(Part 3 of a Croakey series on health reform).

Cost-shifting, blame-shifting and patient-shifting are an integral part of our health system, and the COAG health reforms are unlikely to signal their demise.

Dr Clare Skinner, an emergency registrar in Sydney, has some insights from the frontline about how emergency departments “sell” patients, and questions the impact on patient care.

She writes:

“Among the flurry of health reform announcements made recently by Kevin Rudd was a commitment to the introduction of the ‘4 hour rule’ across Australian Emergency Departments.

The concept is simple and superficially appealing:  hospitals will be financially rewarded if all patients presenting to the Emergency Department are seen, treated and either admitted or discharged within four hours.

It might sound good, but implementation will require major cultural and workplace change, including improved co-operation between clinicians working in the Emergency Department and inpatient specialist teams.

The Christmas 2009 edition of the BMJ contains an article by Peter Nugus, Jackie Bridges and Jeffrey Braithwaite examining the way Emergency clinicians ‘sell’ patients to inpatient teams.

While I congratulate the authors on a coherent and insightful piece of writing, I have to admit that my feelings towards this study are mixed.

On one hand, it is almost cathartic to see this dimension of my work publicly exposed.  In the modern era of super-specialisation, bed block and chronic staff shortages, clinical Emergency Medicine – diagnosis and initiation of treatment – is the easy bit.  Far more difficult is the communication, administration and politics associated with arranging admission to a hospital bed.

During a recent shift, I watched a senior Emergency Physician spend almost four hours on the telephone, negotiating admission of a single patient with a relatively simple primary problem, but complex medical history, to a specialist inpatient unit.

Only a fellow Emergency clinician can truly appreciate the frustration generated by having to consult the Cardiology, Respiratory and Aged Care teams, often multiple times, about every elderly patient who presents to the Emergency Department feeling short of breath, and I hope that this article may generate just a little empathy and understanding from my inpatient colleagues and health service managers.

On the other hand, this article makes me concerned that we have lost sight of what is truly important: providing appropriate, effective, and professional care to our patients.

Although, at one time or another, usually in desperation, I have employed many of the strategies described in the article, I do not believe that deliberately engaging in ‘selling’ behaviour is in the best interest of patients.

Every person who seeks Emergency care deserves to be treated holistically and respectfully, not have their symptoms and signs broken down to conveniently match a specialty definition, nor be objectified as an item for marketing.  As our patients grow increasingly complex, there is a very real risk that health problems will be overlooked, or managed inappropriately, if patients are quickly triaged and admitted to the inpatient unit of least resistance, rather than to the unit with the most appropriate skills and resources available after a thorough assessment.

The authors of the study propose, half in jest, that there may be a place for teaching Selling, Marketing and Packaging 101 to Emergency Physicians and GPs.

Instead, I propose a broader approach.

Open more beds, aiming for 85% occupancy, to put an end to chronic bed block.  Re-invigorate generalism, through funding and employment strategies which reward holistic medical care, rather than super-specialised procedural work.  Appreciate and support Emergency Physicians and trainees, with their unique skill-set and system-based approach, as they aim to provide the best care to their patients.”