Whoever wins in New South Wales after 23 March is facing a gargantuan challenge in meeting the health services of Australia’s most populous state.

Despite spending $23bn on running the health system in 2018 and huge capital works programs at several of NSW’s biggest hospitals, the demand for emergency services is continuing to grow and governments are struggling to keep up.

The latest Bureau of Health Information numbers came out in the first week of March and went largely unremarked during a busy campaign where investment in infrastructure has grabbed the headlines. But the figures underscore the challenge: visits to emergency departments were at a new record, up 3.4% to 749,504 for the October to December 2018 quarter, compared with the same time last year.

This beat the record set in July to October of 2017 when a horror flu season saw emergency departments swamped.

The Australian Medical Association’s NSW president Dr Kean-Seng Lim, a GP, has sounded the alarm.

“We must act now to adequately resource both preventive health and clinical treatment,” he says. “Government must look for new solutions to old problems: how can we better utilise primary care to keep people out of hospitals? How can we incorporate technology to improve health outcomes?”

It’s not just the growing population, though that’s part of it. It’s also to do with ageing of the population, higher rates of obesity and related conditions, and a failure of people to seek primary-level care at their GP before their problems escalate.

Why people don’t access GPs can be sheeted home to the scarcity of bulk-billing doctors and growing gaps between Medicare rebates and the actual doctor charges, thanks to a five-year freeze on rebates by the federal government that is now slowly being unthawed.

That pushes people back into emergency departments, which are funded by state governments.

Tackling these trends in a systemic way would require unusual cooperation between federal and state governments.

One problem highlighted by the NSW AMA is the lack of integrated care in NSW. With the heaviest users of emergency services being the chronically ill, one way to make better use of resources is to ensure a GPs plays a central role in managing a chronically ill patient’s overall care. But such programs require shared funding by both the state and federal governments and that has not been forthcoming.

“Just as we can’t solve Sydney’s traffic problems purely by building more roads, we can’t solve health problems solely by building more hospitals.”

“We need to work on better integration of primary and hospital care, improve access to healthcare in the community,” said Lim.

And longer term, it would involve tackling other contentious issues aimed at prevention of chronic disease such as advertising of fast food, alcohol advertising, a tax on sugar, healthy canteen food in schools, provision of open space in cities, encouraging sport and exercise, more active transport options and better mental health services.

“One sad thing about the debate about health care is we don’t look at it from the patient’s perspective,” the Grattan Institute’s health expert, Stephen Duckett says.

Instead, the debate over healthcare during the NSW campaign has centred almost entirely on who can spend more on infrastructure and nursing numbers, he says.

Both sides promise big on health infrastructure, jobs

The Berejiklian government is running on its record, trumpeting at its campaign launch a “record hospital building boom” .

It has built the Northern Beaches hospital (more on that later) and it has announced significant redevelopments at some of Sydney’s busiest hospitals including $1bn at Nepean, $932m at Westmead Children’s hospital and $750m at Royal Prince Alfred.

NSW premier Gladys Berejiklian is given a tour of Liverpool hospital by Dr Rohan Rajaratnam. Photograph: Dean Lewins/AAP

On the weekend it added $1.3bn to redevelop the Bankstown-Lidcombe hospital, which services one of the fastest-growing regions, and $750m for John Hunter hospital in Newcastle. And it has been promising upgrades in regional hospitals too.

In total it says it will spend more than $8.4bn on health infrastructure across the state in the next four years. That program is part of its economic strategy to bring jobs and growth to the state, and to reinvest the proceeds of privatisation.

The Coalition has recently promised an additional 5,000 nurses, more than 1,000 doctors and 2,000 other health professionals, amid criticism that some of the busiest hospitals were suffering from inadequate staffing. But of course, the Coalition has been in government for eight years, raising the inevitable question of: why not sooner?

Labor has also been promising big on health.

NSW Labor leader Michael Daley (second from left) during a visit to the Women’s Health Centre in Penrith. Photograph: Dean Lewins/AAP

Labor has won the endorsement of the Nurses and Midwives’ Association for its competing plans to hire an extra 5,500 nurses and to legislate for mandated nurse-to-patient ratios in maternity and other wards. It also says it will deliver an extra 4,900 health and hospital workers including paramedics, allied health workers, security guards and cleaning and support staff.

“Currently in NSW, there are no minimum nurse-to-patient ratios in our EDs or children’s wards, with no mandated ratio for each shift,” the general secretary of the NSW Nurses and Midwives’ Association, Brett Holmes, said.

“We need a new, reliable shift-by-shift ratios system to provide a clear understanding of how many patients nurses have to care for,” Mr Holmes said.

“The strain that’s evident in our public hospitals has been taking a huge toll on nurses and midwives who do their best to deliver safe patient care at the bedside,” he said.

