It’s an emergency!

I want to focus on two aspects of the current system that indicate how unintended side effects can cause serious bother. Both are the consequences of moving public money away from the support of public hospitals and into private hospital development. The first concerns how we deal with patients in emergency departments and the second with how we manage patients in the bush.

For sound bites, try these: first, the investment in private hospital beds, but not private emergency departments, have shoved the growing load of emergency patients onto the non-expanding public hospital system. Second, because private health care facilities only go where there is money, they do not go to the country. Consequently rural people are subsidising city private hospitals because of the multibillion dollar contribution to private health insurance from tax dollars. Both these problems deserve to be fixed by whoever is the next minister for health.

It’s an emergency!

First, in relation to emergency departments, the 2006 edition of Australia’s Health, the tenth biennial report from the Australian Institute for Health and Welfare in Canberra, reveals that public hospital bed availability has been decreasing. The report states “between 1995-96 and 2003-04, there was a 2.8 per cent decrease in available beds and an 11 per cent reduction in beds per 1,000 population [due to population growth] … with private beds per 1,000 population remaining stable and public sector beds per 1,000 population decreasing by 18 per cent.”

Sydney emergency physicians, Peter Roberts and Paul Cunningham, calculate there are now 28 private emergency departments and 142 public emergency departments in Australia, but the growth in private emergency departments has not kept pace with the relative increase in private sector beds. Thus, proportionally, an ever increasing load is placed on public emergency departments at the same time as public bed availability has been falling.

Roberts and Cunningham refer to a study published in the British Medical Journal in 1999 by Baghurst and colleagues. These UK doctors examined the daily bed requirements arising from the flow of emergency admissions. They concluded that the risk of “having no bed available for at least one patient requiring immediate admission commences when average bed day occupancy rates exceed 85 per cent” and that “spare bed capacity is essential for the effective management of emergency admissions”.

Large city hospitals in Australia too commonly operate with occupancy rates in excess of 95 per cent. For a hospital with, say, about 350 beds now, an occupancy rate of 85 per cent would require, according to Roberts and Cunningham, an increase of 40 beds or a reduction in bed days of 35 every day. This could be achieved if the average length of stay for every admission was shortened by less than a day. Roberts and Cunningham have provided an approach to solving the problem of access block that warrants the attention of health policy makers and managers.

Beating about the bush

An unintended consequence of the federal government’s multibillion dollar subsidy of private health insurance is the shift of public money for health care away from rural and remote health care towards the city.

In a paper published in the Medical Journal of Australia in 2005, three research workers from The Australian National University, Buddhima Lokuge, Richard Denniss and Thomas A Faunce, examined the effects of the private health insurance subsidy on rural health care. They began by noting that people living in rural areas have 10 per cent higher death rates than those in the city. The figure for people living in remote areas is 50 per cent. So any notion that living in a city makes you sick and that our rural cousins are doing just fine is wrong. Think for a moment of the higher youth suicide rates among remote and rural Australians, and depression among bankrupt farmers.

Second, private health insurance (PHI) is fine if there are facilities where you can use it. Per capita, there are fewer private facilities outside than inside our cities. In the cities, about in 2002-3, about 200 people out of every 1,000 were admitted to a public hospital and about 120 to a private hospital. In rural Australia the figures are 300 and 70; in remote Australia the figures are 400 and 50. Incomes are often lower and as the likelihood of holding private insurance is still heavily dependent on income, so are private health insurance rates. Private health insurance is about 7 per cent lower on average than in urban areas, and is lowest in Tasmania.

Third, as a result of these lower insurance rates, the Commonwealth’s investment in private health insurance has led to a redistribution of about $100 million a year from rural to urban Australia. There is an arrangement whereby Commonwealth funding to the states for public hospitals depends upon private health insurance uptake remaining below certain levels: if more people are insured, over those levels, money is taken back by the Commonwealth from the states on the assumption that they need to provide less public care. However, this favours the city over the country, where PHI rates are lower.

Fourth, given that public hospital care is more common and more important in the country than the cities, because of fewer private alternatives, the relative investment in public and private beds needs to be carefully calibrated unless we are to deprive the bush of its share. In fact, Commonwealth investment in public hospitals grew by 8 per cent across 1996-2003, so gains were made. These, however, were small compared with a growth of 64 per cent in private hospital bed investment.

The Commonwealth has made several worthwhile attempts to improve services in the bush in the past decade, including incentive payments to general practitioners in rural areas who bulk bill, program support for trainee general practitioners and an extensive network of training facilities for medical students, assistance to the Royal Flying Doctor Service, the Rural Chronic Disease Initiative and more. Nevertheless, the main game is the provision of public health services, including hospital care, as the Commonwealth’s intervention in Devonport Hospital suggests they recognise.

Solutions to the problem of rural and remote health care require national policy changes, including compensation for the effects of investment in private health insurance subsidies. This is the proper domain of Commonwealth health policy and it would be good to see the problem recognised and proposals advanced for its remedy. And how wonderful it would be if public debate was resurrected, and governments rediscovered how critical to the health of the body politic public debate can be.