Abstract
It was the end of the academic year in 2020. On the third floor of the Southern Health University's administrative building, the five Vice-Chancellors of the Health Universities were gathering. Outside it was raining, but the patter of drops on the window only served to enhance the coziness of the meeting room. This annual event would take three days. The Vice-Chancellors enjoyed this meeting. They seldom saw each other during the busy academic year and under Professor Hope Brightview's 6 years of chairmanship they had been able to work well together to formulate a rational and profitable distribution of teaching, research and consultation services.
Following the tight fiscal policies of the late 1900s, the improvement in Asian economies and the euphoria following the Sydney Olympics, the Republic of Australia had ceased to be a global camp-follower. This new-found maturity and confidence had inspired politicians to look within the republic itself for creative answers to the social questions the old world had been unable to solve. At the turn of the century, an unusual combination of circumstances had forced a shift in policy direction. Now the eyes of the old world were firmly fixed upon what was being termed in health circles, ‘The Australian Model’.
As she waited for her colleagues to settle into their arm chairs with their steaming coffees and voice-activated laptops, Hope Brightview stretched out her feet, wiggled her ankles around and thought about her role in the formation of the model. She had been 40 and a practicing psychiatrist when, along with a number of her colleagues, she was invited to the Presidential Healthcare Summit of 2005. She remembered the era well; economic boom coupled with an apparent disintegration of whole sections of the community. Unemployment, family breakdown, drug-abuse and crime were soaring out of control. Hope and her colleagues could see society tearing itself down the middle; the educated and commercially experienced were able to take full advantage of the new wealth whilst the uneducated, and commercially or technologically disenfranchised sank deeper and deeper into the black hole of social deprivation. Then, a miracle. The second Australian President, herself a medical graduate, had remarkable social insight and the courage to steer her convictions through the mire of power politics. She was an ‘ideas person’, who had never practiced medicine, but had made her millions through the pharmaceutical industry before heading for a political career. She and Hope had liked each other instantly.
The 2005 Healthcare Summit stimulated a turnaround in State health policies. The over-representation of eminent psychiatrists at the summit was indicative of a new recognition by policy-makers that this specialty could play a critical and vital role in the reintegration of health care. The economically rational ‘healthcare network’ approach of the 90s, when hospital services were being redistributed from metropolitan areas to growth corridors, had performed its task and was no longer required.
Following the famous class action in 2002 when families of victims of a mass murder at a general hospital by a psychiatric patient successfully sued a healthcare network, there had been an urgent review of the way the mental health budget was managed. The case had revealed a culpable ignorance of the issues concerning safe running of mental health services and a fraudulent stripping of mental health budgets at network managerial level. The tabloids had screamed, ‘YOUR HOSPITAL RUN BY CAR YARD SALESMEN!!’ and other similar headlines. The ensuing community unrest, along with mass defection from mainstream medicine by people who could no longer afford or trust the system, focused leaders on the need to bring some well-informed, rational and clear-thinking minds into the debate.
Academics, long vilified for their ivory-tower mentality, were now poised in the perfect position of perceived neutrality. The universities had already wrestled with their own transformation into the three main groups; Universities of Humanities, Technology and Health. Critics of the change to superspecialisation had been mollified through the introduction of compulsory, two year ‘foundation courses’ which crossed faculty boundaries and gave students a good grounding in the history of civilisation, Australian history, and other elective subjects before embarking on their chosen academic or vocational path. As providers of all health care through government funding, the Health Universities were now required to have equal representation of mental health as well as general health specialties at all levels, from the teaching curriculum and research activities to management. At first the medical profession had balked until they understood that the majority of mental health services occurred outside the medical profession and the new university structure brought them into contact with their allied health colleagues at an academic level.
Somewhere, in the street below, an ambulance siren wailed, and Professor Brightview twitched out of her reverie. ‘Now all of you are settled, you'll see from the agenda that we have a lot of important issues too discuss over the next three days. I'd like you to indulge me as I begin with a review of our achievements over the past six years, as this will be my last meeting, and later you will need to elect a new chair’.
