At a time of looming crisis, a vision for health system transformation
January 2020
Croakey Health Media – informed, engaged communities for health
With Dr J Bonning, Dr S Judkins, A Prof D Palmer
Introduction by Croakey: If large numbers of Australians require urgent hospital treatment for the novel coronavirus, how will the system cope?
With great difficulty, one would assume, given the widespread concerns raised in recent months at Croakey about the pressures on Emergency Departments.
In this timely wish list for health system reform, emergency physician Dr Clare Skinner offers 11 suggestions for improving emergency care, many of which would have wider flow on effects.
Clare Skinner writes:
Emergency Departments (EDs) are doing it tough. A recent series of articles published by Croakey have described problems experienced by patients, carers and clinicians, and proposed some potential solutions.
I extend my thanks to the authors of these posts for their courageous truth-telling and creative ideas. You’ve got me thinking about how we might do things better. I hope some health decision-makers, including politicians, have also got reform on their minds.
It’s the time of the year when we all pause, reflect and plan for the future.
Here is my wish list of health system improvements for 2020 and beyond.
Dr Clare Skinner, pictured at Australasian College for Emergency Medicine conference in Hobart, November 2019
1. Review the role and function of EDs
Emergency Departments were designed to provide urgent acute episodic care to patients. As presentations to EDs have grown, so has the complexity of the patients who visit. Around a quarter of patients are aged over 70.
About 15 percent of patients have problems related to drug and alcohol use and seven percent have mental health concerns. In the context of hospital systems with limited beds and resources, poor public and clinician tolerance of diagnostic uncertainty, and increasing concentration of organisational (hospital) risk in EDs, role creep has been extreme.
The time has come to examine the role of EDs in the health system – and then design, resource and support them accordingly.
2. Redesign triage processes
The Australasian Triage Scale (ATS) is a measure of clinical urgency, not complexity. A common misunderstanding is that patients allocated category 4 or 5, or those who are eventually discharged, have simple problems that should have been managed by a GP.
Although not current ACEM policy, simplification of the triage scale into three levels – see now, see next and see later – which is the working reality for most ED clinicians, should be considered to improve understanding and transparency of triage processes.
Many EDs currently manage varying levels of complexity by streaming patients into models-of-care such as resuscitation, acute, fast-track etc, none of which is directly equivalent to a ‘GP stream’.
We should support all EDs to do this reliably in a way that is clearer to patients and heath managers – the NSW Health ED models of care document is an excellent resource.
3. Improve physical infrastructure
EDs need to be carefully designed to match patient numbers, throughput and models-of-care.
When EDs work efficiently they don’t need to be large, but they do need physical lay-outs that allow clinicians to work effectively, with good lines of sight and co-location of functionally related areas, while providing patients with privacy, adequate space for carers, and visual cues for orientation.
Treatment spaces should include a mix of beds, recliners and chairs. Models that move the patient through the department as their treatment evolves, instead of leaving them static, deserve further exploration.
Clear signage and process information should be built into the design – see the ‘A Better A&E’ project for inspiration.
4. Transform the ED workforce
Emergency Medicine is a modern specialty. Until recently, the medical workforce was pyramidal in shape, with relatively few specialists supervising large numbers of doctors-in-training, made up of a mix of emergency medicine trainees and doctors in their immediate postgraduate years, all of whom must complete a compulsory rotation in ED to qualify for general medical registration.
This structure is unsustainable and inefficient – no other specialty supports such high junior-to-senior ratios – but has been preserved in workforce modelling. We need our EDs to be specialist-run, not just specialist-led.
This requires redesign of the rest of the workforce to allow specialists to work at the top of their scope-of-practice – by introducing support roles such as venepuncturists, scribes, advanced practice nurses etc. Highly skilled ED nurses could also benefit from task substitution to free them up to perform higher-level duties – through use of cleaners, clerks, personal care assistants etc.
Supporting ED clinicians to do their jobs efficiently will also mitigate against burn-out and improve retention.
5. Broad options for referral from ED
There is strong evidence that patient safety and clinician morale improve when patients flow through EDs efficiently. This requires capacity in the health system to accept patients from ED and well-designed referral and handover processes.
Most EDs and hospitals have entirely predictable presentation and admission rates, but system capacity is easily overwhelmed by even minor fluctuations in demand. In the short term, we need more available hospital beds.
In the longer term, we need to build genuine capacity for out-of-hospital care – ideally comprehensive and integrated hospital-in-the-home services comprised of rapid access clinics, home monitoring, outreach teams and telemedicine.
We also need a range of intermediary options – short stay units designed for brief admission of patients with undifferentiated or complex problems for a period of further diagnostic work-up or monitoring prior to referral or discharge home. We have an urgent need for models that can provide care to patients with a combination of psychiatric and physical symptoms.
6. Extended hours clinical services
In many communities, the ED is the only health service available after-hours.
The rest of the health system needs to operate at more patient-centred hours. Hospital teams, led by senior clinicians, should round seven days per week at predictable times. Outpatient clinics should open in the evening (until at least 10pm) and on weekends to minimise patient and carer time away from school or work.
Urgent care centres, staffed by nurse practitioners and primary care physiotherapists, should run 12-15 hours each day to provide an alternative to EDs for care of non-complex injuries and wounds – with a mix of booked and drop-in appointments.
Community services should be available to meet demand around the clock, especially to support patients with mental health problems.
