Sometime around the 1930s there were all sorts of scientists working on deciphering equations to explain beta decay in radiation. I am not even going to pretend I understand this, it's not important for the story. What is important is that one of these scientists came up with a theory about why noone was able to come up with an equation that held up. He suggested that some kind of particle that was neutrally charged must exost and be influencing things. And he got laughed at. Dismissed. It wasn't until years later (sometime in the mid 1950s I think) that someone else discovered this particle and called it the Neutrino.
Oftentimes when we're in the midst of out problems we don't recognise the invisible forces that are holding us back from making progress. To do so requires us to have an overarching view of the big picture, remain somewhat detached from what is known and open to possibility, and make ourselves vulnerable as we risk looking foolish to others.
Over the 16ish years I've been practicing as a pharmacist, issues relating to transitions of care, preventable hospitalisations and poor adherence have persisted throughout. In spite of the significant level of investment that has been made into hospital pharmacy services and community based services such as the HMR and DMMR programs, the stats have remained persistently high. If this were a drug trial it wouldn't be looking all that promising. In their recent report, AIHW estimate that around 7% of hospital admissions were potentially preventable, accounting for around 10% of hospital bed days.
It's clearly not acceptable that there were 748,000 potentially preventable hospitalisations in 2017-18. I think this should be seen as an indictment of healthcare policy, not necessarily of the individual providers. Of course we need to improve and we need to strengthen the quality and safety of the community based care sector. But we need to achieve systemic improvements supported by effective policy. Short term policy and chopping and changing the structure of the primary care sector has failed us for too long.
One likely reaction to this sort of data is that we obviously need more resources and services in order to meet these needs. In the case of pharmacists, we need post discharge HMRs, pharmacists in GP practices, pharmacists in RACFs, more hospital pharmacists providing outreach, pharmacists anywhere anyone will pay for them. But I want to be somewhat controversial, zoom out, and take a different viewpoint. I don't believe the best way to fix a fragmented healthcare system is to throw even more people, services and referral pathways into the mix. We need to rethink the overall strategy. Maybe there's something else that's holding us back - the neutrino that we can't see.
I believe the neutrino relates to undervaluing generalist care providers. My firm belief is that we need to start investing in strategies that strengthen the community based workforce. Not through increased numbers, but by valuing and respecting the workforce that we already have and optimising their capability. For too long community based care providers have been considered the poor cousin of their hospital counterparts. The after thought for funding models. If we want to make improvements in things like preventable hospitalisations it needs to start with recognising that our health system will only ever be as strong as our community based sector. They deserve our respect. They deserve to be prioritised. They deserve financial investment.
For my entire career thus far we have been talking about the same issues and making limited improvements. Maybe there's something else going on here that's holding us back, and maybe that thing is a culture that doesn't value community based care and generalist providers. Maybe we need to stop putting culture change in the 'too hard basket' and start taking action to change it. Because it needs to change. I believe that improving the connection between acute and primary care providers is a good place to start.