Moving to the virtual-video, Hope pressed the remote in her hand. A colouful 3-D graph of the state's suicide statistics from 1989 to 2019 fazed into view. The descending slope following a peak in 2007 was testimony to the state's ‘vertical neighborhood’ policy. This had been the brainchild of a small working group formed by the State Health Ministry following the 2005 Summit. The group had consisted of a prominent sociologist, a town planning expert, an anthropologist, an environmentalist, an educator, a primary health clinician and herself as psychiatrist. The task had been to come up with a plan to combat the rising burden of depression and suicide in the community. They were given generous resources and a year to come up with a report. They had been surprised but excited about the immediate rapport and agreement they had reached on so many issues. The common thread of their individual hypotheses was the alienation of segments of society through the ‘horizontal cohort’ structure of current communities. They agreed that the industrial century had forced societies to deconstruct tribal and family bonded units in favor of collections of people based on employment, financial status, education, health or age. When an individual no longer fitted the mould of their group, they had no sense of belonging. It was felt that lessons could be learnt from the preindustrial age and from more primitive contemporary societies where the old, young, fit, sick, clever, slow, rich and poor lived within the same small village: this they coined the ‘vertical-neighborhood’. Thus a shift from one status to another did not leave the individual isolated. Rather, the individual whose status had changed would be welcomed by individuals of the same ilk and valued by the whole neighborhood group which acknowledged responsibility for that person's well-being. The working-group's report had been accepted and the recommendations implemented. It was now a legal requirement for all new residential developments to contain a mix of dwellings, from humble low-rent housing to executive mansions, aged and community health facilities and child care centres. No new building permits were issued unless planners could show how their development could further the policy of vertical neighborhoods. Since the commercial tax laws had changed to encourage businesses to move their head offices to country areas, all new housing developments around the new massive growth areas were required to adhere to these stringent guidelines.
Hope pressed the remote again. The graph fazed out and now a map of the state appeared. It was scattered with bright yellow lights. ‘These are the rehab clinics as the Health Universities set them up in 2007. As you know, most of them closed six years ago and we are left with 10 major centres, four of them in the city’. She pressed the remote again and most of the little lights disappeared. It was a dramatic representation of what had been achieved in drug and alcohol care over the last 12 years. ‘Now’, she said, ‘In terms of the healthcare workforce, you will understand that as a psychiatrist, I am particularly interested in mental healthcare service provision, and you will see that since the abolition of private medical practice in 2010, the university-auspiced healthcare clinics have increased the availability of psychotherapeutic services through the amalgamation of trained therapists from all disciplines.’ A bar chart of psychotherapeutic sessions conducted in the clinics per year appeared at the end of the room. There was a murmur from the VCs and one of them asked whether the exponential rise in sessions meant that people were getting sicker. Hope explained that the health economics faculty researchers had demonstrated that the rise in sessions was associated with previously unmet needs, a shift to mainstream healthcare from ‘alternative therapies’, a lower incidence of clinical psychiatric disorder and cost-saving through a relative diminution of crisis care activities.
‘As you know’, Hope went on, ‘It was not easy to bring all the psychotherapists together into one service. In the olden days such a move would have split the profession. However, enlightened clinical teaching, and improvement in the status of psychiatry as a whole, gave the profession new confidence and an ability to adapt to change in a positive way.’
The professor stood up and paced in front of her colleagues. ‘Perhaps our greatest achievement’, she said thoughtfully, ‘has been in the area of hospital admission counseling. Since all patients and their carers are now involved in the pre-admission, in-patient stay and post-discharge counseling program, we have seen a dramatic fall in readmission rates, and in length of hospital stay; a classic case of having to spend money in the short term to save lives and money in the long term.’
Hope walked over to the window and looked down at the wet street. She turned back to her colleagues and a little sadly, she said, ‘There are two visiting delegations arriving in February, one from China and one from the US. Both are looking at instituting the Australian Model in a few key states although China is further advanced down that path. I'd be grateful if one or two of you could coordinate the visits.’ Returning to her chair, she picked up the piece of paper with the agenda printed on it. ‘And now, I think we should move on to the next agenda item: The Contract for the Provision of Cardio-Pulmonary Healthcare Services to Indonesia. Your turn I think, Michael?’