The pandemic taught us a lot about our health system. Here are just a few lessons, and what we should do about them.
GPs are important and we don’t have enough.
During the COVID wave in 2020 a woman called me from Queensland, worried about her son who was sick in bed in Brunswick with COVID. He couldn’t find a GP and while he didn’t seem to need hospital, it was hard to be sure over the phone. In the end his condition improved, and the government adopted a successful program, developed by GPs at CoHealth, for managing COVID patients at home.
But this example illustrates how GPs are increasingly hard to find, with those accepting new patients often booked out for weeks and charging substantially more than the Medicare rebate. It’s worse in the outer suburbs and in the country, where GPs have always been scarce, and with fewer medical graduates choosing general practice as a career, the problem will worsen.
I suspect the federal government may increase Medicare rebates (payments) to GPs and even limit numbers of specialists, but it’s also time we thought about other ways of providing general practice care.
When you go to hospital you see a salaried hospital doctor funded by the state government. It’s time the state (or federal) government directly funded some GPs in areas of need, which is why this is in our health policy platform. Funding could be used to top-up Medicare, or to employ doctors directly as in some community health organisations, to provide more free primary medical care.
But primary care (medical care not requiring a referral) doesn’t just need GPs, and this policy also includes nurses and allied health staff employed under the same model. Better funded primary care will keep more patients out of hospital, both by preventing serious illness and by managing it when it does occur.
To help the state government get better at working with general practice, we also need an Office of the Chief General Practitioner to coordinate primary care with hospital care.
Our hospital and ambulance system can’t cope with a surge in patient numbers.
Too often this year we heard of ambulances failing to respond to emergency calls in time to save someone’s life. There were many more cases of ill and injured people waiting hours for help.
Announcing shiny new hospital projects won’t solve this until we attend to some less glamorous but important problems.
We need to help health workers move patients through hospitals more easily, by addressing something known variously as “exit block” or “bed block”. Ambulances waste hours “ramped” at the hospital until they can hand their patient over to staff, because the emergency department is full, and the ED is full because the wards are full so can’t take patients from an emergency.
Most medical wards hold patients, often elderly, who no longer need acute care but are waiting for a geriatric evaluation bed, or a rehab or aged care bed. So we need to fund these beds, which don’t make for great media announcements, but are critical to support our hospitals and ambulances.
We also need more allied health staff like social workers and pharmacists working on weekends, to help discharge patients seven days a week, freeing up beds for weekend sports and alcohol-related injuries, rather than waiting until Monday.
Better medical and specialist nursing on-call support for aged care will also reduce the number of ambulance trips to the emergency department for procedures like changing catheters.
We must address burnout in nursing staff and other clinical staff by first ensuring they are adequately paid and lifting the public sector wage cap is one place to start that process. Preventing surging COVID numbers is equally important (see below). Longer term work should look at the reasons health workers are leaving the sector and whether measures such as increased leave or changing career structures would help.
Prevention is always important, even when it’s inconvenient.
Victoria protected the hospital system from COVID with measures like density limits, lockdowns, mask rules, testing, isolation and contact tracing, until late in 2021 when the Omicron wave started to spread rapidly. Around that time, Victoria gradually withdrew disease control measures, relying instead on the high levels of vaccination.
The result was an overwhelmed hospital system, with well-publicised failures such as late ambulances and deaths and the declaration of a “Code Brown” (authorising hospitals to cancel leave and alter nurse patient ratios). When the Omicron wave peaked in January 2022, we had 1200 patients with COVID in Victorian hospitals with many nurses working double shifts. Subsequent peaks in autumn and winter led to hundreds of deaths and put hospitals and their staff under constant stress. I called for the reintroduction of masks and other measures several times during this period.
The lesson is clear - hospital system failure is the inevitable consequence of failing to prevent enough disease.
As I write this in October 2022, we are in a COVID lull, with around 140 COVID cases in hospital, but it would be foolish to expect this to last. Right now Australians have high levels of immunity from vaccination and infection, but we now know this immunity is short-lived and we must expect another COVID wave before long. To keep our hospitals and ambulances running effectively, we will need some disease control measures, and if we introduce milder measures earlier, such as masks and air purifiers, we will hopefully avoid more extreme measures.
While COVID was surging, hospitals were still dealing every day with other preventable diseases like complications of diabetes, smoking and alcohol, and with injuries from road crashes and violence. And COVID was deadly in people affected by some of these conditions, like diabetes.
We’ve long recognised prevention opportunities here and failed to take them, perhaps because the benefits seem so long to be realised. Covid shows that we can delay disease prevention no longer and it must be a priority. There are many small steps that can be taken now. In most states a shop needs to be registered or licensed before it can sell cigarettes or nicotine products, but not in Victoria, so I’ve asked the government to set up such a scheme here. We should stop advertising junk food and alcohol on state-owned infrastructure and more tightly regulate online ordering of home delivered alcohol.
We can’t keep neglecting public dental care…
I recently visited the public dental clinic run by Merri Health in Glenlyon Road Brunswick. They work with the neediest Victorians and often remove teeth from children with severe dental decay, but they don’t have enough chairs and staff to meet demand.
The waiting list for general public dental care in Victoria is 27 months, in my electorate it is 46 months. Long waiting times mean more emergencies like tooth abscesses, which get in the way of reducing the waiting list and so the waitlists snowball. And some of those emergencies end up in hospital emergency departments.
Waiting almost four years to see a dentist in this country is outrageous. We must fund public dental clinics adequately.
…or mental health care
Most mental health care in Victoria is provided by psychologists, GPs or psychiatrists working in the private system, with their fees part-subsidised by Medicare. The out of pocket gap is prohibitive for many.
The public mental health system has been under-funded for decades, and can therefore only barely manage to care for people with the most severe and disabling mental illness.
While the recent Royal Commission should bolster public services, it will take time before the mental health workforce grows sufficiently to achieve this. Many are already waiting weeks to see a GP for a referral, and weeks and months more to see a specialist. All healthcare delayed, particularly mental healthcare, increases the chances a person ends up in an emergency department.
In the short term, we need to increase the number of positions for psychologists and psychiatrists in the public mental health system. We must also ensure the staff in public mental health wards and clinics are adequately paid so we retain them. Social workers and occupational therapists are important but underpaid members of the team needed to support seriously mentally ill people in the community.
What about the mountain of clinical waste?
Ask any health worker and they’ll tell you they’re producing more rubbish, particularly single-use PPE and plastics, since the COVID pandemic began. It’s hard to see how to tackle this problem without weakening the strict infection-control regimes that hospitals and clinics must follow.
Researchers have promoted a range of solutions including reusable respirators (they can look a bit like rubber gas masks) and ventilation hoods over patient beds. Reusable equipment is likely to save money in the long run, if it can be used safely.
Health waste was a problem long before COVID, complicated by a long-term shift toward using increasingly expensive single-use items. I was astonished to see bag-valve-mask resuscitators ($35 each) being thrown out in a hospital ward a few years ago, because their “use-by date” had expired. There was nothing wrong with them and I believe many use-by dates just increase sales rather than protect patients.
Balancing cost, sustainability (including the energy consumption of cleaning), and safety, is a difficult task requiring a dedicated healthcare sustainability unit, rather than leaving these decisions to individual hospitals. That's why I’ve asked the Minister for Health to set up such a unit, with the goals of saving costs, and reducing the waste volume and carbon footprint of our health system.