Given the increasing numbers of people with chronic and complex conditions in our community, Australia’s health system should be geared towards delivering the sort of coordinated and ongoing care required to manage these types of illnesses and disabilities.
However, what we have instead is a worryingly chaotic and ad hoc approach to meeting the needs of consumers who require some mix of hospital, community-based care and other support services.
It makes good economic sense to discharge patients as early as possible from hospitals. But early discharge only makes sense if there is a well-functioning community and social care sector.
Australia’s federated system of government, and the division of responsibilities for health across federal and state/territory borders, is often identified as a major cause of poor coordination and integration within our health system.
However, even within one jurisdiction there can be fragmentation across programs and services, particularly when more than one sector (and government department) is involved. When patients have needs that spread across two levels of government and multiple sectors, for example, social security, aged care and housing, the situation is even worse.
The following article is written by a senior physician at a large capital city hospital who wishes to remain anonymous. In it the author describes how poor communication and coordination between health and other areas of government result in delays, gaps and inconsistencies which obstruct the delivery of high quality care and cause significant wastage and inefficiency throughout the system.
The article describes the problem from the ‘pointy end’ of service delivery and suggests some practical changes to the way we approach the delivery of care to this important group of health care consumers.
Doctor X writes:
I am a physician in a large metropolitan city hospital where all the bells and whistles of heath care are available. My job is in rehabilitation of those who are disabled though injury or illness and I am charged with getting them as independent as possible, to return them home and get them back to work.
But I have also become one of the key figures in clearing beds to make room for others in the emergency ward. I get a call a few times a week with a desperate plea: “Can you discharge anyone? We can’t get people off the ambulance trolleys in emergency. Can you create a few beds? Today?” I always reply that I will see what I can do and I often speak to people and explain why we need their bed and what I can do to get them home safely, albeit a bit earlier than expected. Suffice it is to say that they aren’t always accommodating….
Nowhere to go
But the irony is that there are many medically ready and who want to be discharged but have nowhere to go – and sometimes they spit the dummy too!
Last week we had four people abscond from the ward. Two were unable to speak or understand (rendered so by a stroke (aphasia)), one suffered from talking too loudly and too much (he was affected badly by a head injury (frontal lobe disorder)) and the third couldn’t stand the other three and marched off in disbelief looking for a pub (drug and alcohol problems). It’s not a joke, it’s real.
For one who couldn’t speak, we had been waiting for over six weeks to have a hearing from the NSW Guardianship Tribunal to get someone to make a decision about his finances and housing as he could not. The other who couldn’t speak had agreed to be transferred to a nursing home but we hadn’t been able to source one with availability near his home for over a month.
The fellow who talked too much was also waiting for his brother to find an appropriate nursing home for him. This was no mean feat because he was in his 50’s and would not stop talking, in a confused, illogical manner, unless asleep or indulging in one of his pastimes – heroin addiction. The other just needed an excuse to go to the pub. He returned.
Delays in payments
At the same time, we had another patient, disabled by a stroke, moving into her third month in hospital while we waited for Centrelink to process her sickness benefit allowance because she could not return to her work and needed some money to pay for a nursing home bed as supported accommodation. She had no family to support her in Australia. (Interesting that it takes so long for one federal department (community services) to pay money to another federal department (aged care). Maybe they don’t use electronic banking)
At the same time we waited for processing by the immigration department to extend a visa so we could complete rehabilitation and send a patient who had developed a partial paraplegia. She was on a student visa at the time and needed it to be extended so she could complete rehab to a point where she could return home to get care from her family. She then wanted to return and complete her studies.
In another room in our same ward, we were waiting for emergency housing, usually a six month wait (yes, that is EMERGENCY housing) for a 30 year old with multiple sclerosis who was kicked out of her share care home because she couldn’t manage without help and the NDIS (National Disability Insurance Scheme) hasn’t started in our area yet. Even when it does it start up it won’t supply housing in a jiffy – it is likely to take at least several months. So we had to advocate for her with her flatmates to take her back till the NDIS starts up in about 6 months.
A clear false economy
I understand that rehabilitation involves exposure to the social determinants of health and the psychosocial aspects of people’s health but from a systems perspective we have a clear false economy. The cost of a hospital bed is from $822 (rehab) to $1,500+ (ICU) per night, which is more than the cost of a five star hotel room per night ($250-500/night), a subsidised nursing home bed ($98-150/night) or a rented bedroom in a two-bedroom Sydney flat (approximately $60-120/night).
So why is it that health imperatives are not viewed by other departments as a priority? Why is it that interdepartmental bureaucratic delays cost the community dearly and the individual and family enormously? Surely this is an area of budgetary waste that can be addressed by having better interdepartmental integration.
However, in order to do this you need to have trust between agencies and a collective sense of social justice so that those on the waiting list for services are not assumed to all be “gaming the system” in order to queue jump – and you know what the department of immigration thinks about queue jumpers…..
Integration case managers
Integration of services through the prioritisation of people waiting in hospital beds might assist, as would specialised “integration case managers” who may be able to cut through red tape and take advantage of a prioritised status.
Could health departments be considered platinum frequent flyers with the state departments of housing and community services or is that an ideal to which we cannot easily aspire? Or perhaps we just need a referee/mediator/senior bureaucrat to come in when there is an unwarranted delay of over two weeks to judge the merit of a request from a personal, system and public budget perspective. Probably too much to ask.
Next time they call me from Emergency asking me to clear a bed I was thinking of asking the patients to allow me to transport them to the offices of Centrelink, Federal Department of Aged Care, Department of Housing or the Guardianship Tribunal, so that they can give them a piece of their minds. At least that way we can at share the love.
The writer is a rehabilitation physician in a public city teaching hospital near you!