SEPTEMBER,Edition # 34, 2001

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You would have to ask yourself why a government would be interested in pushing a model of health care that has proven to be totally flawed.
I am talking about the integrated service model that is being developed by some publicly listed service providers.
The models are based totally on American versions that have had a lot of problems in common:

* They (the American models) all deal with public funds (government) and health insurers, and retain a high powered group of lobbyists to ensure that their funding is secure.
* All major American operators have been investigated by the FBI for fraudulent conduct. This conduct has been driven by the payment of incentives to top management and contractors who refer patients to units owned by the corporation e.g a pathology or radiology unit, leading to over-servicing.
* All have required to be intensely regulated by expanded legislation, which also requires a team of inspectors to enforce, because of consistent breaches.
It is a costly system to administer by government.
* They are set up to service the organisation and its shareholders..not the patient.
* They target patient groups that are unable to defend themselves (the elderly, the mentally ill, young children).
* They have all experienced financial difficulties and have not been proven to be stable models of care.

So what is driving our government to give clones of these American organisations an inside track over existing and long standing models, which have a proven track record?

To follow the reasoning we need to have a global look how developed countries are able to provide their citizens with a sophisticated armoury of interventions, for both acute and chronic diseases.
They are now less invasive and require shorter periods of hospitalisation.
In many instances, even the overnight stay in a hospital is now redundant.
What is our perception of a hospital?
The traditional hospital evolved from a need to congregate the infirm in a central place so that they could receive nursing care.
The care was compassionate, but little better than palliative.
Historical patterns in staffing and funding have built a perception that "bigger is better".
Despite the enormous advances in medical services and technology, the worth of a hospital is still assessed by the community at large by the number of beds it offers, without discriminating between the type of beds offered, the level of care provided, or even if those beds are used.
The community perception, regardless of the evidence of adverse outcomes and impacts of being in hospitals, indicates there is some suspicion about the motivation of policies that advocate for managing inpatient lengths of stay, following an acute event.
This is particularly the case in countries such as Australia and New Zealand that have perpetuated the "lying-in" construct inherited from the United Kingdom.

The reality is that a hospital is now a place where technology and the expertise to "drive" it, is concentrated into increasingly fewer beds. A number of studies have indicated that large hospitals are adopting a modular approach of almost discrete "hospitals-within-hospitals" to avoid the inefficiencies inherent within large monolithic hospitals.
The great North American institutions, such as the Mayo and Cleveland Clinics, realised this some time ago, with clinics built around service models, not centred on hospital beds.
These technologies come with multimillion dollar price tags.
Despite the aspirations of many people, and their elected representatives, technology cannot be located in every small community. Even if society could afford such extravagance, significant volumes of cases are required for the operators to achieve and maintain an acceptable level of expertise.
In view of the issues indicated above, it is apparent that health providers, policy makers and funders, need to adopt new perspectives in providing hospital services, particularly in the areas of decreasing the length of stay, increasing day only services and developing strategies for admission avoidance.

To ensure that public hospital beds are utilised to full benefit, patients must have some form of acceptable destination as they are accelerated within the system.
Herein lies the opportunity for private health providers to set up beside (or even within) the public hospital system and receive patients as they pass from the acute phase of their illness to the rehabilitive phase.

The most dramatic change in hospitalisation has been the fall in the period of time that patients are hospitalised, even for major conditions. Factors contributing to this decrease are:
* Minimally invasive operative techniques.
* Non-invasive diagnostic techniques (ultrasound, CT, MRI etc)
* Day of surgery admission
* Improved anaesthetics.
* Perioperative units
* Postoperative analgesia techniques requiring early mobilisation.
* Better community and domiciliary nursing care.
* Evidence based practice.

Some non-clinical factors have also contributed:
* Discharge planning.
* Casemix funding.

There has also been a realisation that hospitals are hazardous places. Thromboembolic episodes, nosocomial infections, antibiotic resistant microbes, pharmaceutical errors and accidents (falls, burns etc), contribute to an alarming incidence of adverse outcomes of hospitalisation.

The ultimate manifestation of decreasing length of stay is the emergence of hospitalisation that does not require an overnight stay. The range, complexity and rate of development of day procedures continue to erode traditional patterns of admission.
This development also gives an insight as to why Mayne Health are currently investing in an increasing number of day surgeries.
The impact on public hospital culture is quite intense, as managers try to cope with rapid and frequent change, often without adequate resources to develop a best practice model.

Admission avoidance has been developed to a fine art in North America, where managed care systems have achieved dramatic declines in admission rates and utlisation of hospitals.
Hospitals are amalgamating, changing their roles, and in some cases, closing.
For hospital based teriary specialists, underemployment, if not unemployment, is a major concern.
With the emphasis on better management of clinical processes, and dramatically reduced utilisation of hospitals, we see the emergence of managed care in the United States, integrated care in New Zealand and the United Kingdom, and coordinated care in Australia.

The key ingredients are better coordination of the continuum of care, partnerships between primary and secondary providers, the creation of a gatekeeping function, and, in some cases, a budget holding purchaser of secondary and tertiary services.
In this way, opportunities are opening up for private enterprise to partner the public system.

The alternatives to admission have emerged as:
* Diagnosis and initiation of management in amulatory care centres.
* Acute Assessment Clinics as part of a Hospital Emergency Department.
* Shared care arrangements between primary care physicians and hospital providers.
* "Hospital in the Home" models.
* Intensive surveillance and preventive programs for patients known to be at high risk of recurrent admission e.g COPD
* Best practice guidelines for common, but serious disorders e.g newly diagnosed diabetes, which in the past would have resulted in hospitalisation.

In this way, hospital medicine is undergoing a revolution of immense importance.
Unfortunately, our governments are not sharing this information with the community, simply opting to close beds and reduce funding to traditional areas without explanation. Detailed explanations would lose many votes.
Governments are traditionally uncomfortable in dealing with small to medium size businesses, the thinking being that these businesses lack resources and are unable to sustain the long haul.
To a certain extent they are correct, in respect of pharmacy, because pharmacy capitalisation has traditionally been controlled by wholesalers, rather than pharmacists in their own right. So in looking for suitable partners to help drive the health revolution, all they can see are the corporate integrated health entities in one convenient package.
And driving this decision is the need to have a partner that can link up with the hospital system in the first instance, and provide anciliaty services (such as pharmacy) as part of the smorgasbord of services on offer.
Size equates to substance, even though past management performances have been less than stable. The recent announcement of Foundation Health that it is experiencing financial difficulties reinforces this view.
The only way pharmacists can deal in their own right is to be of a scale that commands government attention. The time to incorporate, using a sensible professional model quite distinct to the existing publicly listed models, is now.
Only when there are a group of substantial pharmacy players in the marketplace will the opportunity occur to secure an independent future in partnership with government.
And it will not suffice simply being of a large size.
It will require an alliance with other health entities (pathology, radiology, day surgery, specialist groups, GPs) to provide a complete package, or investment in the required structures in your own right.
The current model of a large group of "cottage craft" businesses will still serve some use into the future, but it will be perpetually vulnerable to the predatory activities of the integrated health corporates as they gather strength and penetration of the pharmacy market.
The Guild/Government Agreement expiry date may mark the commencement of this penetration, and many pharmacists may look on in dismay as Guild leaders become paralysed, as the enormity of the problem becomes apparent.

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