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Unhealthy focus on acute care

By Ian Hickie - posted Thursday, 22 April 2010

It's good to look after people properly in hospitals, but better if they don't have to go there in the first place.

When Kevin Rudd promised in 2007 to end the blame game and finally give Australians a national health system, we all cheered. We knew the states had little hope of funding or supplying the 21st-century system that we will need. But those of us in the health professions fear that what we are in danger of being given by the federal government is not a sustainable national health program, but a rather limited public hospital program.

Whenever some doctor, the Australian Medical Association or a federal or state politician says we need more beds, they are ignoring the fact that Australians already spent more nights in hospitals than people from other OECD countries.
In fact, while increasing Commonwealth funding for public hospitals may suit some state treasurers, it may not be good for our health. Many of the problems that patients and working families encounter every day in the health system really stem from grossly underdeveloped primary care, community care, aged care and out-of-hospital specialist care systems. When you only fund acute care hospitals to function well, then they become the only real places for working families to go for all forms of care - not just acute or emergency care.


As the Prime Minister has stated, we have always underinvested in prevention, early intervention and alternative care settings, particularly for older people. Lowering obesity rates and reducing the harmful use of alcohol, particularly among young people, should be high on any real health priorities list.

After a decade of decline, national suicide rates appear to be rising. Suicide is the leading form of preventable death in young Australians. It is also a major community issue during any period of economic downturn and is exacerbated by the persisting lack of access to appropriate mental health services.

When it comes to early intervention, Australian of the Year Professor Pat McGorry has developed world-leading programs in mental health. But they are still not widely utilised in their birthplace, Victoria, let alone elsewhere in the country. The Commonwealth has not mandated these services and the states have not provided them. We would not accept this degree of fundamental neglect in cancer care.

E-health technologies for public health and service delivery (not just medical record keeping) have been developed in Australia and exported overseas. They are still not mainstream in our national system. In aged care, we don't need ''residential'' facilities, we need real sub-acute services that are funded to provide specialised clinical services for the elderly with multiple health needs.

Sadly, the Rudd health plan has not scratched the surface in the key areas of health inequality - mental health, dental care and indigenous health. It's important to remember that Governments pay only 70 per cent of the cost of healthcare - you pay the rest out of your own pocket (directly or through purchasing private insurance). In mental health and dental health, you still need serious cash to get a real service. The current state-based systems are grossly inadequate.

Medicare-based psychological services don't reach the young, those with little cash (given the average $40 gap payment) or those in regional and rural areas. The failure to support accommodation and other social services for those with a chronic mental illness exacerbates homelessness and leads to frequent rehospitalisation.


Most obviously, we still lack serious systems for the management of chronic diseases such as diabetes, lung disease, dementia and depression. Chronic care requires consumer empowerment alongside co-ordinated primary and specialist care outside of hospitals. The national diabetes plan is a small start.

Until Nicola Roxon's clear commitment on the ABC's Lateline last Thursday night, there had been no commitment to mental health reform. The Health Minister's statement that the Commonwealth would fund 100 per cent of community-based mental healthcare may prove to be the first serious step down the path of chronic disease management in Australia.

Genuine integration of GPs, specialised mental health services and community-based organisations for mental health, and alcohol and drug services, could be a model for other disease areas. In this regard, the new national mental health program for young people, Headspace (funded nationally and delivered locally), has been an excellent pilot program.

Given the Prime Minister's awareness of these obvious problems, the limited final offer being put to COAG is puzzling. The primary care package is rudimentary and does not spell out the size or scope of the new primary care networks. The big dollars have been allocated to public hospitals and purchasing of elective surgery from the private sector. The real service commitments, particularly the guarantee that you will be treated within four hours of presenting to an emergency department, are clearly focused on improving the acute care sector only.

There is no doubt that this is a once-in-a-generation opportunity for real national health reform. Rudd is to be congratulated for stating the obvious - we can't continue to sustain a dysfunctional, divided, state-based system. However, before Australians vote this year, they may need to step back and ask whether we are really moving to a new national health system. A limited reworking of the state-based public hospital system is not acceptable.


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This article first appeared in The National Times, April 19, 2010

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About the Author

Ian Hickie is a board member of the Mental Health Council of Australia and executive director of the Brain and Mind Research Institute at the University of Sydney.

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