crisis mode’. There always seems to be an explanation provided by hospital management or the Ministry of Health. These include, amongst others: ‘it’s flu season, it’s Monday, it’s Friday afternoon and the GP clinics are closing, there is an ice epidemic, there is a surge in mental health presentations before the holidays’. To a degree, these are valid statements to explain surges in patient presentations. However, in many ways, these ‘surge explanations’ become excuses to deflect attention away from the crisis. My emergency department always operates at maximal capacity or above. There is almost never any higher gear to kick into and virtually no ability to respond comfortably to a sudden surge in the number of presentations. This situation normalises crisis and makes ‘feeling overwhelmed’ a near-permanent state. There are now very few days (less than 10% of my shifts) where the patient volumes are ‘normal’ for department size and staffing level. It is now the exception for ED doctors to be seeing patients at a comfortable pace and maintain an ‘operationally functioning’ department.”

Not Just a Bad Flu Season

Statistics from the Bureau of Health Information reveal a pattern of year-on-year record demand in NSW.

In 2016, emergency department presentation records were broken in the first quarter and then again in the fourth quarter. And the first quarter of 2017 exceeded the record-setting number seen during the same period of 2016.

“The message the BHI quarterly survey results are sending is that hospitals are facing record or near-record demand at all times of year and that this pressure is continuous, unrelenting and building,” said AMA (NSW) President, Prof Brad Frankum.

More than 720,000 people attended emergency departments in NSW between July and September in 2017, which was the first time there has ever been more than 700,000 patients attend EDs in a single quarter.”While some of this extra activity can be blamed on the horrendous flu season, sadly, this is just part of the same pattern the BHI reports have been describing for years,” Prof Frankum said.

Doctors highlighted that the demands on emergency departments is compacted by the lack of beds.

“The emergency department I work in is now completely overwhelmed most of the time by the on average 30 admitted patients in the department that cannot be moved to ward beds. This leads to many patients being seen in corridors, sitting in chairs for up to 30 hours waiting for ward beds, inability to even basically look after patients and incredibly substandard care that we ‘get away with’ time and again.”

Another doctor wrote: “A few years ago 14 admitted patients in the ED was a crisis. Now it can be up to 40, however the ED is still the same size.”

The AMA Public Hospital Report Card 2017 reveals bed number ratios have remained static and emergency department waiting times have worsened and, in most cases, remain well below the target set by governments to be achieved by 2012-13. The report indicates the percentage of ED patients treated in four hours has not changed over the past three years (since 2013-14), and is well below target. Elective surgery waiting times have worsened, while treatment times have only improved marginally.

One doctor’s response described heartbreaking ED scenes, such as a 90-year-old patient with a UTI languishing on a hard plastic chair for hours.

“This, understandably, is upsetting for patients who then take it out on staff. And having to watch this and be unable to do anything about it is a difficult thing for the staff to face on a daily basis.”

Effect on Patients

Doctors report the stress of an overburdened system is affecting patient care.

“It is now impossible to spend the extra five minutes with a patient who needs it. Time spent with patients starts to feel like a rationable resource. Moments of basic humanity, such as spending a bit more time chatting to a lonely elderly person become a rarity and when they do occur, often feel like we should spend that time doing something else.”

Another doctor stated: “Patients don’t get the care they deserve because we have to stretch our limited resources increasingly thin, explanations given briefly, with little time for exploring the level of their understanding. When a complaint then comes in, or an error occurs, it is seen that it is the individual doctor’s fault, with no blame laid on the system that has created an untenable, overcrowded situation.”

The Health Care Complaints Commission recorded 6,319 official complaints for the 2016-17 reporting period – an all-time high. This is a 4% increase from 6075 complaints received in 2015-16, which was a previous record breaker.

Almost 46% of the complaints were about NSW public hospitals. The complaints most commonly related to emergency medicine (28.7%).

Effect on Doctors

So what happens to the medical professionals working in these conditions?

According to the responses we received – complete exhaustion.

“My team are at risk of compassion fatigue and emotional burn out. When you take caring people and force them to say no, or to treat patients in suboptimal ways, or to work with extreme cognitive overload, something eventually snaps.”

The AMA’s 2016 Safe Hours Audit revealed one in two public hospital doctors are working unsafe hours that put them at significant risk of fatigue. Those who report dangerous levels of fatigue are intensive care specialists (75 per cent), surgeons (73 per cent), obstetricians and gynaecologists (58 per cent), and emergency doctors (38 per cent).

The strain and the pressure on our public hospitals is having a detrimental impact on the health of our doctors.

One doctor stated, “For a few years people stepped up with enthusiasm, giving 120% to the point where they are now burnt out. The most common phrase heard here on shift is ‘I am so over this’.”

Doctors noted that staff are taking sick leave just to have a day to breathe.

Office for the Public Sector figures show that hospital staff took on average five days more sick leave last financial year than 2015-16. Over the past financial year, almost 28,000 hospital workers across more than 100 hospitals took an average of more than three working weeks – 16.51 days – of sick leave. The previous financial year it was 11.76 days. That figure – which includes carer’s leave, “personal days”, and bereavement absence, was relatively stable for the previous three years – 12.36 days in 2014-15, 11.72 in 2013-14 and 11.63 in 2012-13.

