‘Complete mayhem’ as healthcare system buckles under pressure

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‘Complete mayhem’ as healthcare system buckles under pressure

By Lucy Carroll and Mary Ward

A senior nurse working in a critical role at one of Sydney’s biggest hospitals despairs at the tidal wave of patients flooding emergency every day.

“Triage is complete mayhem,” she says. “In 14 years, I have never seen it this bad. I don’t want to do it anymore. How are we supposed to control the sheer volume of patients coming in? We often have two or three nurses staring at a sea of 50 people in the emergency waiting room.”

Paramedics and hospital staff inside St Vincent’s Hospital emergency department this week.

Paramedics and hospital staff inside St Vincent’s Hospital emergency department this week. Credit:Janie Barrett

The state’s hospitals are facing an avalanche of seriously ill patients. Deep-seated problems simmering well before the pandemic have been magnified under two years of the health system operating on a war-like footing.

“You honestly sometimes feel like somebody could die waiting, and you’ll just miss something, you might miss a patient who quietly came in and just didn’t get seen in time,” says the nurse, who cannot be named because she is not authorised to speak publicly.

A backlog of unmet medical needs, staff burnout, the pandemic and a severe flu season have combined to push the system to the brink with one former health official saying “we can no longer pretend” we have universal healthcare.

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Emeritus professor of medicine at the University of NSW John Dwyer says it is time for radical change. “We are not talking about tinkering at the edges. Our healthcare system is no longer fit for purpose. We need to seize the moment with a new federal government. If not now, when?”

The crisis is not unique to NSW. It has engulfed health systems across the country as they battle overflowing emergency rooms and paramedics ramped outside hospitals for hours. NSW and Victorian premiers Dominic Perrottet and Dan Andrews have called for an overhaul of healthcare delivery and for an end to the long-running state and federal divide.

In the past week, the NSW government has promised $4.5 billion to hire about 10,000 new full-time positions at hospitals and health services over four years. This includes $1.7 billion for 1850 more paramedics and 30 new ambulance stations. Health workers will also receive a $3000 thank-you payment.

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“It’s more risky, more unsafe for patients than I’ve ever seen,” the senior nurse says. “It’s mostly because of hospital flow issues and severe overcrowding. We have people waiting 72 hours for a bed on a ward.”

Windowless and time-distorting emergency rooms aren’t designed for days-long stays, but with hospitals in gridlock, patients clogging corridors and ambulances queued 12-deep outside, timely care is now far from guaranteed.

NSW Ambulance has been swamped by record triple-zero calls that have hit up to 3900 daily. With many non-urgent, the state’s senior assistant ambulance commissioner Clare Beech has proposed a trial of 500 taxis to take low-acuity patients to other health services like GPs and chemists.

A patient is treated in the St Vincent’s Hospital emergency department.

A patient is treated in the St Vincent’s Hospital emergency department.Credit:Janie Barrett

“There are a lot of patients who call triple zero because they are unsure about the most appropriate health service to access,” Beech told the Herald. A permanent secondary triage system - a virtual clinical care centre - will be set up so call-takers can refer people who don’t need an ambulance to other health services. It follows similar programs set up in Victoria, Tasmania and South Australia.

Chief operating officer at 13cabs, Olivia Barry, says details of the company’s arrangement with NSW Ambulance are “being finalised”.

However, Dwyer says without addressing big health system flaws the states’ hospitals have no way of easing immense pressure.

“The current system is costing us a fortune and failing people,” he says. “The cost ineffectiveness of the system means even if the Commonwealth meets states’ demands of a 50/50 hospital funding split into the future it will be dollars spent on a system not fit for purpose.”

The state hospitals are dependent on primary care to keep people out of emergency, he says.

“Almost 50 per cent of Australians now have a chronic illness. There has been a failure to stop the tsunami of lifestyle-induced disease.”

What are the solutions?

Major reform could include a move towards a single-funded model of healthcare delivery, that would better integrate primary care with hospitals and focus on prevention.

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People are living longer. Patients are arriving at emergency with complex, chronic conditions, the population is growing and care has been delayed due to the pandemic. There is also a mammoth backlog of elective surgery and doctors and nurses are walking away from the job, utterly exhausted.

Patients can wait weeks to get into a GP. The state’s rural health inquiry heard that wait times to access a GP in Moree are three to six weeks, if one is even available.

Charles Maskell-Knight, a former senior public servant in the commonwealth department of health, says emergency rooms have become so congested because it’s too expensive to see a GP and many have closed their books.

“How long can we pretend we have universal healthcare? The health sector has fallen behind. Bulk-billed clinics are harder and harder to find. Emergency rooms are the substitute,” he says.

Productivity Commission data shows the number of GPs in NSW per 100,000 people is going backwards. In 2020, there were 117 general practitioners in NSW for every 100,000 people, a drop from 120 in 2019. There was a record 1.2 million GP-type presentations to hospitals that were potentially avoidable in 2020-21.

The head of the NSW Rural Doctors Network Richard Colbran says 600 rural general practitioners - who also work as visiting medical officers (VMOs) at local hospitals - have left their positions in the past 10 years. There are now fewer than 200 GP VMOs in rural NSW, he says.

Last month, NSW Health was savaged in a damning report from a parliamentary inquiry into regional hospitals that raised disturbing allegations over the treatment of whistleblowers and highlighted the cover-up of preventable patient deaths. It found staff were frightened to speak up about critical staff shortages and inadequate resources.

