The “Snelling” Health Care Shake-up for South Australia
“Jack” Snelling may only be 42 but as South Australia’s Minister for Health and Ageing. Minister for Mental Health and Substance Abuse, Minister for the Arts, and Minister for Health Industries, he occupies a senior position in the Labor government of Jay Weatherill.
The Member of the House of Assembly for Playford is also one of the most experienced Ministers. He entered the South Australian parliament when only 24 years old in 1997. Over the two decades since, he has held a variety of portfolios, and has been Speaker, Deputy Speaker, and Chairman of Committees. In 2011 he became the Treasurer, after Kevin Foley resigned.
A few days ago (07/02/15) he stunned the public with a proposal for radical adjustment of Healthcare delivery in South Australia. He prefaced his plan by quoting ‘official data’ which showed that an average of 516 more people are dying in South Australians Hospitals than the national average, and that the mortality rate rises further at the weekends.
His view for improving health delivery is consolidation of care into larger, more efficient hospital programs. No need for more beds. Rather the aim is for fewer acute beds, and fewer nurses, but accelerated turn-over. His plan:
- allocates $252 million for 70 more paramedics and support staff, 12 new ambulances, and two new ambulance stations. The extra ambulances will make sure that patients are managed at a centre that meets their clinical needs.
- closes the Repatriation General Hospital,
- downgrades emergency services at Modbury Hospital, the Queen Elizabeth Hospital, and Noarlunga Hospital in favour of three super- emergency departments at the Royal Adelaide Hospital, the Lyell McEwin Hospital in the Northern suburbs and the Flinders Medical Centre for the Southern Region.
- provides 40 new maintenance care beds to be contracted out to the private sector, to accommodate patients waiting for placement in nursing homes or other facilities. This should free up beds for acute admissions.
South Australia’s Public Hospital Infrastructure.
The 8 public hospitals in the Adelaide metropolitan area are:
- The Royal Adelaide Hospital. Est. 1840. 680 beds.
- The Repatriation General Hospital. Est. 1940. 300 beds.
- The Queen Elizabeth Hospital. Est. 1954. 340 beds.
- The Lyell-McEwin Hospital. Est. 1959. 257 beds.
- Modbury Hospital. Est. 1973. 173 beds.
- The Flinders Medical Centre. Est. 1976. 593 beds.
- Noarlunga Hospital. Est. 1985. 82 beds.
- Women’s & Children’s Hospital. Est. 1989. 314 beds.
Surprisingly Snelling seeks fewer not more acute beds. He wants better outcomes for less expenditure. How realistic is this?
Australia’s present population is 23.5 million and is growing under an active immigration policy.
South Australia however has only a small population of 1.677 million, 1.28 million of whom live in Adelaide, but is more than well served with about 2739 public hospital beds, in the eight metropolitan hospitals. This is a bed provision of 2.14 patients per thousand population.
In Australia about 70% of beds are public, 30% private. On this basis it would be expected that there would be about 1173 private beds in SA (in 54 private facilities) for a total of 3913 beds or 3.27 beds per 1000 population. This is an adequate number. The Australian average is 2.6 beds per 1000 population according to the Australian Hospital Statistics report.
Hospital Winners and Losers
If South Australia has provided enough hospital beds in satisfactory condition for its needs why do we need to change the present arrangements, other than to cut costs? The answer lies in the need to bring on stream in the next two years the ultra-modern Royal Adelaide Hospital. A new hospital is to emerge, but must an old hospital close?
The Royal Adelaide Hospital, established in 1840, is a teaching hospital associated with the Adelaide Medical School. It also operates the Hampstead Rehabilitation Centre, a facility that provides for specialised rehabilitation needs and the continuing care of spinal injuries, but is to be closed.
Mike Rann towards the end of his nine-year term as Premier from 2002 to 2011, conceived the idea of building an ambitious new “state of the art” public hospital to cater for the future medical needs of the state.
The new Royal Adelaide Hospital (nRAH) will be the largest, busiest, and most technologically advanced hospital in Australia with 800 single in-patient rooms, including 100 same day beds and will cater for 80,000 same-day and overnight patient admissions per year.
