Victoria is missing a golden opportunity to rethink the health system

When the Spanish flu arrived in Australia at the end of the First World War, infecting almost half the population and killing thousands, it sparked revolutionary healthcare reform across the young nation.

After a response to the deadly flu that was marred by disagreements between quarrelling states, the pandemic became the catalyst for the formation of a federal Department of Health in 1921.

Hospital beds in the Royal Exhibition Building in Melbourne during the Spanish flu of 1919.Credit:Museums Victoria

More than a century later, Australia is reeling after its healthcare system and economy was upended by coronavirus.

With Victoria quickly approaching an election Juan Paolo Legaspi, deputy chief executive of the Victorian Healthcare Association, said that any response to a crisis demands deep reflection and chance for reformation.

Instead, Legaspi is worried we have missed a golden opportunity.

“The big question that we as a society really need to ask ourselves is are we missing an opportunity to reform the healthcare system to keep people well?” he said.

“An election is meant to be the contest of the best ideas. This election was an opportunity to discuss reformation. But where was that?”

Public health experts, medical groups, economists and doctors say there are two glaring omissions in this year’s Victorian election campaign from both sides of politics: a failure of much-needed reform and lack of crucial investment into preventive health.

Perhaps like never before there is pushback against the red-ribbon-cutting format of election promises, and the idea that it’s wise to allocate deeply interconnected parts of the healthcare system into areas of state and federal responsibility.

Coronavirus exacerbated the health crisis. It did not start it. Hospitals have been underfunded for years leading to bed and staffing shortages. Problems with the federal government-administered National Disability Insurance Scheme and aged care have added to the crisis – patients are stuck in wards waiting for mandatory assessments to enter both systems, locking up hundreds of hospital beds every week. Some spend hundreds of days in hospital while they wait for care.

As hospitals have become increasingly overcrowded, emergency departments have become one of the most visible elements of a healthcare system that is heaving and sinking under record demand.

The number of people who have been staying in a Victorian ED for more than 24 hours waiting for a bed to become available in a ward has increased more than 12-fold in a single year, to 3676 patients in the last quarter.

“The cubicles in the department are full, that means that patients wait longer in the waiting room … And because patients are waiting longer to get into cubicles, it means more ambulances are being ramped,” said Dr Andy Tagg, deputy chair of the Victorian faculty of the Australasian College for Emergency Medicine.

Tagg said that with many shifts regularly going unfilled, and nurses working double shifts to fill vacancies, a lack of staff rather than physical space remained at the heart of the problem.

Dr Andy Tagg, deputy chair of the Victorian faculty of the Australasian College for Emergency Medicine.Credit:Wayne Taylor

Healthcare spending has emerged as a welcome battleground of the major parties, which have promised more than $25 billion combined in election health spending, with almost all the money focused on expensive new hospitals.

The Coalition, which has been leading the spending blitz, recently promised $2.4 billion to rebuild The Alfred hospital and more than a dozen other new or redeveloped facilities including a new 275-bed children’s hospital in Werribee.

The jewel in the crown of the Andrews government health spend is a $5 billion to $6 billion expansion of the Royal Melbourne and Royal Women’s hospitals. They have also pledged to rebuild and rename the Maroondah Hospital and embark on major revamps of the Northern, Austin and Monash hospitals, among others.

There has been acknowledgement of the workforce challenges, with Labor and the Coalition both unveiling plans to recruit thousands of new staff.

Labor is subsidising the HECS debt of more than 10,000 nursing and midwifery students, and to give a $5000 sign-on bonus to graduates entering the public system between 2022 and 2024. The Coalition has pledged to pay for the degrees of 25,000 nursing and midwifery students.

However, some say not enough is being done to retain the existing workers, and given it takes years to train new staff, Tagg said some short-term solutions were needed.

He called for urgent funding for expanded acute medical and surgical wards allowing ED doctors to admit patients into the hospital quicker.

“There’s this idea that ‘oh, we’ll build an extra hospital and it will get fixed’, and we know that more buildings aren’t going to fix the current issue.”

Health economist Professor Stephen Duckett is concerned by the tendency of political parties to promise big on capital funding, but fail to set aside elements such as recurrent funding.

He notes billions and billions of dollars worth of capital works for health infrastructure have been promised from both sides, but little mention is made of how much it is going to cost to run the new hospitals.

“Where’s the money going to come from in four years time or five years time or 10 years time to run the things?”

Victoria’s surgery waiting list has soared to near record levels, surpassing 80,000 people; the legacy of repeated pauses during coronavirus waves over two years. What troubles Victorian chair of the Royal Australasian College of Surgeons, Patrick Lo, most, is the patients having their surgery undertaken with more advanced illness and injury.

A COVID-19 patient in the ICU ward of Sunshine Hospital last year.Credit:Justin McManus

There are those with spinal problems, that perhaps, if their surgery was dealt with six months ago, would not experience permanent defects such as numb fingers or toes. He is also concerned about the rising number of people with cancer, who have been diagnosed and operated on, too late.

“Any government that comes into power needs to look at healthcare as a whole rather than silo-ing or fragmenting it as surgical waitlist, or access to a GP. If we are going to come out of this, every of facet of healthcare needs to start being interconnected.”

