The principal reason public hospitals are under severe strain is the number of elderly patients presenting for treatment, many of whom have co-morbidities - an additional chronic condition - and require complex care.
In recent months, health reform groups have seized on the “hospital crisis” to repeatedly call for greater “investment” in “preventative” primary care. They argue that international evidence shows that stronger primary care for high-risk groups reduces the number of “avoidable” hospital admissions.
This was one of the claims made in favour of “a new approach to primary care” in a paper by Jennifer Doggett, released by the Centre for Policy Development in June, which called for a $4 billion, 10-year commitment to establish a national network of multi-disciplinary health clinics.
Both the federal Government and opposition are convinced by the argument-cum-mantra that “prevention” will keep elderly and chronically ill patients out of hospital and relieve pressure on the public hospital system.
The Prime Minister announced on October 31 that a re-elected Coalition Government would fund up to 800,000 Medicare-funded visits a year by practice nurses to people aged over 65, veterans and those too frail to visit a doctor. This followed Kevin Rudd's announcement in September that a Labor Government would spend $220 million to establish multi-disciplinary GP “super clinics” to provide on-going and co-ordinated care for the aged and chronically ill.
But does the evidence really show that these policies will alleviate the hospital crisis?
The Coalition's proposal resembles a similar program introduced into the UK National Health Service in 2003. Practice nurses conducted geriatric assessments, designed care plans, and provided follow-up monitoring for elderly patients not in regular contact with a GP. The Blair Government then incorporated nurse-led intensive case management into its “community matron” policy, even though the evaluation of the pilot scheme found that “case management had no significant impact on rates of emergency admission, bed days, or mortality in high risk cohorts”.
The evaluation also noted that this finding was consistent with the results of the nine Australian co-ordinated care trials of the late-1990s, which tested the hypothesis that case managing the conditions of chronically ill patients would improve health outcomes while lowering costs and hospitalisations.
However, the national evaluation report - published by the Commonwealth Department of Health and Ageing in 2002 - found that only three of the trials recorded any significant reduction in hospitalisations. And even here - as in the much-touted case of the South Australian Health Plus trial - the savings on hospital costs were not sufficient to pay for the additional cost of co-ordinating patient care.
The national evaluation in general found that co-ordinated care had failed to improve patient outcomes and most trials had operated at a loss.
Commenting on the results in the Medical Journal of Australia, Adrian Esterman and David Ben-Tovim explained that “the essential premise that better co-ordination reduces hospitalisations is misguided”.
“It may be that lack of co-ordination in a complex care system operates as a functioning rationing system, so that better care co-ordination reveals unmet needs rather than resolving them,” they wrote.
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