The system is breaking.

I'm angry. Not the sort of anger that leads to lashing out and breaking glasses. Not the sort of angry that leads to road rage and speeding fines. I'm the sort of angry that makes me want to do something. Our system is crumbling while we try mercilessly to hold it together. Our nurses and security colleagues face daily abuse from patients and families. Our emergency departments are overflowing. Our hospitals are in constant bed block. A few weeks ago, every intensive care bed in my entire district was full, and at least five patients in my hospital were on the waiting list for a bed. This is not an isolated event. Hospitals are not meant to be in crisis mode when it is still summer. And yet the grapevine is full of stories of the same troubles across the state.

Driving to work the other morning, it took a solid fifteen minutes to make a right turn. Everyone else commuting had the same disastrously delayed travel times. There was no car accident along our route to block the path; the system is so overloaded that one crash anywhere causes overflow everywhere else. Chronic underinvestment in infrastructure has lead us to this point.

Our friends across the waters in the NHS (National Health Service, for those not in the loop) have been facing similar challenges for years. Reading "This is Going to Hurt" by Adam Kay last week, I was struck not by the heaviness of his experiences (heavy though they were) but the familiarity of his medical life. Certainly, he experienced challenges greater that I have done. But the sense of the creep is real. It is not impossible to imagine our own healthcare system being as burdened as theirs. In the same vein, the recent news around our colleague Dr Kadota quitting her surgical career, something at which she was very skilled, surprised many of us because it was a familiar life. Are those hours intense, we mused? Certainly that many days on call is unusual, but that many hours at work is not. Have we, by familiarity and because when we look around it is a reflection of the same, become desensitised to our own working conditions?

But this isn't even about us. We work on because we don't really know another way. We work on because we care about our patients. And the problem is that we see over and over again how the system fails our patients. Let me tell you a story of an imaginary patient, who is both all of my patients and none of them at all.

Imagine the lovely Martha, 84 years young, still living at home but slowly requiring more assistance from her children. Three of them, now in their late fifties and early sixties, still live in the neighbourhood. They help out where they can, mowing the lawn and taking Mum shopping. Martha still gets the bus to her favourite socials - dancing at the RSL and bridge with some (dwindling in number) friends a few suburbs away. She volunteers at the school down the road, helping children learn how to read, though she's not sure how much longer she'll be able to do this anymore. The kids are so much work.

When Martha turns up to the Emergency department in her night gown at 3am, the staff there know nothing about who she is in the outside world. All they see is an incoherent woman crying out in agony. They put in lines and take her blood pressure and change her into a hospital gown. They take blood tests and give fluids. Her temperature is sky high and her urine is suggestive of an infection. Because she's confused, the Emergency staff do a CT scan to see what's going on and (because I'm telling this story) they find a stone blocking the path between her kidney and her bladder (in a tube we call the ureter). She gets antibiotics and more fluids, and because her blood pressure is less-than-reassuring, some medication to help the blood pressure stay where it should be. And when she's looking a little better, she's whisked away for surgery to bypass the stone with a little plastic tube we call a stent.

This part of the story mostly goes to plan. That's not always the case, particularly after-hours when competition for theatre time can be intense. Not in the sense of one team wanting to "win" against another, more in the sense that there are sometimes more patients needing available resources that then resources can stretch to supply. In this case, there is a sick lady and she gets exactly the care she needs. It mightn't be pretty - very few people like being hooked up to machines or having multiple drips put in their arms. And maybe, in the stress to make sure Martha is alright, we forget to call her family to update them. But the acute problem is seen and treated, and with every hope we will get this lady back to her dance club in a short while.

The problem is what happens next. In this particular scenario, the problem (the stone) is not actually fixed. The kidney is draining, yes, but the stent is only an interim solution. What Martha needs is another procedure, with its own set of risks, to happen to get rid of the stone. This involves going on a waiting list for elective surgery. In most hospitals in my state, the wait for this definitive procedure is three months. That would be fine if the stent was trouble free, but many people have severe pain from these life-saving pieces of plastic. Many people come to Emergency not once, but multiple times, with complaints from them. More attend their GP. Many are started unnecessarily on antibiotics for presumed urinary tract infections, because the dipstick results can be misleading. Younger people take days off work; some end up losing their jobs as a result. Older people often need more help around the house or no longer can care for their grandkids. And, because the system is overloaded, a "three-month wait" is often longer. This is an example; every specialty will have their own similar story.

The time comes around for Martha's definitive procedure, but her letter got lost in the mail and she doesn't attend. It doesn't seem to matter that she didn't know, and she gets put to the back of the list. Meanwhile, the time on the operating list is wasted - another patient could have used that slot and Martha needs to be added in at another time. Additionally, the longer it takes to get the operation done, the longer the procedure time, adding again to burden on the system.

Martha's paid her taxes all her life. She's never had a speeding fine. She's done all the right things, but when it comes to the system needing to help her out, she falls through the holes in the Swiss cheese. But, if, even at 84, she had kept up her private health insurance, she might have been able to have her stone sorted out days to weeks after her admission in hospital.

The private sector has provided an "out" for patients who either have insurance, or can pony up the upfront cash, for their procedures. For the individual, this is great. Get the problem sorted and go back to normal life quicker. Given the already-stretched resources in the public sector, the private can pick up "slack". Because the private system tends to run as a business, there is often less wastage - of time and resources - and also stricter pressure on beds. But the private system drains resources from the public - professionals who get paid more or get offered better working conditions at the private are wont to move. The private system takes publicly trained staff - doctors and nurses all go through training largely based in the public system - with little to no contribution to training. And where, in the public, we will try our best to sort out problems for our patients, at least anecdotally this is not always the case in the private. While money matters at an executive level in the public, on the ground we mostly consider patient care. In the private, everyone is aware of limitations based on funding. Where care in the public is based around specific protocols and guidelines, the private system often employs individual's preferred practices. This is not a dig at people who work in the private sector - we need their services as much as we need every other aspect of healthcare. It's just terribly frustrating that the "have-nots" who are dependent on the public system are so often let down by its complexities and inefficiencies.

Martha, and every patient like her, waits a terribly, terrifically long time for a procedure we know she needs. Should she be admitted to hospital with another concern in the mean time (perhaps a fall from starting a new blood pressure medication), the left-hand of the hospital often fails to talk to the right hand, and when she doesn't turn up to day surgery for her peri-operative work up because she's on the ward, there's chaos trying to make sure she can still have her surgery. No matter how hard we all work to take care of our patients, no matter the training we do to hone our skills, no matter the phone calls or paperwork, the system still manages to let people down.

I spend so much time saying sorry. Sorry you got cancelled from the list. Sorry you've been fasting all day. Sorry I don't have your results yet. Sorry you have to wait so long for your procedure. Sorry I can't do anything to speed it up. And I am sorry. But I wish I could do something to help.

Our health system needs more money. It needs more beds. It needs more people on the ground who can help our brothers and sisters and mums and dads to get their health sorted. And if we weren't all so burdened with long hours and beating our heads against brick walls, we could do more to comfort our patients and call their relatives. 


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