Transforming Health explained: Why the Government wants to overhaul SA’s health system, and what is planned
THE Government says Transforming Health will streamline and future-proof SA’s hospital system — critics say it’s a misguided plan driven by cost-cutting. We explain what is planned and why it’s so controversial.
HEALTH overhauls are nothing new — without them patients would still be housed in dormitory wards instead of single rooms with ensuites, as will be the case when the new Royal Adelaide Hospital finally opens.
Since Labor took office in South Australia in 2002 there have been multiple health reforms, notably the Generational Health Review.
None have generated the controversy of Transforming Health, announced in February 2015 with the slogan “Best Care. First Time. Every Time”.
It comes as the ballooning health bill threatens to overwhelm the State Budget. It now stands at more than 30 per cent of the Budget and is heading towards a projected 50 per cent of spending in about 15 years.
THE CATALYST
In the 2014 State Budget, the Government seized on federal cuts to SA health funding as the reason to freeze major hospital upgrades and overhaul the health system, although federal funding is actually rising — just not by as much as promised by the former federal Labor government.
Treasurer Tom Koutsantonis ended discounts on the Emergency Services Levy to cover $322 million of the $655 million in lost federal funding over four years.
The remaining $333 million was to come from health, with a stark warning — proved true — that a hospital may have to close.
Mr Koutsantonis’s Budget froze planned hospital upgrades at Flinders Medical Centre ($100 million), The Queen Elizabeth Hospital ($125 million), Noarlunga Hospital ($31.3 million) and Modbury Hospital ($27.8 million) as officials worked out what to cut, what to consolidate and what to close.
This became Transforming Health which — according to the Government but questioned by critics — aimed to make the system more efficient while also improving quality of care.
The resultant plan was criticised for lack of detail and short time for public comment. The plan noted that despite plenty of beds and staff, SA’s system has poorer outcomes and longer inpatient stays than some other jurisdictions, and patients’ results including survival varies from hospital to hospital and time of arrival.
Australian Institute of Health and Welfare data shows SA had on average 4876 available beds in 80 public hospitals in 2013-14. This equates to an average of 2.9 beds per 1000 population, easily the highest in the nation, and compared to the national average of 2.5 beds per 1000 population.
Health Minister Jack Snelling has indicated he would like to see the number of beds in SA being closer to the national average — which the Opposition says would see about 500 beds taken out of the system.
Health officials refuse to put a figure on how many hospital beds will be in the system as a result of Transforming Health, however losing about 100 from the southern area and 100 from the central area appear to be on the cards for starters.
Official say bed numbers will hinge on other changes to the system including improved models of care aiming to reduce length of stay in hospital, as well as better community support to keep people healthy and assist them on discharge.
The changes come as health care itself has changed dramatically — there is more day surgery, better equipment, drugs and techniques such as keyhole surgery, which have changed the nature of hospital care and even the need for thousands of beds.
Claims there are up to 500 unnecessary deaths per year in the SA health system were used to market the plan, but this has since been questioned by experts such as epidemiologist Professor David Ben-Tovim whose analysis concluded the data did not support the claim.
The plan noted SA has more hospitals per patients than comparable cities, and only 15 per cent of presentations at ED are genuine grade 1 or 2 emergencies. Discharge logjams also mean some patients stay in hospital up to three days longer than patients with the same condition, while others ready to leave but with no place to go risk deteriorating health and infections.
The State Government recruited three clinical groups who drew up 284 standards for the changes. However, a wide variety of clinician groups, including the SA Salaried Medical Officers Association and the Australian Medical Association, have criticised aspects of the plan.
THE PLAN
At its heart, Transforming Health aims to create a streamlined metropolitan hospital system. The flagship Royal Adelaide Hospital, Lyell McEwin Hospital and Flinders Medical Centre will form the north-south spine of major hospitals with the specialists, equipment and allied services available 24/7 for major trauma and life-threatening cases.
Resources including expertise for major emergency care will go to these “super EDs” rather than be thinly spread among more hospitals.
Modbury, Noarlunga and the QEH will retain 24/7 EDs — but handling non-life threatening and less complex cases. In Noarlunga’s case, ambulances will only take cases unlikely to be admitted, all others will go to FMC.
Ambulances with urgent cases will bypass these three hospitals. Their medical wards and capacity for complex surgery and cardiac care are being wound back, and they will instead focus on elective surgery, routine day surgery and rehabilitation care.
Some people will have to travel further for elective surgery, but the Government argues consolidating the best service available for a once-in-a-lifetime (in many cases) procedure with reduced risk of cancellation due to emergencies justifies the travel.
