State Budget – prescriptions, outcomes and prognoses
6 May 2008
 
More beds for public hospitals
 
What AMA Victoria sought
 
Improved capacity in Victorian public hospitals with an additional 600 hospital beds over four years ($881.8 million)
 
What the Government has delivered
 
Small increases in bed numbers in Warrnambool and in suburban maternity services. These beds need to be supported by more nurses, more doctors and other support.
 
Implications
 
Victoria is experiencing a population boom. According to the Australian Bureau of Statistics Victoria’s population increased by 323 584 people from June 2001 to June 2006 — around 6.7 per cent over the six years.[1]
 
During the same period the number of public hospital beds in Victoria has increased from 12 162 to 12 223 — an additional 61 beds, or an increase of around one half of one per cent.[2]
 
As a consequence of bed shortages we are seeing higher occupancy levels and signs of productivity growth slowing across a range of hospital performance indicators.
 
Victoria already has the most efficient hospitals in the country, with significant productivity increases recorded over the past decade. Victoria continues to set the benchmark for hospital care. However, the rate of productivity growth has slowed dramatically, and there are a number of indicators showing signs of stress:
  • Ambulance bypass rates across Victoria increased from 1.3 per cent to 1.7 per cent from 2005-06 to 2006-07.
  • More Victorians are getting stuck with long waits in emergency departments. 78 000 Victorians who attended an emergency department and needed a hospital bed failed to be transferred within eight hours (the clinical benchmark) in 2006-07. This is a failure rate of 29 per cent. The Government’s projections for 2007-08 released in the Budget papers forecast this failure rate to climb to 34 per cent this year.[3]
  • Less elective surgery was done in 2006-07 than the previous year.[4]
The lack of capacity in Victorian public hospitals is the cause of a number of postponements of elective surgery. When there are no beds to take people after elective procedures, the surgery must be cancelled. As well as the inconvenience for the patient, it means that expensive operating theatres sit idle.
 
Further improvement is being threatened by the lack of capacity and higher occupancy levels.
 
AMA Victoria remains concerned about very high occupancy levels in Victorian public hospitals. When hospitals run at near capacity, they start to run inefficiently with cancelled operations, delays in clearing patients from emergency departments, increased in-patient length of stay, poor responsiveness to patients’ needs and worse patient outcomes.
 
International benchmarks recommend that hospitals run at no more than 85 per cent capacity to ensure safety and quality.
 
The Your Hospitals report[5] notes that ICU/HDU occupancy rates averaged 96 per cent in 2006-07. Limited access to critical care beds impacts upon the quality of care available for both emergency and elective admissions. The limited number of beds affects the flow of patients from elective and emergency services by creating downstream blockages in the system. The challenge for each hospital, assisted by government, is to manage demand for services and patient flow as efficiently as possible.
 
Comment
 
The current capacity problems threaten innovation. Creative patient-based care solutions require room to grow — staff are currently spending too much time and effort in finding the spare bed, rather than spending time working out how to keep a patient out of a bed. Hospitals need the capacity that comes with extra beds, more nurses and medical staff to breed innovation.
 
More hospital beds and innovation will require investment in the first instance, but the pay off will come with more satisfied patients, fewer stressed staff, better use of resources and an improved capacity to manage unexpected demand growth.
 
The Budget has failed to make this investment.
 

Provincial Victorian Medical Workforce Rescue Package
 
 What AMA Victoria sought
 
$116.5 million over four years for a provincial Victoria medical workforce rescue package. The Victorian Government must match the incentives offered by other state governments for general practitioners and specialists. The proposed AMA Victoria Provincial Victoria Medical Workforce Rescue Package includes:
 
  • A Centre for International Medical Graduate Support
  • Payments for general practitioners for out of hours telephone consultations
  • Rural allowances for hospital medical staff
  • Rural locum support service
  • Rural relocation allowances
  • Specialist bridging finance
  • Support for practice amalgamation
  • Information technology support grants
  • Increased CME allowance for doctors in training in rural areas
  • Retention allowances
What the Government has delivered
 
Nothing.
 