As the Herald reported, those that have paid the price are the patients who have suffered physical consequences and the doctors and nurses who dared to speak out. Both have run up against a toxic health bureaucracy that silences dissent.

NSW Health Minister Brad Hazzard.

NSW Health Minister Brad Hazzard.Credit:Oscar Colman

NSW Health Minister Brad Hazzard told the Herald one of the major pressures is the lack of GPs in sufficient numbers, particularly in the regions.

“There has been a failure since 2013 by successive federal governments to pay GPs what they are worth through Medicare. It has acted as a massive turn-off to incoming young doctors,” Hazzard says. “People who can’t get into a GP end up walking into emergency or arriving in an ambulance. That’s not the way it’s supposed to be.

“The funding arrangements that successive federal governments have given the states are insufficient to meet the escalating demand in hospitals. States want to work with the federal government to find more sustainable ways to deliver healthcare in Australia. We have our first meeting with the federal government at the end of June.”

Maskell-Knight says governments have “set Medicare funding levels and walked away, assuming that’s OK”.

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“If you go to a specialist you will face $200 in out-of-pocket costs. Wages in the health sector are also falling behind,” he says.

One leading Sydney doctor says with the city’s “teaching hospitals in crisis”, the Commonwealth “needs to seriously address the problems and not say it’s the states’ responsibility because clearly the states haven’t fixed it”.

Health disadvantage in regional NSW is the most pressing issue, he says.

Australian College of Emergency Medicine president Clare Skinner says the situation in hospitals is getting worse. COVID-19 is also humming away in the background: there were more than 300,000 coronavirus infections reported in NSW during May, and, after a virtual wipe-out during the pandemic, more than 26,000 influenza cases. Other viruses like RSV are also on the march.

In the first week of June, the number of people with COVID in NSW hospitals rose from about 1000 to around 1300.

“We are seeing COVID keep going and some concerns about the transmissibility of Omicron sub-variants. We are also seeing rising cases of influenza A, increased admissions and significant staff sickness and vacancies,” Skinner says.

“We need to get back in the mindset of stopping the spread of infectious diseases. With morale is low, we must make sure clinicians’ voices are heard by decision makers.”

Another senior emergency doctor says while their hospital had tried “every possible work around... at some point, we need to acknowledge the number of beds we have isn’t keeping pace with population growth”.

“There aren’t enough spaces on the wards. Discharging to nursing homes and into NDIS places is difficult. Ambulances will now have increased resources, but they have to be able to offload patients at hospitals. The obstruction isn’t at an ambulance level. It’s on the wards,” he says.

The NSW government says healthcare funding arrangements with the federal government are insufficient.

The NSW government says healthcare funding arrangements with the federal government are insufficient.Credit:Janie Barrett

The blowout in waiting times is underlined in the state’s latest health report card released in March: 56 per cent of people waited more than 15 minutes for a lights-and-sirens ambulance response, about a 20 percentage point increase over the past five years. The state’s elective surgery backlog has skyrocketed to almost 95,000 patients.

Stephen Leeder, an emeritus professor of public health and community medicine at the University of Sydney, says the entire health system has been severely depleted during COVID.

“The freeze on Medicare rebates was a hideous mistake,” he says, referring to a temporary measure introduced by Labor in 2013 as part of a budget savings plan. “We’ve also had a war with COVID. There needs to be a taskforce set up to deal with the major issues in the health system.”

Leeder believes increasing reimbursements to general practices, lifting the salaries of people working in nursing homes by 30 per cent and shifting workloads to the private sector would help.

“We have no real clue what properly funded and resourced general practice would look like, it could go a long way to dealing with influx of patients into hospitals,” Leeder says.

“It’s the most unsafe environment that I’ve ever seen. And there’s no simple fix to it.”

Senior nurse

He is sceptical of Labor’s election pledge to trial bulk-billed Medicare urgent-care clinics, agreeing with other experts they are unlikely to empty the nation’s crowded hospital emergency rooms.

Dwyer says it was vital primary care become multidisciplinary, where clinics include general practitioners, nurses and allied health staff. They could include Medicare-subsidised dental care for some groups too, he says.

“Elective surgery is completely crippled. Hospitals can’t offer adequate surgery because of all the people flooding into EDs and no beds for the surgeons,” he says. “I hope we have reached a stage where change will happen. COVID-19 has shown up so many weaknesses.

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“We really need to take a radical approach,” he says, suggesting a five-year program driven by a special health reform commission.

“The real problem is our healthcare system is sickness centric we do not have the emphasis on prevention.”

The Sydney nurse who spoke to the Herald says it was almost impossible to describe the workload.

“Our whole emergency department is full of geriatrics, but also lots of cardiology patients. We have more delirium, more falls. People are spending their whole treatment time in ED. The other day we had someone wait seven hours to see a doctor after being triaged. The number of people coming in is uncontrollable,” she says.

“Ambulances go for matrix temporarily, but emergency departments can’t close the door to walk-in patients. It’s the most unsafe environment that I’ve ever seen. And there’s no simple fix to it.”

Cut through the noise of federal politics with news, views and expert analysis from Jacqueline Maley. Subscribers can sign up to our weekly Inside Politics newsletter here.

correction

Clare Beech is NSW’s senior assistant ambulance commissioner, not the state’s deputy ambulance commissioner.

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