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How SA's hospital system lost sight of patient care

Opinion

Patient care no longer appears to be the prime consideration in the running of South Australia’s public hospital system. Warren Jones explains how that happened and how it can be fixed.

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In the wake of the previous State Government’s failed attempt at hospital reform, it is important to ask whether the resultant complexity of access to clinical services has eroded the principles of patient care.

Transforming Health aimed to cut costs by closing and downgrading hospitals and reducing or redistributing facilities and clinical services. This process cost, rather than saved, money and, in so doing, diverted the attention of bureaucrats and clinicians away from the primacy of patient care towards ill-considered attempts at efficiency gains.

The abrogation of patient care has several manifestations.

Inordinate attention to the average length of stay (LOS) in hospital

This is a key indicator of service efficiency and its reduction is seen as essential to budget control. The LOS in our hospitals has slowly improved over the past two decades. This has continued unabated under Transforming Health, but in no way reflected the totally fanciful promised 30 per cent increase in efficiency.

The deleterious effects of attempting to further reduce the LOS are considerable. The premature discharge of patients, where problems and care needs have been inadequately addressed, has led to the so-called ‘churn’ effect – that is the repeated re-admission of patients who are often sicker than when they were first admitted.

The statistics for LOS and re-admissions are collected and recorded; the former are published, but the latter rarely see the light of day.

Decreasing continuity of care

The dedicated team approach to patient care in specialty units in our general hospitals has suffered in the disruptions caused by chronic overcrowding and bed shortages.

Patients may bounce between hospitals and services, at times without regard to clinical relationships. They are often inappropriately accommodated away from what should be the ‘home’ ward designed to meet the needs of their medical diagnosis. These so-called ‘outliers’  experience significantly increased in-hospital mortality compared to ‘inliers’ in home wards.

The almost random allocation of patients as ‘outliers’ to a variety of wards throughout our hospitals is also a source of stress, overwork and inefficiency for specialist clinical staff.

In some specialty services in our larger hospitals, a routine ward round may take four hours and cover several kilometres by the time widely scattered patients are identified and located.

Which doctor – does it matter?

There is an increasing and worrying trend to abrogate the role of a patient’s appropriate specialist – it doesn’t matter who sees you, as long as it is a consultant of some sort.

Hence, a patient may have multiple assessments, and re-assessments, at a consultant level, without a timely and effective management plan being formulated. At times, assessments are made on the basis of incomplete information due to the chaotic situation with a mixture of paper-based and electronic medical records.

Once again, the focus of the assessment may be more on LOS reduction than on comprehensive patient care.

The role of ‘non-diagnosis’

The importance of a precise diagnosis, particularly in patients attending an Emergency Department, seems to have been forgotten.

In its place, there is a tendency to make a ‘non-diagnosis’ (eg ‘not a heart attack’) as a means of identifying patients who don’t necessarily require in-patient hospital care.  This, in turn, is a strategy for preserving beds, but at the expense of proper and safe patient management.

An example is a patient with chest pain. The approach, now, is to investigate to establish a ‘non-diagnosis’ of heart attack and thereby to facilitate discharging the patient. Most patients with chest pain don’t have a heart attack, but they deserve better than a default non-diagnosis.

Similarly, the same approach is being adopted with patients presenting manifestations suggesting a stroke. If initial assessment and investigation make this unlikely, they can be labelled with the ‘non-diagnosis’ of ‘not a stroke’.  This means that they may be discharged or require further assessment to make a positive diagnosis.

Such patients may have other complicated or serious medical problems, and their proper management may be delayed by this unfortunate ‘non-diagnosis’ strategy.

The establishment of clinical silos

Transforming Health was primarily a cost-cutting exercise with broad deleterious effects on the hospital system. However, an interesting side-effect has been the enhancement of selected silo-based clinical ‘empires’ largely promoted and run by senior staff who benefitted from their opportunistic support of some components of the Transforming Health Agenda.

These siloed services can be self-promoting but selective in their activities.

A key current driver in the health system is efficiency, with selective admission and exclusion criteria. Using variable application of these criteria, Siloed Services can make themselves look good by declining certain patients. Inter-service linking and coordination are becoming less effective resulting in some patients falling between the cracks – they may not be able to assess services at all.

There are examples of these silos in each of the local health networks. They are likely to complicate the repair of our damaged health system.

Hopefully, they can be re-integrated with other important services to restore equity and access for patients across greater Adelaide.

Restoration of the patient care ethic

Our hospitals are at a post-Transforming Health watershed.

The new Government must find the money and the means to fulfil its election promises. It must further expand future commitments aimed at progressively repairing the considerable damage wrought over the past several years.

This will mean dismantling the present cumbersome centralised administrative framework in favour of a more localised and responsive system.

The counterproductive culture in SA Health with its bloated and burdensome bureaucracy must be reformed. The entrenched positions of senior medical staff must be revised and a broad church of clinical consultation empowered at a senior level to restore the primacy of patient care in the public hospital system.

The health system is under considerable strain. Stretched ambulance and emergency services are the subject of crisis meetings between government, unions, hospital managers and clinicians.   Frontline staff are under increasing stress to meet the demands of efficiency and clinical needs.

It is time for enhanced and meaningful engagement between clinicians, patients, health administrators and the Government.

Reform and repair must be driven from the frontline and should be informed by direct feedback from patients and their relatives and carers to clinicians, rather than filtered through bureaucratic pathways.

If the right messages get through, the Government will have a basis for the timely and responsible use of scarce finances to optimise health and hospital services.

Warren Jones AO is an Emeritus Professor at Flinders University and a former head of obstetrics at the Flinders Medical Centre.

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