Geelong doctor Bernard Shiu.Credit:Jason South

In 2010, then prime minister Kevin Rudd made a bold promise to fix the health system, laying out the case for the federal government to take more responsibility for hospitals and to end the blame game of finger pointing between federal and state governments.

Rudd promised to double the Commonwealth’s contribution to efficient hospital services by promising to pay 60 per cent of the efficient running cost – up from the 40 per cent level recommended by his own National Health and Hospitals Reform Commission.

But Rudd lost the federal election and his dream of hospital reform disintegrated under Tony Abbott’s government. While hospitals are managed by the states and primary care is largely the responsibility of the federal government, there is a growing push for a national approach to address the problems facing the health sector.

“We can’t have that divide between the federal and the state anymore when it comes to general practice,” said Dr Bernard Shiu, a spokesperson for the Royal Australian College of General Practitioners.

The Geelong doctor said providing a government-funded salary to general practitioners working in disadvantaged communities could be one solution to improve people’s access to GP care.

“Prevention is much cheaper than hospital work, but prevention is not glamorous. You don’t see politicians standing in front of us [GPs] … but they will stand in front of a brand new MRI machine, to take a photo, because that’s glamorous.”

A hospital is one of the most expensive hotel rooms you can ever have.′

Legaspi said one of the biggest hurdles in the state’s healthcare system is how fragmented it is, with disability and aged care largely a federal responsibility.

“There needs to be a better way of linking them all up together,” he said.

“Hospitals are the last line of defence, but they’re being used as impromptu supported accommodation for people that really should be either in an aged care home or on a disability package with supportive accommodation.

“A hospital is one of the most expensive hotel rooms you can ever have … in terms of public taxpayer funding. We need to start funding smarter.”

Victorian Health Minister Mary-Anne Thomas.Credit:Penny Stephens

The Commonwealth currently funds about 45 per cent of non-COVID public hospital services, under the National Health Reform Agreement, which the Albanese government says it is “committed to” and is not due to expire until 2025.

States, including Victoria, want to see the Commonwealth contribution rise to 50 per cent.

Victorian Health Minister Mary-Anne Thomas said: “we need a fit-for-purpose funding model – and we’ll continue to work with the Commonwealth and other states and territories as we advocate for a more sustainable and fair agreement”.

Federal Health Minister Mark Butler said the government’s focus was on taking pressure off emergency departments by supporting GPs.

Opposition Leader Matthew Guy (centre) and health spokeswoman Georgie Crozier have unveiled billions in health promises in the lead up to the Victorian election.Credit:Scott McNaughton

“Our Strengthening Medicare Taskforce is identifying the best ways to boost affordability, improve access, and deliver better support for patients with ongoing and chronic illness, backed by the $750 million Strengthening Medicare Fund.”

Opposition health spokesperson Georgie Crozier said it was clear that the acute challenges facing Victoria’s hospitals could not be fixed overnight because of the “years of neglect and underinvestment”. She said the Coalition would ask the Commonwealth to contribute money for infrastructure spending and for help fast tracking visas for healthcare workers and identifying skills gaps.

Recurring waves of COVID-19 have been one of the drivers of the worsening conditions in the state’s hospitals. However, Crozier ruled out any widespread mask mandates or other sweeping restrictions, saying they had damaged trust in government. Opposition Leader Matthew Guy has also promised to scrap the state’s pandemic legislation within weeks, if elected.

Rob Moodie, a professor in public health at the University of Melbourne’s School of Population and Global Health, said what was missing from all the billions of dollars worth of election promises on both sides of politics is any real investment into preventative health.

Victorian Premier Daniel Andrews and Health Minister Mary-Anne Thomas visit the Royal Women’s Hospital in Melbourne.Credit:AAP

“There’s just much focus down the acute end, we’re constantly dealing with the ambulance down the bottom of the cliff and we’re not really thinking about the fence at the top,” Moodie said.

Earlier this year, Saman Coliaie carried his feverish daughter, who had been vomiting profusely for hours, into three different hospital emergency departments across Melbourne.

When they arrived at the Royal Children’s Hospital there was a queue of at least 50 families ahead of them and they waited for four hours. Two-year-old Tina had been unwell for days, but her parents grew concerned she was quickly deteriorating when her temperature surpassed 40 degrees in the middle of the night.

“While we were at the hospital it just felt like she was getting worse,” Coliaie recalls. So, the family drove 40 minutes away, to the Monash Children’s Hospital. There they were told the wait would be another four hours. By this stage, Coliaie said Tina was ashen faced, shivering, and vomiting up her medicine.

Not wanting to wait any longer, Coliaie bundled his daughter back into their car, and drove to a nearby private hospital. He paid a $400 fee and Tina was seen within 15 minutes and admitted. She was given medicine to stop her vomiting. Her fever finally broke.

But the experience left a lingering sense of concern in Coliaie, who is quick to add he has nothing but admiration for the doctors and nurses working in Victoria’s struggling hospitals.

“They were just so short-staffed and what I witnessed there was beyond a crisis,” he said. “It was a very distressing situation to see so many sick children waiting to be treated and staff just completely run off their feet.”

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