Visiting the magnificent Angkor Wat temple in Cambodia, my elderly dad resolutely navigated the steep stairs as I held my breath. My mother, less mobile and more wary, stayed at ground level but the 12th-century ground wasn’t exactly smooth. All I could think was “falls risk”, which casually led me to ask our guide what the local hospital system was like. This invited a lament about the long waits, the cost of care and poor outcomes.
Someone else explained that in South Korea, her wealthy country with universal healthcare, paramedics must call dozens of hospitals to seek permission to off-load patients. A woman hit by a truck died after the ambulance could not find any of 30 hospitals to accept her.
As we spoke, UK doctors were going on a six-day strike for the 15th time in three years to protest about their conditions. Patients were urged to “come forward as normal” and doctors promised to keep them safe, but it wasn’t clear how when tens of thousands of them were away.
Across the Atlantic, where Americans are used to geography determining healthcare outcomes, 47% say they can’t afford the cost of care and graded their country’s healthcare system as a C.
Shaking his head, my dad remarked this is why he felt safe at home where healthcare was universal, reliable and safe. Naturally, I felt a rush of pride but even one-eyed fans of Australian healthcare should sometimes open both eyes to see more clearly. I’m afraid things are not as rosy as my dad imagines although, thankfully, I can’t recall the last time he experienced the inside of a hospital.
The problems facing Australian healthcare are well documented.
During Covid, when we closed beds, deferred screening, delayed rehab and neglected mental health, people didn’t stop getting cancer, chronic pain or depression. They waited and worsened.
The number of patients transferred on time from ambulance to emergency has fallen dramatically while ramping has risen sharply.
Old and frail patients are stuck in emergency or worse, precious intensive-care beds, awaiting a ward. Why are there no ward beds? Because they are occupied by patients who need senior services, rehabilitation and placement. Also, disability support and palliative care.
I have worked on and returned to the medical unit to find the same patient there six weeks and, sometimes, six months later.
Sicker patients require longer stays. (Then, deconditioned, they can’t go home without services that are seemingly impossible to arrange.)
Longer hospitalisation clogs capacity. Where 85% occupancy is considered safe, Australian hospitals often operate at full or over capacity.
Mental health stays in its own abject category. An emergency department is the worst place to calm anyone so staff are used to seeing distressed patients cause distress to others. Security guards are a fixture of emergency rooms but now they are on the wards too.
On a recent round, my team froze at the piercing screams that suggested a violent attack. We cautiously went looking – to find overwhelmed relatives clawing at each other. Security intervened while negotiations occurred. Not everyone behaves like that but the antecedent issues were predictable: helpless patients, hapless relatives and a perceived gap in healthcare delivery. Still, it’s a sad day when a place of healing resembles a crime scene.
Long waits make for sick patients. Sick patients take longer to treat. Longer treatments reduce capacity. Reduced capacity extends wait times for everyone else. Doctors call this “complex care”.
In a new report, the Economist calls it a “doom loop”.
Among 18 rich countries, satisfaction with healthcare quality fell sharply after Covid hit and remains well below pre-pandemic levels. It is typically thought that domestic policy determines the challenges of healthcare but the article points out that, despite healthcare funding being the highest it has ever been, outside Covid productivity has stalled.
The Australian workforce has grown by 20% since 2019 but elective surgeries have flatlined and people are waiting longer to be seen. France, Canada, Germany, the US and the UK are similarly ailing.
But the bit of the report that caught my attention was something that has been right under my nose.
We know that Covid caused a mass exodus of nurses and doctors who resigned or retired early.
But the ones who stayed often reduced (note: not stopped) their “discretionary effort” such as staying back, teaching, mentoring or doing the myriad things that help the profession thrive. Medicine has become more transactional for everyone, not just patients.
When experienced people leave, the inexperienced who replace them need years to gain the confidence and finesse to influence patient care. This impact can be seen right down to administration. When a patient appears miserable in the waiting room, a seasoned clerk will think nothing of telling the oncologist to hurry. The temp wouldn’t dream of it. A veteran nurse knows the difference between suggesting action and demanding action; a graduate nurse might take years to figure it out. Who wins (or loses)? The patient.
The problem is that administrators still think that stress, burnout and “quiet quitting” are individual issues to be expunged even when the evidence shows that they are systemic and affect patient care.
It seems that unravelling the doom loop might be more about method than money.
Modern healthcare is desperate for a robust, structured community focus instead of the current fragmentation. Aged care services must keep stepping up to meet the needs of elders. Outside hospital, physical rehabilitation and psychological help must be more easily accessible.
And in this era of chronic disease, education must begin at school that, while hospitals will always help those in need, prevention really is better than a cure.
