Opinion

Neela Janakiramanan
A health system exposed

In March, researchers from the University of Melbourne and the Peter Doherty Institute for Infection and Immunity presented stark pandemic modelling to the federal government. Made public on April 7, it showed that “an unmitigated Covid-19 epidemic would dramatically exceed the capacity of the Australian health system, over a prolonged period”.

Thankfully, governments listened. Through a first wave, and then a second, Australia’s health system was not overwhelmed, protected by reduced non-urgent services across public, private and community sectors and a suite of interventions designed to “flatten the curve” and “stop the spread”.

Victoria, a state that had as many as 700 new daily Covid-19 cases at the peak of its second wave, has gone many weeks without community transmission of the virus. Yet it now seems the health system is at risk of being pushed further beyond capacity than ever before.

The week began with Ambulance Victoria declaring a “code red” as triple zero was inundated with thousands of calls. Despite all available staff working at capacity, some 130 people in need of an ambulance were left waiting at the peak of the surge. Although no adverse events were reported, clinical scenarios can change quickly and minutes can make a difference. It is dangerous to have emergency services stretched to this degree.

Initial reports suggested the hot weather may have contributed, but the night was not overly warm and summer has only just begun. As such, many of us in the medical community are concerned this week’s “code red” might not be a one-time occurrence, but instead is a manifestation of the escalating demand that often floods into the health system after a disaster.

Dr Sarah Whitelaw, an emergency physician who is on the board of the Australian Medical Association of Victoria, was among those who predicted this. Along with others, she has been warning governments, bureaucrats and administrators since May that the health system needs to prepare for this “wave” as assiduously as it did for Covid-19.

In Victoria, the situation has been further compounded by the state’s prolonged and rigid lockdown. Whitelaw says that across Victoria, patients are exhibiting high levels of distress from untreated physical and mental health conditions for which they cannot access timely care. Amid a generalised deterioration in mental health, unwell psychiatric patients are languishing in emergency departments and short-stay units for days.

Dr Stephen Parnis, also an emergency physician in Victoria, reports a marked increase in both the number and complexity of patients coming through emergency departments in the wake of Covid-19. He says he’s now surprised if he diagnoses patients with just a single medical problem.

As demand has increased, capacity has diminished. There are many pressure points across the healthcare system, each with flow-on effects.

To remain open, hospital beds require healthcare staff, but prolonged closure of national and international borders has impeded the usual recruitment of healthcare workers. There is a 25 per cent reduction in available staff in some areas and workforce seniorities, with existing staff already working overtime. Some healthcare workers are still struggling with complications from workplace-acquired Covid-19 infections; others are exhausted after months assigned to shifts in Covid-19 wards and aged care.

The problem is that if hospital beds are not available, patients can’t move from the emergency department or have elective surgery. If emergency is full, then ambulances must “ramp” – that is, wait in a queue to unload their patient before they can attend the next call. Crowded waiting rooms, long waiting times and prolonged ramping increase rates of deaths, complications, poor outcomes and length of hospital admission.

These issues are mirrored in community health and general practice, too. Dr Mukesh Haikerwal, a GP in Melbourne and former president of the Australian Medical Association, has observed a tidal wave of neglected chronic disease in recent weeks, as well as a jump in new diagnoses of distressingly advanced cancers, delayed presentations of illness resulting in patients sent to hospital sicker and coming home with greater levels of disability, and increased challenges in accessing specialist services.

In Victoria, waiting times for specialist outpatient clinics are not a reportable data point. The only key performance indicator is for entering a referral in the computer; there is none for how long a referred patient waits to see a specialist. According to Haikerwal, the average waiting time for an outpatient appointment at his local hospital is more than three years. This “hidden waiting list” frustrates GPs, and patients. It also conceals the true incidence of untreated disease in the community and means patients have more complex problems by the time they are seen by a specialist.

The pandemic has impacted all outpatient services. A head of service told me that their usual wait of six weeks has now stretched to more than a year. Another said they probably won’t clear their backlog of work for at least two years. Across medicine, surgery, allied health, radiology, screening and diagnostics this story is repeated.

Victoria continues to be challenged by our decentralised health system. In South Australia, a computer program can collate and tweet how many patients across the state are waiting in an emergency department for a hospital bed. In Queensland, any GP or patient can check the waiting time for public outpatient clinics at any hospital. In Victoria, although data exist, they are not available in any useful format. A rural ED physician cannot see which hospital in Melbourne has surgical or ICU beds, nor can patients know what ED waiting times are at different hospitals. Inevitably, this leads to inefficiencies.

Parnis, a former president of AMA Victoria, acknowledges that the Victorian government has made significant investments into healthcare in the past five years. Unfortunately, little of this has been for strategies and systems to better manage surge demand. Nevertheless, few doctors have any appetite to lay blame for the current crisis. While we all worked to avoid the novel terror of a health system overwhelmed by Covid-19, this kind of systemic failure within a health system perpetually operating near maximal capacity is exhaustingly familiar. The priority should now be to fix these issues.

Surges in healthcare demand are usually managed ad hoc by the generosity of staff who put aside their own needs to work longer and harder during peak periods. The difference now is that this post-Covid-19 surge is not a month in flu season, a few weeks after Black Saturday or even a few days after an episode of thunderstorm asthma. It is not limited to one hospital or one clinical service.

This is a surge likely to last months, perhaps years, in a system already exhausted from planning for and addressing a pandemic. This is a crisis where the deaths and complications are spread across many disease processes and cannot be easily counted, or cleanly attributed to system failure, in the way that deaths from Covid-19 are.

While there is every reason to be grateful that the pandemic did not dramatically exceed the capacity of the Victorian health system, there is a real possibility this system now will be overwhelmed without specific interventions.

Where there is limited capacity to expand staffing or physical resources, efficiency becomes important. Whitelaw and others in the AMA have worked with professional bodies to recommend a number of interventions to the state government. These include support for a health system emergency commander, development of ED diversion strategies, and optimisation of funding models, data reporting and communication across the health system.

With our health system at its limit for the foreseeable future, there is also a need for a health system road map to monitor the system across the state in real time and nimbly implement changes in response to demand. And there is a need for the newly streamlined Department of Health to engage with clinical staff, improve data collection and reporting systems, formulate a plan and communicate it effectively.

Pandemics, like many disasters, expose the cracks in our systems. In doing so, they highlight both what is important and what urgently needs to be addressed. It is clear a resilient, well-resourced health system is vital for every part of society. We now have an opportunity to invest in our health system before the next crisis and ensure it is surge-ready at all times.

This article was first published in the print edition of The Saturday Paper on Dec 19, 2020 as "Controlling the surges".

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Neela Janakiramanan is a surgeon based in Melbourne.