Implications
 
The shortage of doctors and other health professionals in rural and regional Victoria is an ongoing barrier to providing health services to all Victorians. The package should be seen as the first part of a whole of government approach to the health of rural communities, which will aid the recruitment and retention of doctors in country Victoria.
 
More doctors are needed. Currently over 40 per cent of country doctors were trained overseas. These doctors are needed and welcomed, but the state’s ability to attract more overseas trained doctors is limited. International medical graduates also need more support, not only to ensure good service delivery but also to promote training opportunities.
 
Ensuring medical staff in country Victoria is not only important for the health of country Victorians, but for the health of country Victoria.
 
Comment
 
The failure to invest in regional medical services is particularly disappointing.
 
Other states continue to provide greater incentives for rural practice than Victoria. As the government is relying on overseas trained doctors, we need to be competitive with other states to attract and retain doctors from both here and overseas.
 

Mental health reform

What AMA Victoria sought
 
AMA Victoria recommended that the Victorian Government commit to the first stages of a mental health revitalisation package — cost $176.5 million over four years.
 
The current review of the Mental Health Strategy, being conducted by the Minister for Mental Health, is expected to drive innovation and reform in the sector, promote a whole of government approach, and improve capacity. It is anticipated that the new strategy will drive innovation and reform by addressing the need for:
 
·         more acute psychiatric beds
·         extra prevention and recovery care services (PARCS) beds
·         a mental health workforce plan
·         continue improving facilities in emergency departments
·         a central registry for high dependency beds for mentally ill patients
·         improved mental health facilities for people in prisons
·         early intervention mental health services.
 
What the Government has delivered
 
$111 million over four years, including PARCS beds, a trial triage service (which should include the central registry) and early intervention services.
 
Implications
 
Children aged 3-12 are at risk of developing mental health issues that will affect their schooling, their career prospects and their family lives into the future. The economic costs to the community where a child fails to receive adequate intervention early are immense.
 
There are serious capacity problems for Victorian mental health services which will be need to be addressed through more beds, including acute care beds and prevention and recovery care (PARC) beds.
 
The recommended Budget funding for accident and emergency departments builds on past Budget announcements for specialised treatment rooms for patients exhibiting behavioural problems. Recent evaluations at St Vincent’s Hospital demonstrate the effectiveness of this intervention, and it should be expanded.
 
AMA Victoria notes that drought assistance through the support line to assist the mental health needs of rural Victorians is due to expire in June 2008. AMA Victoria recommends that this service be continued at least another twelve months. Even if the drought breaks soon, ongoing support will be necessary.
 
Comment
 
AMA Victoria is satisfied in the initial Budget investment in the new Mental Health Strategy. We will continue to work with the government on the new strategy, and expect that the new strategy (due at the end of the year) will be accompanied by a significant funding announcement.
 

Bariatric surgery in public hospitals

What AMA Victoria sought
 
$40.5m over three years for a trial of bariatric surgery in public hospitals. The trial would involve five hospitals being funded to provide two hundred operations each for a three year trial period. In the third year of the trial period, an evaluation of the economic effectiveness of the intervention should begin prior to committing to ongoing funding.
 
What the Government has delivered
 
Nothing.
 
Implications
 
Obesity is more prevalent in lower socio-economic groups, but only about 10 per cent of bariatric surgery is carried out in public hospitals. A significant proportion of the Victorian population who would most benefit from the treatment currently miss out. Funding bariatric surgery is an economically efficient decision for the community and will help promote equity of access to effective care.
 