Effect on Junior Doctors

Many respondents to the AMA (NSW) survey noted that the current situation is damaging the system’s ability to support and advance doctors-in-training.

“Probably the worst impact for a teaching hospital is that by seeing patients in corridors/the ambulance bay, junior doctors are getting a terrible example of how to look after the public and you see it repeatedly reflected in really poor history and examination technique, corner cutting and no ability to appreciate the risk or downside of what they are doing.”

Junior doctors also noted their career progression in this type of environment comes at a huge personal cost.

“As a trainee, it means it is much harder to leave shifts on time – I often stay overtime for at least one hour (unpaid) to finish documentation and other paperwork for patients seen. This impacts on family time and study time. As an older trainee trying to complete fellowship exams, along with raising two older primary school aged kids, I feel stretched on all fronts and don’t feel like there is any support or understanding from the hospital system.”

Some noted that trainees are leaving their specialties. “They see a future of no regular permanent work, high levels of clinical risk, low respect from hospital executives, and terrible working conditions.”

Wait Lists

Doctors highlighted ever-growing waitlists as another source of significant angst for medical professionals and patients.

The latest report from the AIHW reveals that waiting times for elective surgery have increased.

The median waiting time ranges across the States and Territories – from 28 days in the NT to 54 in NSW. The median waiting time in NSW has increased in the last five years – up from 49 in 2012-13.

It’s important to note that the AIHW report only records the number of days a patients waits for elective surgery from the date the patient was placed on the waiting list till the date the patient was removed. It does not include the number of days the patient waited for an initial appointment with the specialist – from the time of referral by the patient’s GP, which is widely known as the ‘hidden wait list’.

One doctor in our survey commented, “In my institution, I have 25,000 patients on an unrecorded waitlist – the waitlist to perhaps in 12 months’ time be given an appointment at some time after that.”

Another doctor described the situation as being akin to a whack-a-mole game. “For every patient that you help, two more pop up on the waiting list. This is demoralising because satisfaction is swamped by the realisation that you can never catch up.”

Us vs Them

Another key theme that emerged in the survey is the disconnect between hospital administration and clinicians.

As one doctor noted, “There is little to no support from the hospital administration who are fixated solely on their bottom line.”

Others noted that the pressure has also created animosity between different departments.

“The hospital expects you to get ambulances offloaded, to get patients to the wards or out the door in four hours, and the inpatient teams want more and more clarity about the patient’s condition before they will accept them to the ward. In the end, the staff in ED are perceived as creating work for the inpatient teams, and it becomes an ‘Us versus Them’ scenario, where we should really be working together for the good of the patient.”

Why is our system stretched?

Population growth, ageing patients, and an increase in chronic diseases have all been identified as contributing factors to an overburdened hospital system.

AMA (NSW) has urged the State Government to examine whether it has allocated enough funding for higher growth areas.

One doctor pointed to South Western Sydney as an increasingly difficult area to service with the current resources.

“The demand is higher [in South Western Sydney] due to less privately funded patients, poor health literacy and education, non-adherence to treatment, lack of money to access treatment and the social issues that surround this area.”
Another doctor commented, “The population is growing and services have not grown with it. People are increasingly demanding of our time and expertise. We have been squeezed just about as much as possible for output and I don’t think there is much left in the tank.”

The latest health data also identifies the growth of chronic disease, particularly in an ageing population.

The 2014-15 National Health Survey found one in every two Australians have at least one prominent chronic condition, while 60% of Australians aged over 65 years, had two or more chronic conditions.

“People are living longer. But it is not as if there are just more patients, like patients were in the 1950s. Today’s patients produce a greater number of complaints or diseases. As they live longer they create more numbers of non-lethal but disabling conditions. The big pressures lie in ENT and in Orthopaedics, let alone Dermatology and Ophthalmology.”

Funding

But the biggest stressor is insufficient funding. At the time of writing, NSW accepted the Federal Government’s health funding deal. The Commonwealth has agreed to pay 45% of hospital funding, while spending growth would be capped at an annual 6.5 per cent for the five years from 2020.

NSW hospitals would get a $9 billion funding boost under the new deal, with the amount of Federal money for NSW hitting $40 billion over five years from 2020 to 2025.

This is not a good deal. In fact, it’s almost exactly the same agreement the Commonwealth trotted out in 2016, but without the $2.9 billion in band-aid funding that came with the 2016 Federal Budget.

The AMA fought against this funding agreement then, and we intend to fight against it now.

This ‘offer’ will not meet the persistent and crushing demands for health services from an ageing population and threatens to push emergency department and elective surgery waiting times to increasingly dangerous levels.

We need better solutions – not the same tired policies repeatedly trotted out under the pretense that they offer something new.

The agreement outlines four strategic priorities for reform in our health system. Notably, improving efficiency and ensuring financial sustainability trumps ‘delivering safe, high quality care in the right place at the right time’. It’s clear what the Commonwealth’s priority is – but at what cost to the public health system and the medical profession?