The Labor leader, Michael Daley has also been promising new hospitals and upgrades. He has committed to building another hospital in north-west Sydney, another high-growth area, promising $700m for a facility that will offer maternity and cancer treatment as well as an emergency department.

Ailing regional health

Daley has has also been focusing on the problems in regional hospitals, which have been wracked with scandals of poor standards of care, negligent doctors, allegations of racism towards Indigenous patients, lack of nursing staff and repeated delays to promised upgrades.

Labor has promised that regional hospitals, including Tumut, Bowral, Manning, Taree, Goulburn, Bega and Shoalhaven hospitals will be upgraded if it wins office.

In its pre-election submission, the AMA made a point of highlighting the much poorer health outcomes in regional NSW.

It is warning of a real crisis in access to specialised medical care in the regions and calling for a comprehensive plan to ensure services are accessible and historical inequities are addressed.

Just building new facilities will not address the problem, they say, because the problem is much more complex.

It’s not just a shortage of specialists in the regions, though this remains a problem. Problems exist for public patients in accessing specialists in places like Wagga Wagga, where the doctors are swamped with their private patients. Rural patients also report long waiting lists to see specialists in other centres, which are coupled with the costs of travelling.

The NSW Nurses and Midwives’ Association says that the nursing crisis is more acute in rural hospitals.

“Many regional hospitals continue to experience a higher volume of patients, yet under the current staffing model those patients receive less nursing hours compared to their city counterparts. It is unacceptable patients are disadvantaged simply for living outside of the city,” says Holmes.

A kangaroo drinks from a hose outside Wilcannia hospital. Labor has promised to upgrade regional hospitals if it wins the NSW election. Photograph: Jenny Evans/Getty Images

The Coalition also have numerous upgrades of regional hospitals on the drawing board, but whether the country voters have run out of patience after eight years will be tested on 23 March.

The surprising win of independent Dr Joe McGirr, who wrested the seat of Wagga Wagga from the Coalition in a byelection in 2018, shows that health services are a potential vote shifter in the bush and there could be some more surprises in rural seats.

Privatisation

The other issue that could cost the Coalition is the Northern Beaches hospital, a public-private partnership, opened in October last year.

While there are no marginal seats in that area, the public-private partnerships experiment has been one of the less glorious achievements of the Berejiklian government. The 480-bed hospital was built by the government for $660m but will be operated by a consortium, led by private hospital operator Healthscope under a $2.2bn 20-year contract.

Within days of opening, clinicians were up in arms about the lack of basic supplies such as bandages, rostering and other organisational failings. The chief executive resigned and the government hastily promised that the hospital would be put back on track.

The Bureau of Health Information data released on 6 March did not include data on timeliness of care provided in the emergency department of Northern Beaches hospital “because of challenges experienced in the implementation of a new information system”.

The nurses union and Labor say it’s the public-private model that’s at fault. They argue that the private operator, Healthscope has an incentive to funnel patient into the private hospital, while cutting costs in the public hospital and funnelling more difficult cases off to other publicly owned hospitals.

While it is probably too early to declare the experiment an all-out failure, the problems will likely mean that the public will be sceptical about privatisation in the future.

Another potential uncertainty is the takeover battle for Healthscope which has seen two rival private equity firms go head to head for control of the listed hospital operator.

The Canadian private equity firm, Brookfield appears to be the frontrunner, but it could mean even less information is available publicly about the operation of the public hospital. Business commentator Michael West has also raised concerns about Brookfield’s corporate structure utilising tax havens and what that will mean for tax paid in Australia.

In 2004, the Carr government bought back Port Macquarie hospital for $35m, after a failed experiment by Nick Greiner’s Liberal government with privately owned hospitals. It was an expensive exercise.

Labor has stopped short of saying it will buy out the private operator of Northern Beaches hospital and is instead promising to install an independent monitor, backed by professional medical staff to ensure proper levels of patient care for public patients.

The problems of this project may well make it much harder for the Coalition, if it is returned, to pursue this type of funding model in health or other areas of service provision in the future.

Open space

In terms of addressing the AMA’s plea for a more holistic approach that focuses on preventative and primary healthcare, neither party has identified a comprehensive strategy.

That would undoubtedly require taking on the federal government over Medicare but also requires putting funds into less sexy services, such as co-located GP clinics at hospitals and programs that address chronic health issues.

The ALP has promised a campaign to encourage children to opt for “active transport” to school, while the Coalition is promising a minister for open spaces and $150m to create more parks.

Premier Gladys Berejiklian has said she wants to reduce overweight and obesity rates of children by five percentage points by 2025 through her Active Kids program and by driving healthy choices in school canteens, but the progress has been patchy so far.

There will no doubt be more announcements during the campaign. But without a coherent strategy, NSW seems destined to spend more of its budget on health every year.