The future of community-centred health services in Australia: 'When too many beds are not enough'

Abstract

The authors welcome a constructive debate on the future of community-centred health services. Therefore, we have written this piece in response to an article published by Cunningham in the previous edition of the Australian Health Review (Cunningham, Australian Health Review 2012; 36: 121–124), which was a very limited analysis and misleading critique of our previous contribution to this journal (Rosen et al. Australian Health Review 2010; 34: 106–115). The focus here is necessarily brief and does not stand in for a detailed analysis of the evidence base. The aim instead, is to draw attention back to the broader political, economic and social dimensions of how the retreat from community health services has affected clinical care. We also outline a response to a longstanding assumption, or belief, that ‘too many hospital beds are not enough’ and may never be enough. How we understand the problem of resource allocation in healthcare shapes the remedies that are considered realistic. We explain that the reasons for the systematic underdevelopment of community health services are complex, historical, and largely relate to political and economic factors, but they are still amenable to change. What is known about the topic? There is a growing evidence base and consensus of expert opinion supporting the gradual shift in health service delivery away from hospital-based models of care to community-centred ones. Wherever possible, speciality community health services should be co-located with primary health care in communal shopping and transport hubs so that patients have access to ‘one-stop-shops’ providing both primary healthcare and community treatment, and support services. It is important that these speciality community health services retain their integrity and control of their budgets, but also that they maintain functional integration with their respective hospital-based services. What does this paper add? In response to a recently published vigorous but narrowly targeted critique of community-based models of care, we explore the wider context of the debate about the appropriate balance between hospital and community health services. We pay particular attention to the current debate in mental health services. What are the implications for practitioners? Clinicians need to understand the historical, political and economic factors that have influenced the underdevelopment of community-centred health services, so as to avoid unhelpful conflicts between specialists and those working in different care settings. Rear-guard attempts to restore the dominance of hospital-centric services are unsustainable in terms of ethics and economic reality. Policy-makers and health planners should instead aim to rebalance resources in the health sector so that people in all age groups and regions have equitable access to the full range of human health and support services across the continuum of care.