Dr Clare Skinner: Every part of the health system needs reforming to put patients back at the centre

We are in the most challenging times our health professionals have ever faced and only deep, structural reform can fix the crisis.

Emergency departments have been in the news recently. We have seen front-page photos of ambulances queuing outside hospitals, and coverage almost every day from all over the state and country of the immense strain and cracks in healthcare systems.

This is the public face of the healthcare crisis consuming the country. But these are more than just pictures, TV news grabs, or words on a page.

This is about people. Real people in need of urgent, lifesaving medical care. Sick, injured, scared and vulnerable people, not able to be transferred from ambulances to EDs, and then on to hospital wards for the further care they need.

These are stories of people having to wait hours in crowded waiting rooms, or being treated in corridors – in some tragic cases suffering avoidable harm, because EDs are dangerously overloaded and unsafe.

This is heartbreaking for frontline healthcare workers, including the highly trained and experienced doctors and nurses working in emergency care. Many senior practitioners with decades of experience tell me these are the busiest and the most challenging times of their careers. They feel things are at breaking point.

When you see ambulances lining the street, or overflowing waiting rooms, it is tempting to think it’s the ED’s fault. You may think if ED staff just worked harder, then the queue would disappear. But I can tell you, hand on heart, we are working as hard as we can.

Meanwhile, we are left to apologise for problems we did not create – imploring people to please be patient with us in the most trying of circumstances.

We are doing our very best in a system that is not working for us or for the people we desperately want to help.

The fundamental problem is the way our health system is structured. Within the health system, EDs sit at the intersection between the acute hospital sector and community-based care.

In Australia, acute hospital care – including EDs – is funded and managed by state and territory governments. Community-based care, including specialist general practice, residential aged care, the pharmaceutical benefits scheme, and disability support care, is controlled by the commonwealth.

It’s an artificial divide, because most people, especially people with chronic illness or complex care needs, will interact with all parts of the system.

This artificial divides results in cost and blame-shifting by governments. This leads to administrative delays and a lack of service integration. Meanwhile, patients and their loved-ones are left trying to navigate an almost impossible system.

Divided public and private health sectors in Australia make things even harder. This has led to rising costs for patients, and it makes measurement of healthcare system performance, and patient outcomes even more difficult.

No wonder we are seeing growing health and social inequity.

If you have experienced an urgent medical problem, or helped look after an unwell family member, you know accessing the right healthcare at the right time is often confusing, difficult and sometimes very expensive. EDs are the only parts of the system open 24 hours a day, and free at point-of-care.

When the rest of the health system is overloaded, costs too much, or is too hard to navigate quickly, then ED demand builds.

But when the whole system is overloaded, as is currently the case around so much of the country, all the hospital beds are already full.

Many patients in these ward beds are being treated for acute conditions, but many are also waiting for placements in aged-care facilities, or for disability support funding to be authorised, or for places in an appropriate community mental health outreach program. They are only in hospital because they have nowhere else to go.

Full hospitals mean people who have been assessed by ED clinicians and need to be admitted to hospital must wait in the ED. Therefore, there are no beds for treatment of new patients who arrive in ED.

It becomes standing-room only in the ED waiting room, but the problem is not caused by EDs. A lack of capacity and poor flow across the entire health system is creating this crisis.

Solutions to this healthcare emergency are not simple, and do not lie in the emergency department. Deep, structural health system reform is required to bring our siloed health services together into a co-ordinated, effective, patient-centred system.

Possible strategies include a single payer for all health services, and better use of monitoring and data to improve patient experience and outcomes. Patients, carers and frontline clinicians must be involved in system redesign.

In addition, we must make sure that every part of our health system, including EDs, has adequate staffing and capacity to ensure the system can function effectively as a whole.

The Australian health system last had a major upgrade in the 1980s when Medicare was introduced. Australians are now living longer and, thanks to advances in clinical science, have significantly different health needs. It is time to think again – to design a health system that is fair, safe and effective for all Australians.

The recently elected as Australian Labor Party prides itself on the party of Medicare, the party responsible for the last major reforms to the healthcare system.

Our appeal to this new government is to be brave, and to not relegate fixing Australia’s healthcare system to the too-hard basket. Our appeal to the people, the consumers of healthcare in Australia, is to please reach out to your freshly elected members and make sure they know just how important healthcare is to you and your family.

The health system we have now isn’t normal, isn’t fair and isn’t safe, but with leadership, it can be fixed.

Dr Clare Skinner is an emergency physician and president of the Australasian College for Emergency Medicine


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