Within the hospital complex will be a number of commercial enterprises, including gymnasium, crèche, post-office, shops, and a food hall. Architectural features, art works, and gardens will add to the hospital ambience
It is the single largest infrastructure project in the state’s history, and the largest hospital construction in Australia’s history. Construction started in 2011, and is to be completed in the second half of 2016. Bringing the new RAH to fruition is the government’s major focus in the health budget.
A consortium, the SA Health Partnership, comprising Leighton Contractors, Hansen Yuncken, Macquarie Capital Group, and Spotless is responsible for the construction and provision of non-clinical services, until hand-over when the repayments are completed.
Structural construction cost is about $2.1 billion, but debt repayments will be $397 million per year for 30 years beginning in 2016 when the hospital is finished. If there are no cost over-runs, the total payment will be A$11.91 billion.
The building of nRAH will not end the government’s funding needs. They have agreed to re-locate The Medical School, the Dental School, SA Pathology service, and most expensively The Women’s & Children’s Hospital by 2023, to the new campus. How will these initiatives be paid for and will the new hospital be able to house all the departments of the old one?
The hospital to lose out is the Repatriation General Hospital (300 beds) in the southern suburb of Daw Park. The Commonwealth government built it in 1940 during the Second World War to treat Army casualties. It is not commonly known that Repat has for some years functioned as a community hospital, as well as providing a dedicated medical service for Veterans., including those of the Korean, Vietnam, and now Iraqi and Afghanistan conflicts.
It has complemented the Flinders Medical Centre as a teaching hospital for students of the Flinders Medical School. It has provided treatment in all medical and surgical specialities (except heart surgery, and neurosurgery) including the Professorial Urology Unit serving both hospitals. It has had an Emergency Department, a Professorial Psychiatric Unit, a Rehabilitation and prosthetics Unit, and has operated a highly regarded Hospice.
These recommendations will increase congestion in Acute Care Public Hospitals
Congestion in the Emergency Departments of the Royal Adelaide Hospital and Flinders Medical Centre will increase as a result of a down-grading of the Emergency Department of The Queen Elizabeth to non-critical care, and the loss of beds at the Repatriation Hospital. The whizz-bang new RAH, offering private room accommodation, and multi-disciplinary care, will be a certain run-away winner for patronage.
Aggregation of specialist departments in the one hospital allows sharing of facilities, and staff, and brings economies of scale. Departments must compete against each other for patients and funding. It facilitates multi-disciplinary management of multiple injuries and complex illnesses. It justifies the extra amenities and services the new hospital will supply and enhances the image of the hospital.
Some medical problems are best-managed by concentrating cases in specialised units or hospitals if the population justifies. Veteran care has been viewed in this light until now. The need for surgical management of War injuries may no longer exist but Veterans have long enjoyed preferential access to free treatment in a dedicated facility that is to be dismantled. Instead they will have to join public hospital queues.
The proposals further diminish the beds and facilities available for longer-term patients.
Governments have saved with shorter admissions and day-surgery. The desire for further cost savings has driven policies that shorten hospitalisations for other conditions, and return the patient to their home environment. But this is just not always the best course of action.
It is a shame that:
- Rehabilitation and convalescent beds will be lost with the closure of Hampstead and Repat Hospitals.
- Will there be a public Hospice facility for the palliative care of cancer, and the dying, when Repat closes?
- There is a woeful shortage of beds for psychiatric treatment since the state’s traditional mental hospitals have been closed.
- The standard of community psychiatric care is deficient. The number of violent disturbances by mentally disturbed patients in public places is increasing, and placing an unfair load on our police force. We need paramedics and nurses with psychiatric training to advise and assist the police, and to supervise continuing patient treatment.
The greatest omission is the lack of provision for mental health patients. The mentally disturbed are disruptive in busy Emergency Departments. In spite of this many have been kept waiting for days in hospital Casualty Departments waiting for a bed in a psychiatric facility. There is an urgent need for specialist mental health units or hospitals.
I fear that the hospital needs of patients with chronic diseases and disabilities are being subordinated for ultra-modern prestigious acute-care hospitals.