Emergency physicians call for whole of system reform

June 2021

InSight+ (mja.com.au)

With Dr S Judkins and Dr J Bonning

There has never been a greater appetite for whole-of-health system reform.

In recent weeks, we have seen state health ministers agree that public hospitals are in crisis, pointing out that hundreds of acute hospital beds are occupied by people waiting for aged care or disability services.

The Australian Medical Association has joined the call, warning that patients are being harmed in clogged emergency departments (EDs) and in ambulances queued outside, recommending significant investment in primary and hospital care.

Reports from the Royal Commission into Victoria’s Mental Health System and the Productivity Commission into Mental Health have made it clear that large-scale redesign of mental health services is urgently required.

The media spotlight has been on ED overcrowding. Tragic stories accentuate the need for change. ED clinicians feel the impact of overcrowding every day — people treated on ambulance stretchers, in corridors, or in the waiting room; people waiting hours for diagnostic tests and procedures; people who come to hospital with poorly managed chronic or social conditions because there is nowhere else to go. Access block, where patients who are admitted and require an inpatient bed are delayed in the ED for 8 hours or more due to lack of hospital capacity, compromises all aspects of ED care.

Emergency physicians know that ED overcrowding is a sign of dysfunction across the broader health system. While we are constantly striving to improve the quality of emergency care, we highlight that most of the solutions to overcrowding lie outside the ED.

InSight+ recently published an article by Dr Simon Judkins describing the critical state of ED overcrowding across Australia. A poll attached to the article asked readers whether they agreed with the statement: “urgent reform is needed to support the acute care sector of Australian health care”. To date there have been 1160 responses, with only 11 disagreeing or strongly disagreeing. The results were overwhelming.

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There is clear evidence that ED overcrowding is associated with preventable morbidity and mortality. Emergency physicians have spoken up about this for many years, but responses have been inadequate. The system has become increasingly overloaded, fragmented and dysfunctional. Factors causing ED overcrowding have an impact on everyone who is treated in or works in the health system. Addressing overcrowding is not just an issue for EDs, the problems and solutions are complex and shared. The time has come for all of us to work together to create a safer, fairer and more patient-focused health system.

Much of the problem lies in the way our health services are governed and funded. Community and primary care, including GPs and residential aged care facilities, are regulated by the federal government. Acute hospitals are managed by the states. Add in a heavily subsidised private hospital sector and opaque (and often confusing) health insurance products and it is no surprise that the acute health sector is a mess, with cost-shifting, duplication and excessive bureaucracy. Review of governance and finance arrangements to drive best-practice, health-promoting, collaborative care must be an urgent priority for reform.

The divide between federal and state governments is responsible for a persistent problem: patients waiting in acute hospitals for residential aged care beds, and a pervasive myth that EDs would not be crowded if only people visited their GP.

Blame and cost-shifting between levels of government must stop. We must also stop blaming patients for coming to the ED. People with simple health issues that could have been managed by their GP do not require a bed in the ED, complex diagnostic testing, or admission to an inpatient unit. So-called “GP-suitable patients” are categorically not the cause of hospital access block. We must better appreciate the cost and access barriers that drive people to seek acute treatment in an ED instead of primary care, and design and resource the health system differently.

COVID-19 has highlighted new risks of ED and hospital overcrowding. It is impossible to practise effective spatial distancing and infection control in an overloaded clinical environment. Redesign efforts in response to the pandemic have demonstrated that clinicians from diverse specialties and professions can work together with managers, patients and carers to rapidly implement collaborative and safety-focused solutions. We should harness this spirit of cooperation to build a “new normal” health system. It is disappointing to see clinicians slip back into old, disconnected ways when we should continue working together to drive innovation and excellence.

What would an improved system look like? From an ED perspective, it is all about access.

We need access to senior clinical decision making, with regular inpatient team ward rounds, clinics and consultations beyond office hours, seven days per week. We need access to skilled health care workers in adequate numbers to allow balanced rosters over extended hours, with access to leave, rest and education, supported by smooth and integrated training pathways.

We need timely access to diagnostic tests and results. We need access to information, including well designed digital systems that cross hospital–community–patient interfaces and consistent, evidence-based national clinical guidelines.

We need collegial access to health service managers to troubleshoot problems and find clinically focused solutions.

Above all, we need streamlined patient flow in, through and out of acute hospitals, to ensure that patients requiring admission from the ED always have access to an adequately staffed appropriate inpatient bed, with public hospital bed capacity proportionate to the predicted population demand.

Of course, the majority of health care does not happen in hospitals. An improved health system must be centred on access to excellent, well resourced, primary and community-based care. We need access to GPs who are appropriately remunerated, connected and supported. We need after-hours access to subacute services, such as the “Safe Haven Café” for mental health care and child health clinics.

We need hospital-in-the-home models to support treatment of people in their usual environment, and timely and affordable access to medical specialist, dental and allied health care.

We need a residential aged care sector which is driven by care, not profit, with adequate numbers of registered nurses and around-the-clock access to contextualised medical advice.

We need health promotion, access to timely preventive measures, and better attention to improving the social determinants of health.

An effective health system requires all these components, across the full spectrum from individual to population level care. As clinicians, it can be difficult to see beyond our professional silos and it is tempting to advocate (and compete) for our own direct priorities, especially in times of budgetary constraint. A functional system requires balance and coordination. No single service or sector holds all the answers.

You are likely to be familiar with the National Emergency Access Target (NEAT), also known as “the 4-hour rule”, which was implemented across Australia in 2012. While intended to drive resourcing and capacity across the entire health system, the one-size-fits-all measure did not consider the needs of different patient streams, making it possible to hit the target and miss the point. It was easy for hospital executives to focus on patient movements in and out of the ED but not on resolving the fundamental problem: that the entire system was running over capacity. Evidence has shown that there are improvements in patient mortality and morbidity when we adopt a hospital-wide approach to patient flow through proper resourcing, staffing and hospital capacity. A more nuanced approach and a broader understanding of hospital access targets will be required as we move forward.

It is time for action on ED overcrowding and access block. Emergency physicians cannot do this alone. The problems are too complex, and solutions largely sit outside the ED. We need whole-of-system collaboration to drive meaningful change. Poor access to care threatens the health and safety of patients and clinicians. We have a shared responsibility to do better, including learning more about system-wide problems, redesigning our own processes and practice, and making more deliberate efforts to collaborate across professional and service boundaries to improve care.

The Australasian College for Emergency Medicine continues with significant advocacy on ED overcrowding and access block, calling for greater state, territory and federal government collaboration to alleviate significant pressures.

We ask that colleagues in other specialties and professions stand with us to advocate for change. Together, we must engage with decision makers and work towards a common goal: timely access to affordable, safe, and effective health care for all Australians.

Dr Simon Judkins is the Immediate Past President of the Australasian College for Emergency Medicine (ACEM).

Dr John Bonning is President of ACEM.

Dr Clare Skinner is President Elect of ACEM.