Political gold in the post-virus health hump: why we'll need at least eight new hospitals in the next five years

At the end of this month, COVID-19 will have been in Australia for two years. Since it arrived it has disrupted the operations of many of our hospitals and health centres, caused tens of thousands of our health workers to be diverted from their normal functions, and created a serious backlog of increasingly urgent surgeries and other treatments. Perhaps two million Australians are sitting on hospital waiting lists for planned elective surgery. Many thousands of them have been waiting for more than two years. The real line is in fact much longer - perhaps 50 per cent longer - because some people have not been seeking treatment they know has not been available because surgery theatres, intensive care units and hospital bed space has been diverted to the urgent needs of coronavirus patients.

As we have seen over recent weeks, the strain put on the health workforce by the pandemic has virtually brought the system to breaking point, with exhausted workers being asked to cover the shifts of others who are burnt out, sick, stressed out or actually leaving the health care system. That has not been a problem confined to hospital health care, because it has affected the numbers and the energy available in aged care institutions, in screening and vaccination programs and in coping with the increasing numbers of infected Australians asked to confine themselves in isolation. Even as programmed and planned tasks have been achieved, for example in vaccination programs, the complexity of the task has steadily increased with the need for booster shots and the vaccination of primary school children.

I do not suggest that our health authorities, or their political masters, are oblivious to problems which may well put a hump of about a 10 per cent increase in normal demand for health services for the next five years, with a medical workforce that may well be smaller than now. Certainly, the system is not recruiting, training or graduating medical workers - primarily doctors and nurses but also allied health workers - at anything like the scale that is necessary, in spite of umpteen warnings about increased demand, for example from the royal commission into aged care.

The hard gruelling work of the pandemic - even at high risk and comparatively low pay - may have some inverted effect of providing extra status, purpose and meaning, as well as job satisfaction for health workers. But it has stretched many to the limit. It has put their relationships and lives with their families at risk, and reminded many that there are better paid jobs with a good deal less stress. Nursing turnover has always been high, in part because of low pay, but it has been increasing.

The crisis has also put doctors under stress, including in the community - stress aggravated, in many cases, by the failure of politicians and the government to deliver on promises about the availability of vaccines, test kits and other supports. But there are particular problems with many of the medical specialties, with simply not enough specialists being trained, or available, to deal even with routine demand, let alone significant backlogs. In many disciplines, the problem is aggravated by a tight control of output from professional colleges seemingly determined to limit supply so as to maintain very high remuneration.

All up, the existing system may need the equivalent of an extra Westmead-sized hospital in NSW, fully staffed including with specialists, the equivalent in Victoria, and, in each of the states and territories, a new fully-staffed hospital of at least the size of the state's biggest, over the next few years. On top of that, the system may well require a 50 per cent increase in trained nursing carers in aged-care homes and a doubling of the size of community-based care staff. That is not only a measure of the backlog, but a reflection of years of cutbacks, reduced capacity and ebbing expertise - so amply demonstrated during the pandemic.

The practical consequences of these backlogs, and the sharp increases in costs and in demand for services will fall on the states and territories. But such challenges cannot be airily dismissed by the Commonwealth as problems for the states, in the manner of Scott Morrison regarding the provision of rapid antigen testing equipment. They have been predictable consequences of a national emergency, and in exactly the same way that extra Commonwealth spending to bolster the position of big and small business, or pandemic-caused unemployment was. They invite substantial extra Commonwealth investment in new health care facilities, in education policies designed to increase the size and quality of the medical workforce, and in attempting to rebuild the sort of public health system that will help reduce the need and the cost of acute care facilities such as hospitals and aged homes, promote a generally healthier population and maintain a force in being able to deal with future health crises.

Nor is it simply a matter of catching up with the backlog of surgery - most of which will be fully cost-effective in the sense that it enhances the quality of life of the patients and allows them many more years of active life in the community, rather than as people with disabilities

It's also a matter of catching up with patients undergoing care for cancer, and other serious conditions, many of whom have had less than adequate care, or access to specialist facilities over the past few years. And also of catching up with undiagnosed patients through screening programs that have been forced to take second place or been scratched altogether. Or dealing with mental health issues - some of which have been neglected during the pandemic, some of which have been caused by, or aggravated by the pandemic itself. As well, a significant number of people who had COVID-19 now have long COVID - with long-term symptoms needing continuing treatments.

Waiting lists are, of course, always politically sensitive, and, like budgets, often manipulated by administrators and ministers who appreciate that one can turn the tap on and off at will. But the backlog is no mere waiting list, and denying the theatre space, staff and resources to getting them down would be an entirely false economy. It would first be transferring the real cost to the patients themselves, forced to cope with poor health, and reduced capacity to lead useful lives of dignity within the community. It is also to load costs - often greater ones - into other parts of the health system, forced to cope with the consequences of denied or delayed treatment.

A parliamentary committee looking into similar backlogs in Britain warns against a mere focus on targets that are able to be weighed, measured and counted. Doing so - recording progress by the length of the surgical waiting list for example - risks deprioritising equally important areas such as primary care, the provision of health services in the community and mental health services - all of which play a crucial role in keeping people healthy and out of intrinsically expensive places such as hospitals.