Bariatric surgery is an appropriate intervention for some people experiencing the most advanced and persistent form of the disease, morbid obesity. It is considered appropriate for patients that have a BMI above 35kg/m2 (with co-morbidity) or above 40 kg/m2 (with or without co-morbidity) and have:
 
·          had many failed attempts at losing weight by alternative means;
 
·          commitment to a strict eating and exercise plan and follow-up; and
 
·          an acceptable operative risk.[6]
 
Bariatric surgery has been evaluated by the NHMRC[7], the UK National Institute for Clinical Excellence (NICE)[8] [9] and the US National Institutes of Health (NIH).[10] All three agencies have explicitly recommended that surgery be made available to selected morbidly obese patients. A surgical approach to obesity treatment is also supported by the Australian Safety and Efficacy Register of New Interventional Procedures — Surgical (ASERNIP-S)[11] and the Medical Services Advisory Committee (MSAC).[12]
 
Patients who have had bariatric surgery reportedly lose between 50 to 70 per cent of their excess weight and over 80 per cent of patientsso no further signs of diabetes, hypertension, hyperlipidaemia and obstructive sleep apnoea.[13]
 
Comment
 
The government’s work on preventive health care, such as the WorkHealth Initiative, is applauded, but there are significant gaps in treatment options.
 
Bariatric surgery is a proven intervention for a minority of morbidly obese people, and should be funded in line with best practice guidelines. Currently, it is a treatment only available to those who can pay, rather than those most in need.
 

Fluoride

What AMA Victoria sought
 
AMA Victoria recommends that the Victorian Government provide fluoridated water to every Victorian — cost $7.8 million over three years.
 
AMA Victoria supports the Government’s approach to improving fluoridation access to more Victorians, and recommends that the funding be made available to ensure that every Victorian has access to fluoridated water by 2010.
 
What the Government has delivered
 
$11.4 million over four years, including delivery of fluoridated water to 90 per cent of Victorians by 2011.
 
Implications
 
Dental caries are the second most costly diet-related disease in Australia, with an economic impact comparable with that of heart disease and diabetes.[14] In Victoria, approximately $1.5 billion was spent on dental services in 2004–05, representing 6.9 per cent of total health expenditure.[15]
 
In 2004-05 the Department of Human Services analysed hospital admissions in Victoria caused by dental ambulatory care sensitive conditions (ACSC). It was found that dental ACSC admissions had risen across the State since 1994 with dental caries or associated conditions accounting for more than 80 per cent of all dental ACSC admissions, and 95 per cent of ACSC admissions for 0–9-year-olds.[16] These admissions were treated with removal of teeth in more than 75 per cent of cases. These extractions could all have been prevented with earlier intervention.
 
There is a significant difference in ACSC admission rates between and within regions across Victoria. Access to fluoridated water was found to be a significant predictor of the difference. That is, dental ACSCs were found to be significantly higher in catchment areas with lower access to fluoridated water. The analysis demonstrated the value of providing fluoridated water supplies in reducing dental disease and subsequent need for treatment, especially for treatment in hospitals.
 
Following a recent systematic review of the safety and efficacy of different forms of fluoridation, the NHMRC concluded that:
 
Fluoridation of drinking water remains the most effective and socially equitable means of achieving community-wide exposure to the caries prevention effects of fluoride. It is recommended that water be fluoridated in the target range of 0.6 – 1.1 mg/L, depending on climate, to balance reduction of dental caries and occurrence of dental fluorosis.[17]
 
Comment
 
AMA Victoria is very pleased that the Government has made a commitment to fluoridated water for over 90 per cent of Victorians. This initiative will make a substantial difference to dental health.
 

Background
 
 The challenges facing our hospital system include:
  • A growing population and a shrinking number of hospital beds. Demand for public hospital services, both inpatient and emergency, has increased dramatically. The recent Ministerial Review of Victorian Public Health Medical Staff noted that, “a significant reduction in bed numbers and extremely high occupancy rates (sometimes in excess of 100%) … this causes considerable stress.” There are critical shortages in intensive care and high dependency units in particular.
  • Not enough doctors. Between 1996 and 2006, the Victorian population grew by 518,000 people, while the number of GPs increased by one. There are shortages in many other specialties right across the state.
  • Waiting lists growing. Despite the Government refusing to release the latest hospital performance figures (which were due in March), the last set of figures (for the first half of 2007) show that waiting lists are increasing.
  • Performance criteria that say it’s alright for one in five Victorians to receive clinically inappropriate care. The Government’s own performance measures show that the Government is happy for more than 250,000 Victorians each year to fail to receive clinically appropriate care.
  • Crumbling infrastructure. Decades of neglect have seen several major hospitals in urgent need of a revamp. Most importantly, we need a fund for the replacement of vital medical equipment and a huge increase in investment in hospital IT infrastructure.
  • Rural crises. Many regional areas are critically short of doctors, nurses and other health care professionals.
  • Unhappy doctors leaving the public hospital system. The Ministerial Review identified the threat of doctors withdrawing from the public sector in favour of the private sector as the “Reasons that attracted clinicians to public hospitals in the past are rapidly disappearing.”
 
