An Open Letter to the NSW Premier
Dear Mr Minns,
You recently cited that Monday 3rd August, 2026 was, “the biggest ever recorded winter’s day in history” for Sydney Emergency Departments (ED), with more than 10,000 presentations to hospitals in this city alone. However, instead of considering a sustainable and appropriate response that may reflect the root cause of this issue - the country's rapidly ageing population, the growing prevalence of chronic disease, the exponentially increasing cost-of-living crisis and subsequent inability of families to afford primary healthcare appointments, the ever-expanding void of general practitioners, the deteriorating mental health crisis, and most importantly, the physically dangerous and psychologically taxing working conditions of hospital workers - you simply advised the public to “avoid hospital” unless their life was in danger.
Fortunately, it is not the responsibility of the general population to recognise their imminent death. If every person had an understanding of how fragile and easily lost human life can be, I can assure you that the rates of anxiety, depression, alcohol misuse, substance abuse and general disarray would be more unmanageable than it already is. One of the many roles of the doctor within the ED is to draw on our knowledge of physiology and human disease (pathology) and apply it to the individual patient sitting / standing / screaming in front of us. Based on the suspected disease trajectory, as well as the patient’s medical history, clinical examination, blood and scan results, and most importantly, their ability to function within the community, we formulate a disposition: is this patient safe for discharge home, or do they warrant an admission to hospital? Sometimes, bringing a patient into hospital is not a direct reflection of their life teetering on the cusp of death, but rather, a necessary step for ensuring the safety of either themselves or the community.
Take, for example, an 89-year-old lady who until a recent fall, was managing just fine at home with the help of her daughter. Unfortunately, a trip in the garden resulted in a fractured right wrist, and with her daughter being overseas (as all people in their 50’s are entitled to be), the elderly lady is unable to cook, clean or shower for herself. Or a 48-year-old gentleman who until last year, was working full time for himself as a builder. An unexpected diagnosis of gastric cancer left him unable to work while he endured twelve months of surgery, radiation and chemotherapy. He has no active income and minimal financial security. He struggles to pay rent, let alone pay for GP appointments and medications that keep his cancer at bay. He presents to hospital in a state of general deterioration, with no single problem that will kill him overnight, but no way to thrive at home. Like the elderly lady, he too has been pushed to the periphery of society due to an inability to function in a way that society deems appropriate. The Emergency Department is where people like these patients present to be scooped off the floor from their lowest point and offered a glimmer of hope that their life may return to a point beyond simply existing.
As clinicians, our job is a nuanced as the people that we treat. Mostly, it is a vocation that is complex, varied and rewarding. However, as reflected in the weekly reports of physical violence, abuse and hospital lockdowns, Emergency Departments are not only becoming a challenging environment in which to work, but a physically dangerous one. To you, and others observing from a distance, a “busy day” is reflected by a certain percentage more of patients checking into hospital. To those of us who have access to the locked doors beyond the waiting room, any day - busy or not - would be enough to leave a member of the general public with post-traumatic stress disorder. It is not uncommon for security to be wrangling a drug-affected patient to the ground adjacent to a young post-operative patient haemorrhaging blood in the form of projectile vomit, spattering the resuscitation bay a shirz-coloured maroon. All while a confused geriatric patient wanders the corridor, barefoot, threatening to slip on a trail of stale urine dripping from a disinhibited patient that believed it appropriate to urinate outside the medication room. The Emergency Department is the convergence of society’s combined crises - on any given day, we simultaneously manage the mental health crisis, the drug crisis, the e-Bike crisis, the chronic disease crisis, the COVID crisis, the ageing population crisis - all at once, on days that never end. The result is more patient’s through the waiting room door, longer wait times in uncomfortable plastic chairs, growing frustration, and ultimately, patients that die in hospital before being reviewed by a doctor.