"There is also a risk that a new targets culture has unintended consequences, including compromises in the quality and safety of patient care. This is not a hypothetical concern considering that precisely this unintended consequence arose the last time tackling large waiting lists was a political priority."

Hidden demand, the parliament's health and social care committee said, includes not just "missing patients" -- people simply not seen or identified over the past two years - but people with mental health issues exacerbated by lockdowns and people with medical conditions who have faced interruptions to their usual care - and whose health may have worsened as a result. There is also a backlog in public health, where children have missed out on universal programs largely delivered at school. The committee said it had heard powerful testimony from patients who had felt "abandoned" by the national health system, who had had to "fight" for care, and for whom delays in treatment meant ongoing uncertainty, with lives left on hold.

There will always be some politicians who will see health care as mere costs on the system, without appreciating that investing in, and maintaining a healthy population is an investment that pays real dividends. Health care, moreover, is a naturally increasing part of the economy, given that the population is ageing; costs are more easily restrained by providing quality services efficiently than by rationing health-giving services that considerably improve the quality of life.

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For those whose approach is also touched with an undue emphasis on the public-private divide, public health expenditure is often considered a bad thing simply because it involves public servants - implicitly a drain on expenditure - rather than can-do capitalists, whose every action creates jobs and investment.

The statesman, rather than the drudge, will recognise the opportunity that is being created in the course of renewing health services after the disruptions and diversions of the pandemic. It provides new opportunities to consider the problems as a whole, rather than, as so often happens in practical administration, as bits that can be dealt with only piecemeal, and usually with no great strategy. It provides new opportunities for Commonwealth-state agreements about responsibilities, that allocate responsibility and accountability rather than feeding the blame game. It allows a new focus on developing, maintaining, providing continuous education for, and properly paying an enormous workforce of up to 750,000 Australians, including 100,000 doctors and 20,000 dentists, 300,000 nurses and midwives, and 150,000 allied health practitioners.

It also involves a chance for a careful and measured look at the development of better IT and telecommunications, including increased opportunity not only for providing health care in remote locations, but "tele-health" consultations for patients with chronic conditions, or mostly needing pharmacy scripts or regular pathology checks. That also provides fresh opportunities to find savings and efficiencies in payments for pharmaceutical dispensing and drugs. In a new environment focused on quality outcomes and better bang for the buck rather than mere cost-cutting, service reduction and the substitution of "personal responsibility" for general health insurance, it may well be possible to deliver better outcomes at a lower price.

But it does involve a sense of mission - some vision and some commitment - rather than a mere intention to restore things to the way they used to be. That sort of approach can produce, at best, only incremental change at the margins, and, as has been repeatedly shown, outcomes as much influenced by the promotion of the vested interests of providers rather than the public interest. The Financial Review, for example, has suggested that the great shortage of RAT kits was primarily a consequence of the deep opposition to using such kits from professional pathologists. This was not, of course, framed as being motivated by their vested interest in a lab-based business model.

I have no strong feelings about men's tennis (though I much enjoy women's tennis) but I am a serious devotee of irony, not least that emanating from Scott Morrison, who even by American and Pentecostal standards is a notable irony-free zone. The past week has seen deep indignation at the arrival in Australia - with a valid visa - of Novak Djokovic, for the Australian men's tennis championships, which he has frequently won in the past. Novak has been openly resistant to vaccination, and is said to have suffered from COVID, which may or may not confer some immunity, but only a fraction of that conveyed by vaccine.

By the usual standards, or the rules to which Morrison expressed such attachment, international visitors are not allowed in unless they have been vaccinated. Yet the Australian Tennis Federation, on some jag of its own, tried to create some exceptions, which Djokovic said he complied with, and was thus given a visa. Unluckily for those who were attempting to enforce the "rules are rules, unless you are a friend of the minister" rule, Border Force handled the inquisition of Djokovic with characteristic ham-fistedness and lack of honour or proper process, and Djokovic's visa was upheld by the court. The government promptly announced that the minister for immigration would consider deporting him on "character" grounds, and the minister on Friday followed through.

The rationale for the vax rule is, of course, that Novak should not be exposing his fellow competitors or game officials to risk of the dread coronavirus. On a matter such as this, the dotty views of Novak about choice, or the dangers of vaccination must step aside to the requirements of the general health of the many.

While not hectoring Djokovic, thus providing leadership on the Australian Way, Morrison was attempting to cajole premiers, and the public into the idea that people with coronavirus need not isolate nor do anything much to avoid spreading the bug if they were largely symptom-free. This was so as to keep the engine of the economy turning over, as well as keeping nurses, teachers, shop workers and truckies able to carry on. Adherence to earlier rules - designed to reduce the risk of transmission - was said to be reducing the daily workforce by 10 per cent, and, were schools to be closed, would bring that to 15 per cent.

A person testing positive to coronavirus, whether by RATs (if you can find one) or PCR test (if they will let you do one) is highly contagious, whether or not she is showing symptoms. Morrison, and those of his advisers who put the health of the economy ahead of the health of Australians, are judging that most of those they infect will develop mild symptoms only, or none at all. That may be so, but the latest variant, Omicron, is likely to infect many more people than the Delta or earlier variations. Thus the "small percentage" of serious symptoms - some life-threatening - may well exceed the Delta tally.

All in all, I should think that the average tennis groupie is safer from Djokovic than from her next-door neighbour, or, for that matter, Border Force.