In attempting to bridge the gap between two icons of health care — the pubic hospital and general practice — the National Health and Hospitals Reform Commission (NHHRC) makes recommendations aimed at building stronger primary health-care networks; an approach that has been neglected for too long. These include recommendations about the future of public hospital outpatient clinics.
Quoting work from 1997 in Victoria, the commission said: “Outpatient services have been described as the ‘poor cousins’ of the health system — a remnant of the pre-Medicare system, which provided free specialist care for ‘the poor’.”
Is this a realistic appreciation or an appropriate position? It does not describe the outpatient services as I know them.
The recommendations aim to include outpatient services when defining the targets for the continuum of care, to ensure that outpatient services meet the needs of patients and that they provide more services in community settings. These aims are unquestionably worthwhile.
But within the recommendations there is a danger that a key interface of the public hospital with its patients will further atrophy if some of the ideas prevail.
In New South Wales when Medicare was introduced, physicians and surgeons, except for a heroic few, refused to work in outpatient clinics. They said it was far better for patients to see them in their private rooms where their fees would be subsidised by Medicare. But there’s a catch — many specialists require an up-front fee, specialists are few and far between in disadvantaged areas and super specialisation means patients end up traipsing from one specialist to another. The problems are an order of magnitude greater in rural areas.
I recently saw a young woman, from a poor family in a rural township, who was troubled by progressive polyarthritis. She had had several orthopaedic procedures. More than anything she needed to see a rheumatologist but the only rheumatologist available required an up-front fee of $300; a sum the family could not afford.
“The poor” still seek, but rarely receive, the services that public outpatient clinics have the capacity to provide. Outpatient clinics have become rump organisations of the health-care system because medical specialists preferred their private rooms and state governments have been only too keen to transfer the costs of treatment to the Commonwealth.
If you want to know how hard it is to provide an outpatient service in a public hospital, ask a public psychiatrist, addiction or pain specialist in New South Wales. You will then learn how the existing Commonwealth/state systems have to be fudged to provide decent care to those who can’t afford health insurance.
When public hospitals have well-established outpatient services, the clinics are an important portal to the public system for patients with complex and life-threatening conditions other than going through the emergency department. Not only are they important points of first contact, they can be a safety valve for the emergency departments.
The NHHRC is proposing that the “Commonwealth meets 100% of the efficient cost of public hospital outpatient services using an agreed casemix classification and an agreed, capped activity budget”, which will effectively bundle outpatient clinics with out-of-hospital primary health care. On the other hand, the public hospital will be funded differently and be under state government management.
There is no doubt that the community needs better access to specialist services closer to where they live and work. However, the proposed arrangements carry the risk of further marginalising public hospital outpatient clinics, which should be an important buffer in the transitions between the community and intense in-patient care for “poor patients”.
Ian Webster is Emeritus Professor of Public Health and Community Medicine at the University of New South Wales and consultant physician.