Governments that want to improve health should focus their efforts on community-based care rather than just on hospitals. That is the crux of new article, titled “The future of community-centred health services in Australia: lessons from the mental health sector”, in the journal, Australian Health Review.
One of the article’s authors, Professor Alan Rosen, a longstanding advocate for improved mental health care, has also written the missive below, to our hospital-centric PM. This is only the first instalment:
Dear Mr Rudd
Is your proposed health system reform refrain just about hospitals or is it supposed to amount to fundamental transformative reform of the whole health system? So far, your melody could be construed as a riff on the old song: “let’s twist again, with hospital-centred care”.
The health care currently provided or proposed by Australian governments is too hospital-centric and will not address the greatest pressures on our health system, concludes our paper in the current Australian Health Review. We review current international reports and studies, indicating that hospital-dominated health care produces limited health outcomes and is an unsustainable health care system strategy.
You would be well aware by now, Mr Rudd, of the growing body of international evidence which suggests that such community health services should be placed in their local shopping and community centres, closely linked or co-located where possible with primary health care, and functionally integrated with their respective hospital-based services. Despite this global consensus, hospital-centred services continue to dominate health care services in Australia. Some state governments, eg NSW, have presided over a retreat from, or even dismantling of, community-centred health services, selling their sites to help pay for rebuilding hospitals.
Yet, in both your announcement of the federal government’s proposed Health Reform package and in the one-sided health debate against Mr Abbott’s policy-free zone, you repeatedly represented health as “hospitals”. Your focus was almost solely on “waiting times, elective surgery and hospital beds”, speaking as you did of consultations with the community as “101 consultations with hospitals” as pointed out by Professor Ian Hickie (The Drum, abc.net.au 23 3 10).
Like Mr Howard, with his blatantly electioneering rescue of a surplus Tasmanian hospital, you are in danger of perpetuating the myth that the taller our community’s monolithic general hospital on the hill, the better it serves as a temple to our collective immortality. But we know that you know better.
Professor Lesley Russell (Weekend Australian 27-28 Mar 2010) finds it curious that you have chosen to focus on hospital funding and governance, pandering to traditional media and voter preoccupation with procedural waiting lists. Is this any surprise? Not really, but why have most of your proposals so far been so old-hat? Especially when virtually all the national reports you considered and commissioned have advised that the healthcare system for the 21st century must focus on “prevention, better management of chronic illness, and the coordination of care”, with a renewed and much more consistent emphasis on community care.
Even Mr Obama’s US Health legislation has provisions to ensure a) coordination of community care to divert people from needless emergency presentations and b) that innovation and evidence of improved outcome are constant drivers. Where is your commitment to these basic principles? They should be front and centre.
OK, so you have tantalised us with hints that there is more to be announced, which is almost reassuring, considering the lack of detail so far, especially about how we might shift from your concentration on paying for efficient hospital outputs to paying for better quality and safer health service outcomes.
But the wider mental health community is worried that most of your core announcements may have already been broadcast, dissipated on this narrow hospital-tuned bandwidth – maybe all there is to come is a gestural twiddling with the knobs to slightly adjust the tone and target age-group audiences of primary health and mental health care?
Of course, Prime Minister, hospitals ARE important, but mainly for urgent and technically complex diagnostic investigations, for managing acute trauma, for complex multisystem diseases and the stabilising and intensive treatment of acute and severe recurrent conditions, particularly when they endanger life.
For most other disorders, the hospital-centred model has relied on simplistic ideas that there is efficiency and better controls in larger aggregations of services on general hospital sites. However, there is a growing realisation that, with monitoring and communications technologies, and many intensive treatments being more portable now, most treatments (other than complex surgery) can be delivered in the community just as well, often with more safety.
You would already know that community-centred ambulatory care has been demonstrated to be a more cost-effective alternative to hospital-centred care, particularly for preventing disabilities, and for persistent, long-term or recurrent conditions, such as obstructive airways disease, diabetes, cardiovascular disease, renal care, strokes, severe psychiatric disabilities, palliative and elderly care.
Despite this, we continue to direct funding from community-based care to hospitals. Having been put in charge of community health, these historically underfunded hospitals just can’t resist temptation. Also many traditional interests are vested in hospital-centred empires and careers.
We wrote our review from the vantage point of our long experience in directing and developing integrated community and hospital mental health services, valuing and advocating strongly for enhancing both components. With the shift from centralised mental health services within stand-alone psychiatric institutions, we thought that mainstreaming mental health services within acute general health services would provide access to less stigmatising treatments and better general health care for our clientele. It did, to some extent, for a while.
But, as Professor Pat McGorry lamented recently (Weekend Australian 6-7 February 2010), the gravitational pull of planet acute general hospital has sucked all the oxygen out of community health and community mental health services just when they are most needed. General hospitals have been steadily siphoning their resources ever since they got their hands on them, sucking even their dregs to feed the insatiable demand for ever-more high-tech procedures and facilities. McGorry argues that even this minimalist system of community mental health care has withered, has been forced to retreat into the bowels of the acute hospital, and to reinstitutionalize as sedentary outpatient care.
You might decide that the Commonwealth should fund all primary and community health, or all mental health care separately on an integrated basis, but if you do, please don’t leave hospitals or only doctors (even GPs) in charge of community care, or like Monty Python’s dead parrot, it will cease to be.
However funded, we must channel a much larger proportion of the badly needed enhancements to community-based alternatives to hospital-centred care. Globally, the centre of gravity of health care is clearly shifting from hospital-based care with occasional outreach only at the convenience of administrators and clinicians, to community-centred care with in-reach to hospitals only as necessary.
So Mr Rudd, please don’t leave us twisting in the wind. Our community health services are gasping for oxygen here. Give us a sign that you are on your way to revive them and make a real difference to Australian health outcomes. Like in the US, this is a once-in-a-lifetime opportunity.
Secretary. Comprehensive Area Service Psychiatrists’ Network; Associate Professor Department of Psychological Medicine, University of Sydney; Professor, School of Public Health, University of Wollongong
• Stay tuned for the next letter to the PM, coming soon…