Of course, a one-dimensional solution is neither appropriate, nor will be effective, for addressing the issues that have disintegrated the “overrun public health system.” It is no longer good enough to flag that emergency departments are at breaking point. The Australian healthcare system broke years ago, fractured by the stress of the COVID-19 pandemic and fragmented further by the rebound increase in elective surgeries, staff burnout and influx of decompensated chronic disease. However, if there is one uniform solution that would offer the best chance at decompressing hospitals and the growing tension amongst staff, it would be this: invest in resources that prevent people from presenting to the Emergency Department when they do not have to. This is not the same as directing people to “stay away” from healthcare. It means funnelling money, human resources and education into services that aim to keep people well, thus allowing emergency resources to be reserved for those in an acute deterioration or disaster.
Such change requires a fundamental shift in the value placed on primary healthcare providers, reflected firstly in their remuneration, and secondly, by their availability to the community. The Medicare Benefits Scheme (MBS) - the “Bible” by which general practitioners (GPs) book and bill patients - does not reflect the exponential cost of living that GP - as practitioners, businesspeople and members of society - are privy to. $45 per 20 minute appointment (the current government rebate provided by the government for a Standard Consult) does not allow for much left over cash, considering this payment must be divvied between the clinician, clinic staff, the operation of the business, health insurances, clinic equipment and computer software. Consequently, most general practices have been forced to mixed billing at the bare minimum, shifting the cost to the patient.
Unfortunately, for many young people, working-class families, people with disabilities, Aboriginal and Torres Strait Islander people and pensioners, the money required to fill the gap payment (anywhere between $40 - $60 for a Standard Consult) simply does not fit into their weekly budget, often leaving the public health system (i.e. the Emergency Department) to shoulder the burden of acute-but-not-life-threatening issues, mental health deteriorations and inadequately managed chronic disease. The most obvious solution to combat this issue would be to embrace primary healthcare as a branch of the public health system, rather than as a privatised sector. This would require an overhaul of Australia’s healthcare system as it has been operating for the last 100+ years, which is highly unrealistic, to say the least. In the absence of such change, the rebates offered to GPs should be increased to reflect the current financial climate, with the aim of allowing more GPs to bulk bill, thus minimising the financial barrier that stands in the way of so many people accessing primary healthcare. What is more, doctors - particularly junior doctors - should be incentivised to explore and pursue General Practice training. The saying that “one cannot know what they do not see” stands true in the context of current hospital-based medical training, in which some doctors can progress through their entire medical degree and junior training without truly understanding the scope of the primary health practitioner. Many of those that are exposed are discouraged by the isolated work conditions, poor compensation and added stress of operating a business, leaving innumerable gaps in the jigsaw puzzle that is a healthcare system.
Finally, I strongly believe that the general population needs to be educated better regarding the basic principles of wellbeing, broad brush-strokes that seem to have been lost in the current climate of online influences and niche wellness trends. Instead of optimising, society needs to be reminded of the basics of health - daily movement, a varied diet, good social connections and minimal alcohol. There was, indeed a time in history in which breast cancer screening did not exist and tobacco smoking was endorsed by the government. Nowadays, both of these things are as foreign to young people as dial-up internet. Let this be a reminder that change is possible, and when led by industry experts and non-biased leaders, can be a positive movement for society.
The time for changing society’s perception of the role of the Emergency Department, and inadvertently, the inhumane burden of stress, disease, chaos and death on those working within them, was actually six years ago. I was hopefully at the time that the COVID-19 pandemic would be a catalyst for positive momentum. However, we are well past 2020 and the disarray that came with it. It is time for proper discussion, introspection and implementation of policies that reflect the financial and health status of Australia now. My colleagues and I are not asking for more money (although appropriate pay, leave and working hours is another discussion) - most of us would take improved working conditions over more money any day of the week. Ironically, for us in the public health sector, this does requirement investment into services beyond the hospital - GPs and urgent care clinics - so that next winter, instead of advising people to “stay away” we as a community can direct them to the most appropriate services that reflect the type of care they deserve.
Yours sincerely,
Dr Madeleine Brown
Emergency Department Registrar