ED is not the most appropriate setting for many patients, but there will be no genuine alternatives until we have senior clinical-decision making and diagnostic testing available outside business hours in other settings. Industrial awards need review to appropriately reward increased after-hours work and ensure adequate rest between shifts.
7. Clever use of information technology
Health needs to get much smarter with IT – to support clinicians in their work, to provide patients with better access to high quality information and to drive system improvement.
An important first step is for each patient to have a detailed electronic health summary, ideally compiled with the assistance of their GP, with updates to be authorised by the patient or their guardian. This summary should form the basis of all the patient’s health documentation.
We need electronic medical records that are designed to support clinical workflows, are simple, intuitive and communicate effectively with other systems.
We need excellent, interactive health information websites, to empower patients to research and treat their own conditions, and to advise them how and when to seek professional help – including booking online appointments and electronic reminders. These sites should be supported by chat and phone clinical advice, with complex questions escalated to a doctor with training and expertise in telemedicine, and authority to order diagnostic tests, prescribe treatment and refer directly to clinical services other than ED.
Computers and support staff, using the same websites, could be placed in ED waiting rooms to guide patients in their treatment choices – along similar lines to the successful concierge model implemented by Service NSW.
8. Health-promoting governance and financial structures
Cost-shifting between health services provided by commonwealth, state and local governments drives inefficiency and fragmentation. Fee-for-service payment structures are not effective for chronic and complex care. Opaque private health insurance products muddy the picture even further.
We need comprehensive reform of health funding to drive and support good practice.
We need to value and reward cognitive work as well as procedural work. We need to ensure that high quality care is affordable and accessible for all members of our community, not just wealthy people living in cities.
We need governance strategies, including key performance indicators (KPIs), that prioritise quality and safety, that drive efficient use of resources, and that promote health rather than disease management.
Time-based performance targets need reconsideration to drive efficient patient flow through the entire hospital and health system, not just in the ED.
9. Strengthen primary care
GPs are the backbone of our health system. We need remuneration systems that provide reasonable recompense for all aspects of their work, which reaches far beyond direct patient care.
We need better integration of general practice with the acute hospital system. We need to provide GPs with the administrative and clinical support they need to do their jobs well.
We need to encourage and support generalism, because our patients with complex conditions need holistic, longitudinal and coordinated care – and studies show it is safer and more cost-effective too.
10. Rational and sustainable use of health resources
We need to train and support all health professionals to allocate scarce healthcare resources appropriately. Patients and carers need to partner with clinicians in ‘Choosing Wisely’ – avoiding futile, unnecessary and sometimes harmful over-diagnosis and over-treatment.
We need to ensure that clinical guidelines are high-level, evidence-informed and developed through expert review and revision – ideally at national level, to avoid duplication, contradiction, confusion and conflict-of-interest. We need to minimise waste and environmental damage from healthcare.
11. Positive workplace cultures
We need to care for people who care for patients. This requires training and supporting health leaders, ensuring performance targets are realistic and patient-focused, transparency around planning and budgeting, clinician and patient engagement in decision-making and excellent people management.
It requires attention to workplace design, team relationships and rostering – to allow meal breaks, education, adequate sleep and connection. It requires genuine support for diversity and inclusion, including flexible working and training options. It requires humanity, compassion and care.
Blast from the past?
The sad thing is that none of these suggestions are new.
Similar recommendations have been made many times before.
Have a look at the Walker Inquiry Report (NSW 2004), the Garling Report (NSW 2008), the health section of the Australia 2020 Summit Report (2008), the National Health and Hospitals Reform Commission Report (2009), or Productivity Commission Reports into the Hospital System (2009) and the Health Workforce (2006).
More recently, similar recommendations have been made in the Productivity Commission’s draft Report into Mental Health (October 2019), the Interim Report of the Royal Commission into Victoria’s Mental Health System (ongoing) and the Interim Report of the Aged Care Royal Commission (ongoing).
I’ve also written about these issues before – see my article ‘Inside the Emergency Department’ written for the MJA in 2007, or ‘Reforming public hospitals: an assessment of the Garling Inquiry’ published in 2008, or a piece co-authored with Jeffrey Braithwaite and Mei Ling Doery ‘A values-based health system’, also in the MJA, published in 2011.
Over the years, numerous opinion pieces for Croakey, New Matilda, and The Sydney Morning Herald have also made the case for change.
Why haven’t all these reports and recommendations created the desired changes?
The Australian health care system is highly complicated. Three tiers of government deliver a hybrid public-private model. There are countless stakeholders – politicians, public servants, the professions, pharmaceutical and medical device companies, health insurers, not-for-profit organisations, charities and consumer groups – many of whom have an interest in preserving some aspect of the status quo.
Coordinating change will be difficult – it requires co-operation and collaboration, putting aside differences to build a new system that puts the needs of patients at the centre. It needs clever strategy, political vision and courageous leadership.
The system is unsustainable. It is not good for patients or clinicians. It is costing money and lives. We cannot continue on the same trajectory. The time has come to act.
I’ve got my fingers crossed that in 2020, my New Year’s resolutions carry through.
• Dr Clare Skinner is Deputy Chair of the ACEM Council of Advocacy, Practice and Partnerships and Director of Emergency Medicine at Hornsby Ku-ring-gai Hospital in Sydney, NSW, Australia.
This article was written with support and input from Dr John Bonning (ACEM President), Dr Simon Judkins (ACEM Immediate Past President), and Dr Didier Palmer (Chair of ACEM Council of Advocacy, Practice and Partnerships).
