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Editorial
Research and the acute-care hospital of the future
A grand history of failed predictions is an argument for scientific prognostications
MJA 1999; 170: 292-293
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It is difficult to explain the history of healthcare systems, and the
interpretation of contemporaneous events is even more challenging.
The hardest enterprise, however, is that of futurist -- if it is to be
done well. It involves extrapolating past and present trends,
anticipating coming events and painting a cogent picture for
posterity.
Many people have failed miserably for various reasons.1-3 Lord Kelvin's claim in 1895 that "heavier than air flying machines are impossible" foundered on inadequate modelling. Technological change exposed the conjecture by the Chairman of IBM in 1948 that there was "a world market for about five computers". Arrogance probably led to the insouciant prophecy by the US Secretary of the Navy in 1941 that "[we are] not going to be caught napping". The recent prediction by the Australian Private Hospitals Association that the private health insurance rebate has the potential to "completely eliminate public hospital waiting lists"4 will no doubt be sorely tested. Hillman, in this issue of the Journal,5 combines the skills of historian, contemporary commentator and futurist to survey the acute-care hospital. He expresses views with which many would agree. The hospital sector has emerged in response to a wide range of policies and practices, many of which are no longer relevant. More recently, advances in practice and technology have been impressive, but the sector is exhibiting signs of systems failure,6,7 despite the skills and efforts of the individuals who work within it. Measures such as diagnosis-related groups (DRG) funding, involving clinicians in management, basing decisions on evidence and continuous improvement initiatives represent both a recognition of the problems and an indication that people with different perspectives on the healthcare sector, including policymakers, economists, clinicians and managers, are searching for solutions. Some recent trends seem destined to continue. These include further compression of length of stay, increased outsourcing and privatisation, renewed efforts to manage quality of care, and greater use of care options such as ambulatory care, day-only hospitalisation and home care.8,9 However, mere extrapolation is an insufficient basis for prediction given the many changes in clinical practice that could hardly have been anticipated. Further, in view of the lack of strategic vision of most Australian governments, there is no coherent framework for these trends. Moreover, the trends have been influenced by unfortunate constraints. For example, we have maintained the illogical splits in healthcare financing between the Commonwealth and the States despite 50 years of expert opinion that this system is counterproductive. It similarly makes no sense to separate private and public insurance. To allow privately insured patients to congregate in privately owned hospitals ensures there is little or no helpful competition across ownership types. Exactly how the healthcare delivery system will change is open to debate, which is one of the reasons Hillman's contribution is timely and useful. He paints a plausible picture that will no doubt stimulate valuable discussion and will be validated or invalidated over time. We would do well to heed four main points in the article. One is to consider how the idea of "hospitalist" -- essentially a specialist in acute-care and emergency medicine who releases other specialists from these activities -- would translate from the American to the Australian context. Second, the community health-hospital interface needs to be better integrated. Hillman envisages a more prominent role for general practitioners and community medicine, and the experience of the National Hospital Demonstration Program and the Coordinated Care Trials is of considerable value. Third, there will be challenges ahead for medical education in a more complex system.10 The fourth point is the emerging need for more research on the delivery system. The Health and Medical Research Strategic Review has shown that Australian research support is less than that of other Organization for Economic Cooperation and Development (OECD) countries ($28 per capita, compared with a GDP-weighted OECD average for developed countries of $42).11 There are thus grounds for increased expenditure on health and medical research, but health services research appears to be especially at risk. The Figure shows the most recent National Health and Medical Research Council (NHMRC) data comparing the relative success rate of grant applications by research field. The type of research that Hillman calls for is within the very field for which it is most difficult to secure NHMRC funding, the largest, and in some cases the only, source. Yet there are undoubtedly further gains to be made in delivery efficiency, structure and quality of care by enhancing health services' research efforts. We could head in several directions. At one extreme, there could be an intensification of what we have today -- more pressure to produce, more privatisation, more band-aid attempts to link fee-for-service general practitioners with public hospitals and home care services under strictly capped budgets, and more quarterly worrying about private health insurance, even with the 30% tax rebate. On the other hand, we could shoot for the social democrats' dream -- a single public insurer, all-encompassing area health services, multidisciplinary clinical teams as the prime contractors, increased preventive and community services with hospitals demoted to providers of intensive care beds, and so on. Health services research tools, such as critical historical incidents analysis, policy evaluation, scenario planning, computer modelling, decision analysis and risk assessment, can provide guidance to decision makers. They will help reduce the mistakes of the past, illuminate present problems and make future predictions more precise. Jeffrey Braithwaite Don Hindle
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