In 2013-14 more than 11,000 elective procedures were cancelled, of these 41 per cent were due to hospital-related issues such as clinicians and theatres being diverted for sudden emergencies.
The Repatriation General Hospital will close in December 2017, despite former premier Mike Rann’s pledge it would “never, ever be closed by a Labor Government”.
Efficiencies supposedly will mean less beds are needed and chronically crowded EDs will be freed up due to smoother patient flow.
Critics are sceptical, fearing the three “super EDs” will struggle to cope with the extra demand as the second tier hospital EDs are wound down.
As things stand hospitals such as FMC regularly have to cope with ambulance ramping — queuing in the carpark with patients because the ED is currently full beyond capacity.
However, SA Health data shows dividends are now flowing with overall reduced average waiting times at hospitals including the Lyell McEwin and Modbury, and also patients spending less time on average in hospitals such as the RAH and QEH.
The changes have already addressed two major issues identified as problems — lack of orthopedic services in the north, with Lyell McEwin now offering 24/7 emergency orthopedic work, and the variation in outcome for stroke patients. Acute stroke services are now consolidated at the RAH with specialists on hand 24/7, and specialists stroke services are available at Lyell McEwin and FMC daily from 8am-8pm.
The SA Ambulance Service will play a bigger role with the changes, bypassing second-tier hospitals as “EDs on wheels” when carrying major emergency cases. The service is getting 12 extra ambulances. While protocols now call for complex and life-threatening cases to be transferred to the super EDs, SA Health says there is latitude for doctors in hospitals such as Modbury to make unilateral decisions.
“Modbury Hospital is no longer an emergency surgery hospital, however as with all clinicians based at every hospital across South Australia, SA Health supports its clinicians taking immediate action to save a life or limb and stabilise a patient, in the rare situation that there is no alternative,” it says.
No decision has yet been made about a location for a major eye clinic originally planned for Modbury Hospital. Questions also remain about outpatient clinics, which may be consolidated at fewer sites.
THE FALLOUT
Protest letters have been written by concerned doctors from hospitals from Lyell McEwin in the north to Noarlunga in the south over aspects of the changes to EDs.
Modbury doctors are also deeply concerned about patient welfare, graphically shown by two recent cases reported by The Advertiser. In one case a man ready for surgery was instead transferred to Lyell McEwin under the new protocols and subsequently lost a testicle, although officials say the delay did not cause the outcome. In another a man who presented at Modbury with chest pain was transferred to Lyell McEwin then to Ashford where he eventually had a triple bypass.
Concerns by clinicians employed in the public hospital system is reflected in letters such as one from emergency department specialists at Lyell McEwin Hospital which states: “We note there is rhetoric being delivered (by SA Health) to promote these changes to staff and to the public, yet this rhetoric conflicts with the judgment of medical practitioners who are in a position to know the true likely outcomes”.
They warned of the dangers of their ED being overwhelmed, resulting in “potentially avoidable deaths”. Modbury Hospital doctors signed a similar letter saying winding down the hospital will “put patients at increased risk” as did ED doctors at Noarlunga before plans to turn that ED into a walk-in clinic bypassed by ambulances was overturned.
A letter from senior clinicians at QEH Hospital blames “dysfunctional management” for the “debacle” in the plan to shift facilities from Hampstead Rehabilitation Centre to the QEH. The plan is now being revised.
The Colleges of Surgeons, Physicians, and Emergency Medicine, and consumer groups such as Paraquad SA, are hostile to various aspects of Transforming Health.
Royal Australasian College of Surgeons regional manager Daniela Ciccarello wrote to The Advertiser noting Transforming Health “does not have surgeons’ support”.
While the college — and medical groups such as the Australian Medical Association — acknowledge the need for change, her letter noted with this plan the “devil is in the detail” but that detail is largely absent.
“With bed closures and downgrading of emergency departments imminent, we remain very concerned about the capacity of the system to safely care for surgical patients,” she wrote. “We have surveyed our fellowship and there are strong and clear indications of significant concern. There is no evidence to support the claims of the TH Team, who say 95 per cent of clinicians are in support of these controversial plans.
“Our findings suggest the opposite, and cite significant concerns with patient safety, patient access to surgical services and future teaching of surgical trainees.”
With plans for an undisclosed number of bed closures there are also significant industrial concerns about redundancies, workloads and staff being shifted to new locations.
Unions representing doctors, nurses and ambulance officers are bracing for fights over redundancies, rosters and resources.
THE COST
Under the Transforming Health plan, we will see a cut of $900 million from the Health budget over four years.
The Government has spent $30 million on two major consultancies, Deloitte and McKinsey, according to evidence given to Parliament’s health estimates committee. Documents obtained under Freedom of Information show another $3 million has been spent on public relations campaigns, promoting Transforming Health, while $56 million so far has been spent on the project team implementing Transforming Health.
