The growing burden of chronic disease is forcing hospitals to rethink their role, shifting from episodic treatment to prevention, home-based care and closer integration with primary care.
Modern hospitals have borrowed a lot from the battlefield. We can still see the remnants in terms like ‘triage’ and ‘ambulance’ – both derived from Napoleonic practices of military medicine.
And despite the many challenges facing acute hospitals, they still more or less excel at urgently assessing, stabilising and treating people, with scarce resources, and in order of priority.
But in the 21st century, hospitals are no longer fighting the right war.
Today, the health system is creaking under the strain of chronic conditions. A growing share of what fills our wards isn’t unexpected or emergent. It’s the patient with emphysema readmitted for the fourth time this year. The older woman whose kidney disease has quietly deteriorated because nobody was watching between appointments. The heart failure exacerbation that could have been caught a week earlier with a phone call or a connected device.
If you follow how we spend our health dollars, you would think that we believe in a very simple and linear (if not circular) path for people to navigate our health system, where what patients need is either clearly primary care (“see your GP”) or clearly hospital-level care (“go to the ED”). The reality is we have a growing number of patients with chronic conditions who need something in between, and who are lost in the fuzzy borders between two binary care settings which are funded, staffed and managed in fundamentally different ways.
Even more bafflingly, they still don’t share most of their meaningful clinical information with each other.
Prevention is everyone’s business
Set against these blurred boundaries, an implicit assumption has taken hold: that the role of primary care is in maintenance and prevention, and hospitals need only focus on the urgent repairs. But that’s a dangerous dichotomy. One that, in the long run, only perpetuates the cycle of discrete ‘admissions and discharges’ between two care settings, while patients get caught in the middle.
Hospitals sit at a unique and under-utilised vantage point to complement primary care in the tasks of prevention. They see what happens when prevention fails. They are the home of unique data, specialist expertise, clinical trials, capital equipment, and multidisciplinary workforces that position them to intervene earlier in complex care and to manage health outcomes at a population level. They also interact with patients at critical moments in time – before a surgery or after an important diagnosis – when readiness to make changes to modifiable risk factors can be heightened.
The question is whether hospitals are willing and able to re-organise around that opportunity.
Prevention as core hospital business means moving from episodic encounters to continuous and connected care. It means accepting that what happens in the weeks after discharge matters as much as what happened during the admission. It also means looking beyond clinical interventions – which in some studies is only estimated to contribute 20% to a person’s actual health outcomes – and towards the social determinants of health that are actually driving the burden of disease: housing, loneliness, food quality, poverty, health literacy. Hospitals cannot solve all of these alone, but they can screen for them, connect patients to the right supports, and design care models that account for their real lives and not merely their organ systems.
Four fundamental shifts that change the equation
If hospitals are serious about this, four strategic shifts are required.
First, move from silos to networks. No single hospital can deliver prevention alone. It requires genuine partnerships across primary care, community services, aged care, and mental health. Hospitals need to become hubs in a functioning system, rather than working as standalone institutions. This demands a willingness to share patient care, data, and accountability for outcomes with others in the system.
Second, move from activities to value. Fee-for-service models reward volume. A genuine shift towards prevention requires funding models that reward keeping people well. Value-based care (paying for outcomes per unit cost to deliver them) is a structural prerequisite for making prevention viable at scale and Australia is falling behind the progress being made in other OECD nations on payment innovation and measuring outcomes that actually matter to patients.
Third, move from hospital visits to home. For many people, particularly older Australians with complex care needs, hospitals should be seen as a care setting of last resort. Delivering care in the home, supported by hospital-grade clinical oversight, keeps people where they recover best while freeing capacity for those who urgently need an acute bed.
Fourth, move from sickness to wellness. Hospitals have always defined their purpose by the specific conditions they treat and literally get paid for doing so. The future demands they also define it by what they prevent: investing in risk stratification, proactive outreach, personalised advice, and early intervention pathways that stop deterioration much, much further upstream.
St Vincent’s approach: bringing care home
Across St Vincent’s network of public hospitals, private hospitals, and aged care facilities, we have set an ambitious target to provide more than half of our care outside of traditional settings by 2030. We have a steep hill to climb, but our growing ‘Care at Home’ models are already demonstrating that we can safely deliver many forms of care beyond the hospital walls.
In our new ‘Hearts at Home’ program, remote monitoring gives clinicians visibility over patients who would otherwise fall through the gaps between appointments and the ability to intervene when needed to prevent a hospital admission. St Vincent’s partnership with the Commonwealth Government to deliver the Medicare Mental Health Check In – a new national digital service offering support for people starting to experience mental health challenges – demonstrates that the clinical expertise of a tertiary precinct can be effectively democratised via digital tools, so that people can access high-quality and evidence-based care from their living room.
Similarly, our emerging models to support aged care facilities with hospital-based multidisciplinary geriatric medicine teams means more proactive and preventative care for older people. On the near horizon, wearable devices, connected sensors, and intelligent alerting systems will allow even earlier detection of risk and faster, more personalised responses.
A critical juncture
Australian hospitals face a choice. They can continue to face into the battle, continuously refining the pace and productivity with which they move patients from triage to inpatient wards to discharge. Or they can look outwards, see the system they sit within and the broader context driving patient and population health, and take a greater responsibility for making the whole thing work.
The demand for hospital care isn’t going to disappear. But with the right models and a genuine commitment to prevention, a good deal of it never needs to arrive at the front door.
Dr Rob Marshall is the Chief Strategy and Transformation Officer at St Vincent’s Health Australia and an Adjunct Professor of the UNSW International Centre for Future Health Systems.
HSD’s summit, The Great Prevention Pivot, is being held in Canberra today and tomorrow.