The next time she can’t breathe, should I take her to hospital or just wait it out?
I remind myself that this man has diligently cared for his ailing mother for the past two years and is now navigating her inevitable decline. She has heart failure, renal impairment and chronic back pain. Two weeks ago they waited eight hours to be seen then left. Two weeks before that, at a different hospital, she got so tired of lying in a trolley that she begged to go home. This time, after 10 days in hospital, her breathing improved but at the cost of a mild delirium. The cause of the delirium? Morphine prescribed for back pain. The cause of the back pain? Lying in bed all day, hesitant to walk in unfamiliar surroundings without help. And where is the help?
It’s the same everywhere. Providers are sick and burnt out and those who remain are busy answering so many demands and dealing with so much paperwork that a daily wash and a daily walk have become luxuries.
I want to tell him that not every unwell patient needs to be rushed to hospital, especially vulnerable ones like his mother, who have an equal chance of getting better or worse. But saying “you decide what to do’ is unfair.
I would recommend seeing her local doctor but amid the GP scarcity, she hasn’t found anyone willing to take on a “complicated” patient. A regular nurse practitioner to troubleshoot her problems would be ideal but I can’t access such a service. She is linked to clinics at three hospitals. But the heart service steers clear of the kidneys, the kidney team want nothing to do with her back pain and the pain doctors are so overstretched that one missed appointment sends her back in the queue for six months. She is fed up and has given up.
Realising that hospital is the least useful destination, I say, “You know our doors are always open, just bring her in.” His face falls. It feels bad to give bad advice.
Once people were reassured by hospitalisation. With changing demographics and diseases, and a greater awareness of the risks, they are more cautious.
In the face of a national healthcare crisis, framed by upcoming elections in Victoria and New South Wales, comes an astonishing competition between the two major political parties to dot the states with new and redeveloped hospitals at a cost of billions.
But the reaction to such an abundance of gifts has been muted from the people who should be celebrating the news. Professional bodies and health experts point to the lack of skilled workers at every level to staff these facilities. Training a doctor takes 10 years. Training a judicious doctor takes 10 more.
Even if the “pipeline” were healthy, hospitals flooded with young doctors, nurses and allied health providers would inject fresh ideas – but holistic medicine requires the wisdom of experience. If tired, overused and burnt-out providers give up on public hospitals, there is a good chance of beds lying empty –as already happens in many hospitals.
But the biggest problem with the race to erect more hospitals is that this is a time to move care into the community.
More than 800,000 patients are admitted to hospital for potentially avoidable reasons. I meet many of them on my medical rounds. The elderly man with an infected toenail who could have been saved by a regular podiatrist. The asthmatic woman who needed a trusted GP to prescribe inhalers and coax her to stop smoking. The diabetic patient who “decompensated” due to inadequate community care.
Add to this all the confused patients who could have been treated more appropriately in their own facility and the dying patients who yearn to be at home but whose families lack the support to honour their wish. And the patients who are not sick enough for a psychiatric unit yet not well enough to go home. When mental illness intersects with disability, incarceration and homelessness, keeping troubled patients in hospital seems like knowingly writing a wrong prescription.
Just recounting these people makes me anxious for the future of healthcare, so picture the worries of those charged with managing the whole system.
With the healthcare crisis firmly in the public eye, politicians have two choices.
They can understand healthcare as both vocation and business by talking to actual providers – from cleaners and clerks to doctors and nurses, who will tell them that honest healthcare trumps shiny buildings. All too often the quiet heartbeat of providers is overpowered by the drumbeat of managers who have different (not necessarily wrong) incentives. Understanding the intricacies of healthcare is painstaking work likely to reveal alarming deficits and some obvious solutions.
Healthcare is no more or less important than a host of other public goods including education, disability support and affordable housing. Taxpayer dollars must be committed with care and transparency, which calls for an honest portrayal of priorities.
The second choice is easier and, in an era of distraction, more tempting. It involves sweeping aside the nitty gritty of the healthcare crisis and hoping new hospitals will fix old problems. But they won’t. What’s more, the “build and they will come” sentiment will deliver worse outcomes if it detracts from general practice and other community-based services delivering comprehensive, coordinated care for chronic diseases and at the end of life.
A time-honoured lament in healthcare is to point the finger at the federal or state authorities, depending on who owns the finger. But I have never met a patient who found this dichotomy to be a sensible explanation for why it’s impossible to see a GP for preventive care but so easy to spend a month in hospital solving the same problem, exacerbated and incurable. We deserve better.
Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
