Art Nahill: Curing our overcrowded emergency wards

OPINION

There has been much written of late about the severe overcrowding experienced by Accident and Emergency departments around the country.

This is a chronic and relapsing problem that occasionally flares to the point where it makes headlines, but is indicative of a much deeper disease that, unless urgently and creatively addressed, may prove fatal to the New Zealand healthcare system.

As a practicing physician for nearly 30 years who has worked in both the primary and secondary health sectors in the US and New Zealand, I do not use such alarmist language lightly.

The New Zealand healthcare system is badly broken and no longer fit for purpose. It does not work for patients, particularly low-income Maori and Pasifika, who have difficulty accessing timely, high-quality, and equitable care.

It does not work for doctors or nurses who deal with chronic staff shortages and ever-increasing numbers of complex patients, contributing to unprecedented levels of stress and burnout.

And our system, pushed as it is, may collapse at some point under the weight of continued population growth, the increasing prevalence of diabetes, obesity and their attendant problems, or the next global pandemic.

Not unexpectedly, the most recent flare of emergency department overcrowding has led to pleas from many quarters for more health funding and the training and hiring of more doctors and nurses. While these measures will undoubtedly help for a time, they do not address the root problems of our current system and will therefore soon prove insufficient, as they have before.

What is needed instead is a radical re-imagining of both health and healthcare in New Zealand.

What is needed instead is a massive commitment to disease prevention rather than to disease treatment; to mitigating the environmental and social vectors of disease such as poverty, insecure housing, poor nutrition, addictions, and childhood trauma.

The writer George Orwell, no stranger to penury, once wrote that being poor “annihilates the future”. Psychological studies over many years suggest the condition of poverty impairs cognitive development and function, even among adults.

Impoverished individuals have altered perceptions of the future compared to those who are more financially secure, which may help explain higher rates of non-adherence to healthy lifestyle changes and medications, and non-attendance at doctor’s appointments.

Faced with cheap, tantalising but nutritionally toxic food choices, so ubiquitous in low-decile neighbourhoods, the alarming rates of obesity and diabetes also found there is not coincidental.

And is it not hard to understand why taking time off from work and paying to see a busy GP (who may or may not know you) for 15 minutes may be less desirable than going to an emergency department after work where everything, including any necessary blood work, X-rays, and specialist consultation, is free.

Pouring more resource into the upper tiers of the healthcare system without addressing the drivers of disease out in the community is foolhardy and will ultimately meet with failure.

Perhaps it is time to try new solutions – such as mitigating the paralysing effects of poverty through universal basic income which, in several instances where it has been tried, has been associated with better overall health measures.

Perhaps it is time to eliminate the business model of primary care and bring it under the umbrella of the public system.

Rather than trying to fill the chronic shortage of health providers in low-decile and rural areas with more GPs, perhaps it is time to train and employ armies of non-physician health workers (like China’s rural “barefoot doctors”) who live in the communities in which they work to provide basic health care and stewardship and bridge the gap between patient, GP and the hospital system.

Perhaps it is time to treat the proliferation of fast food, fizzy drinks and even alcohol as the urgent public health threats they are.

Perhaps it is time to establish a co-ordinated Plunket-like system for drop-in mental health services, addictions and family counselling.

Would such radical changes be expensive? I am not a health economist but would venture to guess that these measures could prove significantly less costly in the medium-to-long-term than tinkering around the edges of a system on the brink of implosion.

And because it would take more than one or two political and budgetary cycles to know if such changes were producing the desired effects, broad local and governmental support would be required as well as meticulous data collection and regular analysis.

Few countries in the world are better poised to implement the innovative changes needed to create a functional health system. We just need the creativity and collective courage to do so.

• Art Nahill is an Auckland physician, clinical educator, and writer.

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