The Hospital tail wags the Health Dog

Two key principles in any health system must be:

1. Health care and information based on the patient and as close to the patient’s home as possible. Institutional care and hospitals should be the last resort.

2. An actively involved community in determining health priorities because we can’t have all we want. Unless the community is involved, resources will go the influential and media savvy.

One clear example of where our health system does not give priority to where Australians think our health dollars should be spent is mental health. The plight of Cornelia Rau says it all – a mentally ill woman was locked up for six months beyond the care of family and friends. The Cornelia Rau case is only the tip of the mental health iceberg that is in our midst. Many of our mentally ill are homeless or in prison. It is a ‘disgrace’ as Tony Abbott says.

We have the wrong model of health care with the hospital at the centre. The best model is where there are strong core services in the community – primary care – that is linked to hospitals but not driven by hospitals.

There is ample evidence that we have got the cart before the horse in health care with our emphasis on hospitals.
-We have more hospital beds per capita than comparable countries – about 50% above the Canadian rate and 30% above the US rate.

-In some states almost 70% of state health dollars are spent in hospitals.

-The health debate is invariably about hospitals.

-30% of people in hospital needn’t be there if there was adequate other support in the home or in the community, particularly those with chronic illness, the mentally ill and the aged.

By a primary health care system, I mean a system which focuses on population needs, rather than institutional interests, that addresses the social determinants of health, particularly poverty and disadvantage, focuses on health promotion, illness prevention and early intervention, insures equitable access to health services and has a community involvement and participation. Such an approach recognises that there are limited resources and that we need to maximise the wellbeing of the population within those resources.

Why is primary care so essential in building a healthy community?

-Our autonomy and dignity as patients is much better enhanced if we can be treated either in our home or as close to our home as possible. Hospital should be our last resort and not our first resort.

-The greatest cause of bad health in Australia and elsewhere is poverty – poor diet, poor lifestyle, lack of exercise, stress, and lack of self-esteem. These problems which of course go far beyond health can only be really addressed in the community.

-New drugs, orthopaedic and cardiology procedures have greatly improved health and life expectancy, but the great advances in health around the world have come through public health and preventive measures – clean water, sewerage, vaccination, improved diet and exercise. The biggest improvements we could make in Australia today in health would be effective and aggressive campaigns against smoking and obesity. It is better to erect barriers at the top of the cliff to prevent falls, rather than have a fleet of ambulances at the bottom of the cliff.

-It is cheaper to treat patients in a primary health care setting than in an expensive tertiary hospital. Early intervention reduces the cost of care.

-Failures in the primary health care system cause untold and expensive repercussions in the rest of the health system. Delays in treatment make for a worsening of health conditions. A 2003 survey by the Prince of Wales Hospital in Sydney revealed that 79% of the frail aged patients in winter that year need not have been admitted to hospital if there was adequate clinical care (GPs and nurses) in the community and in the home.

Primary care must be multifunctional in nature and provide a range of clinical skills – doctors, nurses and allied health such as physiotherapy and dietary support. The nature of primary health care clinics will vary enormously from community to community depending on the age and size of the community. Employment in primary health care clinics will also vary. Some will be private, some public and some will be a combination of both. Some will have salaried staff and some will be remunerated on a fee for service basis. The key must be clinicians working as teams to provide an appropriate range of services in the most efficient way. The days of the lone general practitioner, usually a male and working 70 hours a week, are well and truly passing.

Why then do we have such a hospital centric system with primary health care very much the Cinderella? I suggest there are several reasons.

-So much of medical practice is now based around specialisation and the interests of specialists. They lead so much of the debate. As members of the community, we often feel that what we need is more generalists and fewer specialists.

-People within institutions, usually hospitals, are not surprisingly concerned about the interests of their institution. We all attach loyalty to an institution and in the process we often lose sight of the real goals of a health system, the wellbeing of patients.

-The division of responsibility between the commonwealth and the states works against integrated care and getting the balance right between hospital and non-hospital care. The commonwealth largely funds primary care (GPs) and the states partly fund and operate the hospitals. The result is dysfunction between the two.

-The debate about health is driven by insiders – ministers and doctors – and the community is excluded.

-The media reports the debate between the insiders and entrenches the view that hospitals equal health. The Mental Health Council of Australia said it all in the title of its 2003 report, ‘Out of Hospitals, Out of Mind’. We are preoccupied with what happens in hospitals and forget other critical aspects of health care.

-The hospital lobby is much more media savvy and influential than the primary health care lobby and those concerned about mental health. We see it time and time again with hospital interests taking a new crisis story to the media. Hospital hot buttons are so easy to press. But scarcely anyone makes the argument that the reason why hospitals are under pressure is because the primary health care system is under resourced and is not working well enough. If only divisions of general practice had similar media attention.

-There is a lack of honesty at the political level as to what the system can reasonably provide. We are not faced up to the essential fact that we have to make choices in health. Priorities have to be set. Because there is little debate, the urgent (hospitals) gets more attention than the important (primary care).

What is the way through this tail-wagging-the-dog problem where hospitals are invariably more important than non-hospital care? I am certain that there is only one effective way.

It is an informed and involved community. And by that I don’t mean lip service, tokenism, but genuine community involvement in numerous ways and at many levels and over a long period. But so often the community is not informed and not involved. Sometimes that is deliberately so. Some ministers believe that they represent the community, so why is there a need for direct community participation in setting priorities in health. And some clinicians believe that the public doesn’t really understand the important issues so it should be left to them to make the decisions.

My experience is that when the community is well informed and involved it comes to realistic views about the important priorities in health. Very often that view is quite different to the fairly superficial discussion and views expressed in the media. So often the media projects the interests of people within hospitals concerning hospital waiting lists, emergency departments and the need for new high tech equipment rather than the interests of the community.

Let me illustrate what happens when the community is genuinely involved and consulted.

In 1996 a 12-month consultation was held with people in western metropolitan Adelaide. Many meetings were held and community members were thoroughly briefed and informed by experts in health issues. The community members were told about the options and their costs. These members came up with some quite clear views on the priorities that they thought were important in health. Briefly, they listed the priority areas as – mental health, better information, aboriginal health, home-based care, palliative care and consumer involvement.

Asked about those areas which should receive less priority, they listed – life-extending interventions in last stages of terminal illness, some fertility treatments, bureaucracy, non-essential surgery and hospital super specialties. After reading that report, no one can ever tell me that the public cannot understand the important issues and decide between them.

From my experience in two State-wide health reviews, several issues stand out as being of high priority. They are mental health, including particularly amongst young people and aboriginal health. It was not hospitals, despite the iconic status which hospitals rightly enjoy in their communities.

In summary, two important principles of a health system stand out

1. We need to change the model of care to one based on primary health care principles and practice rather than a health care model based on hospitals. Hospitals must be integrated effectively in the system but they must not be allowed to dominate.

2. The key to change is a genuinely well informed and involved community. Unless we win the debate through involving the community, the insiders who control the present hospital centric system will continue to monopolise the debate and the resources.

John Menadue is Chair of the Centre for Policy Development

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