Fee or free?

Mark Ragg | August 22 2000 | Sydney Morning Herald (subscribe)

Who will better care for you - a public hospital or a private? The answer, writes Mark Ragg, seems to depend on what's wrong with you.

We all know public and private hospitals are different, don't we? Private ones have edible food, for a start, and carpets. Bigger rooms. Cleaner walls. Maybe a glass of wine with dinner.

Public ones are noisy and crowded. But you can trust them. They have the professors, the smart ones. They're good guys, doing research and stuff. And they're not out to get your money.

Still, private hospitals give you your choice of doctor, which means you get the best, as your choice must be right.

Until now, that's been our fairly limited view of things. But the first public analysis of data collected by the Australian Council on Healthcare Standards (ACHS), the industry body responsible for quality control in hospitals, suggests things are not as simple as they seem.

The ACHS has found that public and private hospitals manage emergencies and severe illness equally well, but differences emerge for less rushed matters.

With the Federal Government encouraging us to join private health insurance, and penalising many who don't, objective measures of the quality of care are timely.

But the measures are not always easy to comprehend. For example, people with strokes are treated very differently in public and private hospitals.

Public hospitals are more likely to use a CT scan which, the ACHS says, is not vital, but helps with planning. Perhaps that's to do with the attitudes of staff, perhaps with the fact that research projects on stroke, which would require CT scans, are usually done in the public sector.

But it's on discharge that things really vary. Public patients are three times as likely as private patients to move from hospital direct to a nursing home. Public patients are more likely to have in-hospital rehabilitation. And private patients are more likely to go home.

You might think that's because private hospitals care for less-ill people, which is the case in many areas of medicine. But the death rate of 16 per cent is the same in public and private.

Can wealthier people afford help at home? Do private hospitals run better community rehabilitation programs? Do public hospitals push people into nursing homes without enough thought? Maybe they are really sicker in public hospitals, but receive better care, bringing the death rate down to that in private hospitals with healthier people?

And look at the differences after anaesthetics. The report shows that people in public hospitals are less likely to have severe pain than those in private hospitals, and less likely to need prolonged stays in recovery the latter is a sure sign that something has gone wrong. Against that, there are fewer breathing problems after anaesthetic in the private system.

Anaesthetics are administered differently in the two systems. Public hospitals more freely use nurses and registrars, or trainee specialists, while private hospitals leave most of it to the specialist. You'd think that would result in better care in private, but what if having all that back-up, even of a less experienced nature, helped?

And you'd have to wonder whether the lower staffing levels in private hospitals make a difference. With more nurses in a public hospital, does that mean better observation of pain, and earlier moves to control it?

The figures don't show. They weren't designed to. The data comes from performance indicators developed by the ACHS in conjunction with the who's who of organised medicine. Specialist colleges of anaesthetics, emergency medicine, medical administrators, physicians, obstetricians and gynaecologists, ophthalmologists, pediatricians, psychiatrists, radiologists, rehabilitation specialists and surgeons all played their part, as well as the Australian Day Surgery Council. Performance indicator development was also funded initially by the Federal Government.

These performance indicators are used by hospitals to monitor their quality, and are given to the ACHS for collection of national data. The ACHS warns they are not perfect, and are still being refined. They aren't weighted for the age, gender or illness of patients.

In some areas, that's significant, because public hospitals tend to look after more older and sicker people than do private ones. So the finding that public hospitals have more people going to intensive care after theatre is not surprising sicker people are more likely to have problems after theatre than healthier ones.

Michael Roff, the executive director of the Australian Private Hospitals Association, thinks this lack of weighting makes the data "simplistic and perhaps even dangerous". These results don't show whether the performance of public or private hospitals is good, bad or indifferent, he says.

For example, the results of a cardiac surgeon at a large private hospital showed that his patients were more likely to die or suffer complications than those of his colleagues.

"There was pressure from the health funds, wondering whether they should keep paying for services offered by this surgeon," Roff says. "When people looked into it, they found it was due to the referral pattern. This man was thought of so highly that he got all the most difficult cases sent to him. That's why the figures came up as they did."

Bob Gibberd, the director of the Health Services Research Group at Newcastle University and a consultant to the ACHS and to the NSW and Federal governments on performance indicators, argues they are still valid.

"They really show where problems might lie within a part of the health system," he says. "They're a screening tool, and no screening tool is perfect. And in some cases, the differences between parts of the health system are so great that it doesn't matter that they're not adjusted. The differences are real."

Mark Cormack, national director of the Australian Healthcare Association, which represents public hospitals, believes they reflect reality to some extent, while not showing the reasons for that reality. The complementary roles of the two sectors account for many differences, he says.

Private hospitals manage the predominantly elective admissions they seek, while public hospitals have to manage the emergencies that come their way, which can comprise more than 50 per cent of all admissions.

Public hospitals also deal with more teaching and more research, while private hospitals can refine their business practices to suit the niche they wish to develop, he says.

There's some indisputably good news: the report confirms that in some areas Australia is up with world's best practice.

For example, about 70 per cent of people having a heart attack receive clot-dissolving treatment within an hour of arrival at an emergency department. This is consistent with international practice, says a former president of the Australasian College for Emergency Medicine, Dr Richard Ashby.

The number of unplanned readmissions to hospitals had declined from previous years as a result of improvements in practice, at a saving estimated to be "in the millions of dollars".

The death rate after bypass surgery of 2.5 per cent, a similar death rate after elective repair of an aortic aneurysm, and a bleeding rate of less than 1 per cent after tonsillectomy, all stand up well to international comparison, says Peter Woodruff, chairman of the clinical indicator working party of the Royal Australasian College of Surgeons.

However, Woodruff says there is room for improvement in some areas. In almost 20 per cent of children who have their appendix removed, the appendix was not inflamed. And malignant skin cancers were removed incompletely in about 10 per cent of cases.

There must also be concerns over findings that only 43 per cent of child-ren having their tonsils removed fit the criteria developed by the college of surgeons. These are areas in which, if the aim of performance indicators is fulfilled, surgeons will be looking for improvement.

How hospitals can lift their game

Hospitals don't collect all this information for fun; the aim is to improve the quality of their work.

As you would expect, the ACHS report shows some people undergoing operations have problems afterwards some have trouble breathing, or have severe pain, some get very cold, some recover very slowly and a few have a cardiac arrest.

The measures hospitals have taken to overcome such problems include:

using electric blankets on all pre-operative and post-operative beds to prevent hypothermia.
putting space blankets over all patients being transferred from the ward to the operating theatre (then sending used blankets to the city homeless).
replacing the air-conditioning system in the operating theatre.
developing protocols for pain management.
recalibrating faulty thermometers.
running an education program on epidural pain management.
increasing the use of PCA machines, in which patients control the amount of pain-killer they receive through a drip.
keeping intravenous fluids in a special warming cupboard.
funding research projects to deal with nausea and vomiting in the recovery room, the prevention of hypothermia and the management of pain after surgery.