The public hospital of the future

Faster and faster and better and better, or faster and faster and worse and worse. These are the only two pathways into the future for Australia’s public hospital system.

Public hospitals are very special places — large numbers of committed, high quality clinicians, registrars in training, medical students, nursing and allied health staff care for a diverse range of people with particular needs determined by diagnostic diversity. But the organisation and infrastructure of public hospitals are designed for times past and are not changing rapidly enough to meet the demands of the next decade or so. Although I am optimistic about the future of public hospitals, they face significant challenges. Four issues exemplify these challenges.

• In the “good old days”, a patient knew who his or her doctor was. Today, with the interdisciplinary team approach to patient care, and rotating interns, registrars and consultants, the one-on-one doctor–patient relationship is rapidly receding or long gone. There is a need to prevent complete fracture of this vital personal link.

• In the “good old days”, a quick ward round on Saturday morning sufficed for discharge planning, as the final decision was left until Monday. Now the question is “How many patients did your unit discharge last Sunday?”, reflecting the increasing demand on beds and the need to make best use of available resources.

• In the “good old days”, older, frail patients were unlikely to have elective surgery, and, if they did, they would be admitted 2 or 3 days before the operation “to get them ready”. Now, when an 82-year-old man with ischaemic heart disease, chronic respiratory disease and cognitive dysfunction is admitted for a hernia repair, it is often on the day of surgery, but a 2-week postoperative stay is likely, and the procedure can be life threatening if care is not optimal.

• In the “good old days”, it was assumed that errors and omissions did not occur, or, on the rare occasion that they did, it was because of individual carelessness or ignorance. We now have strong evidence that, despite best intentions, suboptimal care can occur, and patients are at risk of being harmed by system failures.

I believe that the organisational structure of hospitals, not their buildings, will be unrecognisable in 10 years’ time. Senior doctors will re-engage in the planning process. Boundaries between various specialist and general medical and surgical units will blur or disappear, and the focus will be on patient care.

The relative shortage of funding for hospitals will remain. Although we are spending more than ever on healthcare — both in absolute terms and as a percentage of gross domestic product — it is likely that, in the future, the proportion spent on hospitals will continue to decline. Thus, efficiency and effectiveness will become unstoppable driving forces. Despite the perception of most clinicians that more money is the solution, there is a view in government health departments and treasuries that increased funding does not always solve the problems of delay in access to treatment, waiting lists and poor staff morale. These financial pressures will test the role of public hospitals as centres of excellence for therapy, training and research.

• Medical staff need to embrace change. Senior hospital doctors need to become part of the solution rather than part of the problem by taking on clinical leadership. The relationship between general medicine and specialty medicine needs to improve. The care of individual patients is paramount, and should overcome parochial issues of patient ownership and bickering about the respective size of hospital departments. This improved relationship is likely to occur rapidly, as the current trend is for new “general physicians” to be specialist physicians in disguise. As the traditional “pure” general physician retires, we will go through a phase of subspecialist physicians, with general medicine as an interest. In the longer term, there will be a new cohort of general physicians whose responsibilities will combine elements of emergency medicine, intensive care, aged care and internal medicine.

• The learned colleges need to change. The general medicine training program needs to be restructured, with more exposure to ambulatory practice, emergency medicine, administration, safety and quality improvement, as well as cost-effectiveness and resource allocation.

• Hospital executives and health department heads need to change. They will need to rediscover the skills and experience of skilled clinical staff, engage them in the planning process and supply adequate funding for public hospitals. They will need to recognise the academic strengths of major teaching hospitals, which train the doctors of the future and devise the therapies of the future. Either funding for teaching hospitals will have to increase appropriately or rationing (perhaps termed prioritisation) will need to become more overt.

• Hospitals need to change. They need to be more efficient, with better organisation and more staff. The culture and attitudes of the staff need to change, with the focus on the needs of the patient. There is a significant danger that the needs of patients will be overlooked in the complicated and fast moving public hospital systems of the future. The complex pathway of the patient through this system needs to be directed efficiently and with humanity by the hospital case managers of the future. Let us continue to call them general physicians.

In the absence of these changes, public hospitals will become a thing of the past.