Spending on hospitals includes $2.3 billion on the new RAH, FMC $185.5 million, Noarlunga $10 million, Modbury $32 million and $15 million on a veterans’ mental health precinct at Glenside.
The Government says $314 million has been spent on Lyell McEwin but this is since 2002, spending to incorporate Hampstead into the QEH was to be $22 million but is still being negotiated, while $16 million will go to the SA Ambulance Service with 12 extra ambulances, 72 new staff and new ambulance stations.
The Auditor-General says Tranforming Health is yet to deliver any cost savings but is projected to do so in the future.
THE FUTURE
The Opposition says Transforming Health is a cost-cutting exercise and has called for it to be put on hold until at least the new Royal Adelaide Hospital opens. The State Government says the reforms will create a more efficient system with better outcomes for patients. And regardless of the critics, the Transforming Health team led by SA Health acting chief executive Vickie Kaminski are determined the South Australian health system will be transformed.
Why hospital reform is a political landmine
In a case of history repeating, several of Transforming Health’s centrepiece reforms stem from Labor and Liberal reviews dating back to 1999.
Surging costs of running an extensive public hospital system, in particular, have spurred this long-running political aim to restructure services to save cash and put a greater focus on patient care. But they have been sunk by popular backlash at service cuts, fuelled by empire-building doctors and other health professionals reluctant to sacrifice longstanding fiefdoms at particular hospitals.
This has meant cost pressures rise amid ever-increasing demands for services. This was nailed by respected public and private sector veteran John Menadue in his 2003 Generational Health Review, commissioned by the new Labor government.
“It is clearly unsustainable for SA, with 12 per cent lower per capita incomes than the rest of Australia, to spend 4 per cent more on health with no discernibly better outcomes,” Mr Menadue said at the time.
He gained a striking impression of the implicit view in some quarters that SA had unlimited health dollars, imposing continual pressure and demands for better equipment, more drugs, more beds and more surgery.
“Even if the government doubled the numbers of hospital beds, they would quickly be filled, with further demands for new beds,” Mr Menadue said.
Similarly, a 1999 health review for the-then Liberal health minister Dean Brown involved providing specialist services at fewer hospitals but was thwarted by public protest.
But the rising cost is still unsustainable. Health was the biggest expense in the July State Budget, costing an estimated $5.81 billion in 2016-17.
An extra $527 million was budgeted to spend on the health system as patient numbers rise about 3 per cent and, Treasurer Tom Koutsantonis said, to offset federal cuts.
Continuing fierce public resistance to SA health reform was starkly demonstrated by a Galaxy/Sunday Mail poll published in late September, which showed almost two-thirds public opposition to the Transforming Health reforms.
The statewide poll of 869 voters revealed 64 per cent of respondents were opposed to the plan to cut back services at some hospitals and boost them at others. Even a majority of Labor supporters — 56 per cent — rejected the State Government plan.
At the time, Health Minister Jack Snelling declared all major reform was initially unpopular. “As the benefits of these reforms become increasingly evident, I’m confident public support will grow,” he said.
Opposition Leader Steven Marshall said health professionals opposed the cuts, while the Liberals particularly rejected Labor’s cuts to outer metropolitan hospitals and the Repat’s closure.
“It is time for Labor to put an end to their dangerous plans,” he said.
Particularly with the Repat’s closure, Mr Snelling has managed to avoid the firestorm of widespread and sustained community protest that accompanied previous proposals — even half-hearted — to shut the Daw Park facility.
Displaying a level of political adroitness, he has abandoned and overcome former premier Mike Rann’s iron-clad 2010 promise that: “The Repat Hospital will never ever be closed by a Labor Government.”
The centrepiece of Labor’s health reform is unstoppable — the $2.3 billion new Royal Adelaide Hospital, plans for which were first revealed in 2007. Even if uncertainty has plagued the opening date and this has blown out until next year at the 800-bed new hospital, it is clearly — and understandably — being positioned as the linchpin of the state’s health system.
This is clear from the official Transforming Health website, which declares the new RAH will be “one of the best modern hospitals in the world”. “We now need to design a health system that will match our world-class infrastructure,” the site says. Mr Snelling is, effectively, charged with bringing into reality plans drawn up in much earlier days of state Labor’s 14-year reign, particularly the SA Health Care Plan 2007-2016 developed by his predecessor, John Hill.
Its centrepiece was the new RAH — controversial plans were ditched to call it the “Marjorie Jackson-Nelson Hospital” for the-then beloved state governor. This would be the pre-eminent centre for major medical treatment.
