Curing access block: how to provide better access to acute hospital services

With access to vital public hospital services becoming increasingly more difficult in Australia, hospital specialists outline the problems, note some progress and offer advice and solutions in the latest edition of the Medical Journal of Australia.

In an editorial, Professor of Emergency Medicine at the Chinese University of Hong Kong, Peter A Cameron, and Associate Professor Donald A Campbell of Royal Melbourne Hospital's Clinical Epidemiology and Health Services Evaluation Unit, detail the effects of what has become known as 'access block'.

A State-by-State analysis of access block and how it is affecting medical services in Australia's public hospitals accompanies their report.

Professor Cameron says we need a coordinated approach to address the underlying problems in the health system.

"The causes of access block are not straightforward, but appear to correlate with major decreases in hospital bed numbers, community residential care facilities, and with changes in workforce and community attitudes," he says.

"Access block has been with us since the 1980s, but in recent years, in Australia, it appears to have become both endemic and critical across all our major cities.

"There is now evidence that access block causes poor patient outcomes and interferes with efficient hospital functioning."

Professor Cameron and Associate Professor Campbell say major contributors to access block in Australia include:

• Lower bed numbers
- the total number of acute hospital beds has decreased over the past two decades, with a 15 per cent decrease in public hospital beds occurring from 1995 to 2000.
• Community-based treatments
- although many patients with chronic or complex illnesses are treated as hospital outpatients or in the community, when serious complications occur they present at hospital emergency departments, increasing the patient load on the acute care system.
• Workforce
- training programs for doctors, nurses and allied health workers do not yet reflect the new hospital healthcare workforce model, which is team-based, with multidisciplinary input and multiple levels of expertise, even within disciplines, and this is leading to low morale.
• Social Changes
- the demise of the extended family and changes in the demographics of marriage and childbearing have led to more elderly people living alone, and with greater feminisation of the workforce fewer people can be carers, meaning many partially dependent people will seek care from the hospitals.
• Funding Models
- payments to hospitals and healthcare providers are rigid and reward rapid treatment of uncomplicated conditions. In the community setting, payment is for episodes of care rather than continuity of care. Complicated emergencies, time-consuming conditions involving multiple medical specialties, and social issues stretch the time and financial resources required, and are dealt with piecemeal. Patients with complex or multiple problems frequently have no alternative but to attend a public hospital emergency department.

Professor Cameron says systematic management of access block is only just beginning to be discussed at a policy level.

"We now have the evidence that a more strategic Australia-wide approach is necessary to address the underlying problems in the Australian health system," he says.

"Our politicians must address the following issues if solutions are to be agreed and put in place:

• Workforce
- reasons for rigidity in work practice and roles within the healthcare workforce need to be explored, and, where there is no evidence to support limitations in practice, rules should be changed.
• Funding
- look at funding hospitals for procedures, whether provided on an inpatient or outpatient basis, which might allow a hospital to provide these services even when beds are not available. Provide funding that allows a hospital to experiment with new clinical pathways.
• Healthcare delivery systems
- initiatives such as medihotels, placing patients in a transit lounge before discharge, day-of-surgery admission for elective surgery, short-stay wards, and centralised bed control can all save bed-days.
• Residential care
- reform within the subacute and residential/community care sector is necessary to improve efficiencies within the acute care sector and to provide appropriate long-term care to patients.
• Service prioritisation
- the public must become involved in the debate about which healthcare services are essential. The present rationing method is in essence a lottery - whether your ambulance is allowed to arrive at a certain hospital, or whether your elective surgery is on or off, depends on the capricious availability of beds.

Professor Cameron says these are all grassroots policy prescriptions, which have come direct from the people working in Australia's public hospitals. Full details of the situation in each State and Territory are reported in this edition of the Medical Journal of Australia.

The Medical Journal of Australia is a publication of the Australian Medical Association.

CONTACT: Professor Peter A Cameron, peter.cameron@cuhk.edu.hk

03 94552856 (until 2.2.03)

852 9046 5920(Hong Kong Mobile from 3.2.03)

Judith Tokley, AMA Public Affairs (0408) 824 306