Background – Dandenong Hospital
 
The Your Hospitals Report provides data on hospital performance and is available at: www.health.vic.gov.au/yourhospitals
 
For Dandenong Hospital, the report shows:
 
·         Total admissions have increased nine per cent, from 39,045 in 2005/06 to 42,730 in 2006/07.
 
·         Emergency department presentations have increased 6 per cent in this period; from 42,675 to 45,312.
 
·         The number of category three patients seen within 30 mins dropped from 94 to 88 per cent.
 
·         The number of patients admitted to a bed within eight hours dropped from 87 to 84 per cent.
 
·         Semi-urgent elective surgery patients admitted within 90 days dropped from 56 to 58 per cent.
 
Background – Bendigo Hospital
 
The Your Hospitals Report provides data on hospital performance and is available at: www.health.vic.gov.au/yourhospitals
 
For Bendigo Hospital, the report shows:
 
·         The number of emergency department presentations has risen 11 per cent from 2005/06 to 2006/07 (from 35,112 to 39,222).
 
·         Non-urgent elective surgery patients admitted within 90 days decreased from 92 to 87 per cent from 2005/06 to 2006/07.
 
·         Patient satisfaction dropped from 96 to 92 per cent in this period.
 
·         Total admissions have increased from 26,879 in 2005/06 to 27,587 in 2006/07.
[2] Available at www.aihw.gov.au, Hospital Statistics reports.
[3]Budget paper #3, p. 86
[4] From the Your Hospitals report, available at www.health.vic.gov.au/yourhospitals.
[6]American Heart Association, Science Advisory, November 1997.
[7] National Health and Medical Research Council. Clinical Practice Guidelines For The Management Of Overweight And Obesity In Adults. Canberra, September 2003.
[8] Clegg A, Sidhu MK, Colquitt J, et al., Clinical And Cost Effectiveness Of Surgery For People With Morbid Obesity, National Institute for Clinical Excellence, Southampton, 2001.
[9] NHS National Institute for Clinical Excellence, Guidance On The Use Of Surgery To Aid Weight Reduction For People With Morbid Obesity. Technology Appraisal Guidance No. 46. London: NICE, July 2002.
[10] US National Heart, Lung, and Blood Institute. Clinical Guidelines On The Identification, Evaluation, And Treatment Of Overweight And Obesity In Adults. Bethesda, MD: NHLBI, 1998.
[11] Chapman A, Game P, O’Brien P, et al, ‘Systematic review of laparoscopic adjustable gastric banding in the treatment of obesity: Update and re-appraisal’ Australian Safety and Efficacy Register of New Interventional Procedures — Surgical, Royal Australasian College of Surgeons, Adelaide, June 2002.
[12] Medical Services Advisory Committee, Australian Department of Health and Ageing, Laparoscopic Adjustable Gastric Banding for Morbid Obesity, MSAC reference 14. Assessment report. Canberra, 2003.
[13] Buchwald H, Avidor Y, Braunwald E, et al, ‘Bariatric surgery: a systematic review and meta-analysis,’ JAMA, 292, 2004: 1724-1737.
[14] Australian Health Ministers’ Advisory Council (AHMAC) Steering Committee for National Planning for Oral Health 2001, Oral health of Australians: National planning for oral health improvement: Final report, South Australian Department of Human Services.
[15] Australian Institute of Health and Welfare (AIHW) 2006, Health expenditure Australia 2004–05, Health and Welfare Expenditure Series no. 28. AIHW cat. no. HWE35, AIHW, Canberra.
[16] Source: Victorian Admitted Episodes Dataset
[17] Available at www.nhmrc.gov.au.