What happens upstream impacts downstream. It’s not rocket science so why don’t our health bureaucrats do something about it?
This morning I swam in the crystalline waters of Kingscliff Beach*, Northern NSW. The sun reflected a million sparkles off the perfect barrels of oceanic aqua. As far as the eye could see the beach was bordered by wild green scrub and a vast blue sky (stay with me).
My heart soared. I sensed the “oneness” of everything. A knowing that all was connected, that a shift in one part of the ecosystem created impacts in another. Polluting a river upstream will destroy ecosystems downstream. Investing in clean rivers upstream means you keep UNESCO off your back about the Great Barrier Reef downstream.
Then I drove past the new Tweed Valley Hospital that the locals and the real estate agents are pretty excited about. My ocean-inspired serenity vanished, replaced by a sense of futility and anger.
When will state governments stop plugging the gap in healthcare with shiny new hospitals?
When will they stop buying votes with a downstream solution for people who are really, really sick, instead of meeting needs upstream so that people won’t get sick in the first place?
This is not about whether people in Northern NSW need a hospital or not. My family hail from Murwillumbah. I know they will benefit from a new hospital. However, I know they would have benefitted far more from investment in primary care and the social determinants of health that would have stopped them from getting sick in the first place. Upstream, downstream.
The state-federal divide of healthcare funding blocks really clever, strategic, public health improvements. It is beyond my comprehension that state and territory health politicians don’t insist on changing that.
It’s also worrying that local governments delight in approving housing developments but don’t ask whether people will be able to walk to the shop and get fresh veggies for dinner. Or walk their dog safely at night. Or walk to a café where they’ll be able to connect with their neighbours. Or have ready access to healthcare, both primary and tertiary.
It’s bewildering too, that the federal government invests a mere drop of its health budget into prevention.
The last budget gifted only $53.4 million over five years into prevention. It pales in comparison with the Australian Digital Health Agency’s promised $951.2 million over four years.
Professor Simone Pettigrew is director of Health Promotion and Behaviour Change at The George Institute for Global Health. She told Hospital and Healthcare that the funding allocated to preventive health “seems out of balance” with the burden of chronic disease on the population.
“Chronic conditions contributed to nearly nine in 10 deaths [89%] in 2020 and were involved in 5.8 million hospitalisations [52% of all hospitalisations] in 2019–20,” she said.
“Taking action on these important determinants of health will improve Australians’ quality of life and enable us to live longer, healthier lives.”
To all health policy makers and local governments, here’s a phrase you need to burn into your hearts, souls and brains; social determinants of health.
Monica Mayer, director of the health and human services team at Deloitte, said that social determinants of health could impact more than 80% of health outcomes by some estimates.
“Improving diet, food security and literacy are key social determinants of health,” she told Health Services Daily.
So why do we get so excited and pat ourselves on the back when the ribbon is cut on a new hospital? Oh, I forgot. Votes.
There are some examples of clever health providers working across jurisdictions to link primary care and tertiary care programs.
Regional commissioning is live in Healthy North Coast and Central Coast Health Local Districts. Inala Primary Care is another good example. Chief executive Tracey Johnson works with local hospitals to pre-empt epidemic outbreaks in a community that has three jails and the largest population of welfare recipients in Queensland.
However, these are outliers and are usually the result of hard-headed persistence by a handful of individuals who constantly push the barrow uphill to make it happen. The system does not reward this clever behaviour. On the contrary, it rewards busy beds in hospitals and the next drug for diseases that are caused by structural disadvantage.
In contemplating all of this, after a serene, glorious morning swim, my self-righteous fury turned to the houses of parliament. Not just politicians but the policy makers who sit in jobs-for-life making uninspiring decisions to follow the crowd.
I have worked as a public servant. I know how bureaucrats work. Don’t buck the system is the unspoken mantra. If they want that senior executive level job, they must play the politics. Make sure they spend all their budget by 30 June each year or they won’t get more the next. It’s easier to follow the crowd and make sure their salaries keep coming in to pay for those private school fees and orthodontic work; privileges many of the children they are making policy for will never be able to access.
Upstream is where it is at, people. If inspiration is needed, go have a swim at Kingscliff beach. Look far and wide to the horizon. Walk on clean sand, breath in unpolluted air. Try not to look west at the shiny new hospital that has cost the NSW government/taxpayers a whopping $723.3 million. It will open next year and holds the title of one of the largest regional capital health investments funded entirely by the state.
Politicians and public servants are paid to serve the public. Perhaps more of them could start doing so by challenging the notion that a new hospital is the answer to all of our healthcare challenges.
This week the AIHW released a national report on hospital emergency department care showing 8.8 million Aussies presented to a public hospital ED in 2022-23. It was only a small rise on the previous year (8.79 million). And the waiting times continue to climb. Just 65% of patients were seen on time for their urgency category, down from 67% in 2021–22.
I’m far from convinced that more emergency departments are the answer when they are just bricks and mortar. Finding and funding the appropriate workforce to meet the demands of such large numbers of patients is a challenge everywhere in Australia with the hospitals we already have.
And take a look at this AIHW statistic. Only three in 10 (29%) patients seen in the emergency department were admitted to hospital for further care. Doesn’t that suggest that if we can properly treat the other seven in 10 patients appropriately in a primary care setting, they might not need the ED at all.
It comes down to preventive care, to accessible, connected, timely and affordable care in the primary setting. And it still doesn’t seem to have occurred to policy makers and bureaucrats that appropriate investment in these things will pay huge dividends from a health costs perspective.
But more importantly it will keep Aussies healthier, happier and out of hospitals. And shouldn’t that be the priority? Like I said, it’s not rocket science.
*Burning GP summit will be held at Mantra on Salt Beach at Kingscliff, 14 and 15 June, 2024.
Burning GP is a new event brought to you by The Medical Republic and Health Services Daily. Over one and a half days, we will bring together key leaders and influencers from general practice, government, and the technology sector to examine key trends affecting the profession of general practice and map out an alternative and more positive trajectory for the sector.
Burning GP – GPs taking back control of their destiny.