The next rung down would be a “spine” of tertiary hospitals. There would be the Lyell McEwin in the north, the “Marj” in the city and Flinders in the south. Other hospitals, particularly the QEH, Modbury and Noarlunga, would focus on elective surgery, rehabilitation and the aged. The hospitals would all “relate” to larger ones in their regions.
Closing the QEH, the Repat and Modbury was discussed internally, particularly at Treasury’s behest, but did not go forward publicly. This was because closing a hospital would have caused bed capacity issues until the “Marj” opened.
Perhaps unremarkably, many of these principles were similar to the Liberal government’s 1999 review, which also suggested downgrading the QEH. This, along with the proposed Repat closure, became a lightning-rod issue and resulting public outrage torpedoed any change, making subsequent generations of politicians wary of health reform.
Mr Hill detailed the politics in his book, On Being a Minister, published in February. “While I accepted that our state’s health budget — like every other state health budget — was growing faster than our revenue base, I would never accept that the way to reduce costs was by reducing access for the sick. The only long-term effective strategy to reduce spending is through improving general community health, thereby reducing the need for hospitalisation. We also need to use existing resources more efficiently, for example by reducing duplication and by having senior doctors available at all times and not pay through the nose for them to come in after hours. ... All of these strategies were being pursued — none was politically easy or short-term and all required upfront additional expenditure; but the long-term benefits will be a healthier community and an affordable healthcare system.”
Labor view: Our reforms are already showing the benefits
By Health Minister Jack Snelling
There is nothing more gut-wrenching than seeing your child sick or injured. As a dad of six, I know that awful feeling all too well. All you want is to make them better.
Just two months ago, that was the case for me when, as he usually does, our 12-year-old Frank hit the soccer field for his weekly game. A few minutes into the match Frank took a pretty nasty fall. Unable to move his wrist and in a lot of pain, we knew he’d done some damage.
That helpless feeling kicked in as I bundled him into the car and headed for the Modbury Hospital emergency department. All I wanted was for him to be better. Frank was promptly seen by a brilliant nurse practitioner by the name of Stuart Smith and scans confirmed he had broken his wrist.
He was put in plaster and discharged only an hour after we had arrived at the ED. The increased role of nurse practitioners to treat patients like my son is just one example of how the way we deliver healthcare is constantly changing as we find better and more innovative ways to do things, and we make better use of our health workforce.
As we headed home, that earlier feeling of helplessness subsided. I realised that in our time of need, just like any good parent would do for their child, our public health system had stepped in. The experience also confirmed to me that by reforming our public health system and making it the best it can be, I was doing the right thing.
Transforming Health is doing just as the name suggests; it is literally transforming and modernising our public health system by taking the best proven clinical practices of modern medicine and implementing them here in South Australia.
As was the case with my son, South Australians are spending around 22 minutes less in metropolitan emergency departments compared to last year.
We’ve also seen huge improvements in other areas. Stroke patients are being treated quicker and recovering better than ever before. We’ve opened new ambulance stations and put on extra crews, we’ve almost completed a new rehab centre at Modbury Hospital, while expansion work is well underway at Flinders Medical Centre.
I want for every South Aussie what I want for my family, both now and in the future — and that’s to have access to the best public health care for many, many years to come.
Liberal view: Transforming Health is based on falsehoods
By Opposition health spokesman Stephen Wade
Transforming Health is built on a web of lies. The first lie is Labor’s claim that Transforming Health is a health improvement strategy — it isn’t, it is primarily a budget cuts plan. You don’t improve health services by closing hospitals, downgrading emergency departments and leaving our ambulance services overstretched.
The second lie is that the plan is “Transforming Health” — you can’t transform health with a plan focused on metropolitan public hospitals, but which ignores primary health, the regions, mental health and so much more.
The third lie is that the changes are supported by 95 per cent of health professionals. A recent AMA survey showed that more than 60 per cent of their members felt that Transforming Health undermined patient care. A growing wave of health professionals are publicly voicing their concerns.
The biggest lie was when the Weatherill Government promised to deliver world-class health care when all the while it was planning to dismember our hospitals.
Transforming Health is deforming health. Bureaucrats, rather than clinicians, are deciding which services will be provided to which patients. This is lunacy.
Eighteen months after the plan was announced there is real concern about both its impact so far and the lack of clarity on where displaced services will be provided in the future.
A Marshall Liberal Government will salvage what we can from Labor’s wrecking ball.
Positive change can only be achieved by working with the community and health professionals. This will be a hallmark of a Marshall Liberal Government.
We will end centralised control from SA Health’s head office. We will establish boards that bring together clinicians, the community and broad expertise to develop local solutions to local problems. Respect and honest engagement will unlock better care and support better health.