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Due to rising costs and neglect in forward planning, the financial position of Australian hospitals has never been worse.
THERE is plenty of discussion about the sad shape of the Australian public health system, but this quote is not from today. It appeared in 1955.
Management of the public health sector is difficult. It was difficult in 1955, and is even more difficult now.
Public health sector managers regularly deal with conflicting policy goals, increasing demand coupled with decreasing resources, a wide range of stakeholders with disparate interests, and a highly trained, largely independent and industrially sophisticated workforce.
Alarmingly, recent inquiries into health system failures have consistently pointed to a lack of management systems and processes, suggesting that our current approach to management development is not working. Studies focused on human resource management practices that would be considered basic in other industries, have found these to be severely lacking in health care.
The paucity of employer-supported education in public health care has negative implications for the performance and potential for improvement of the sector. Even the National Health and Hospital Reform Commission recommended “investing in management and leadership skills development and maintenance for managers and clinicians at all levels in the system”.
How did Australia come to the situation where a $95 billion industry essential to our health is characterised by unskilled managers and leaders?
There is a perception that effective management skills can be learned on the job. Competent clinicians are often “promoted” into management positions, often without management training.
It is estimated that there are more than 30 000 managers working in the health care system in Australia (in government departments, hospitals, community health services etc), but less than a quarter display the formal qualifications required for membership of professional associations of Australian health care managers (Australasian College of Health Service Managers and the Royal Australasian College of Medical Administrators).
We need more effective approaches to the development of management skills. Health professionals are required to hold evidence of competence, so why are managers not held to the same standard?
In 2007, the Victorian Health Services Management Innovation Council initiated a management development program using just-in-time action learning principles. The program aimed to enhance the capacity and confidence of the participants to implement change, and to deal with a range of situations using strategic thinking and problem-solving skills.
The program ran for 3 years with 137 participants from health services throughout Victoria. Action learning addresses real problems of importance to participants in real time through a quasi experimental approach that follows a cycle of “problem–diagnosis–action–review–learning–action”.
The evaluation of this program suggested that many public health sector managers felt inadequate, alone and unsupported. Following the program, the respondent participants reported that their work was more meaningful; they were more confident about their ability to do their job; they were more self-assured about their capabilities; and they had more opportunities to decide how to do their work. That is, they reported greater empowerment in their roles.
The ability of the program to strengthen empowerment was an important finding of the evaluation. If managers are not empowered, they are less likely to provide opportunities for their staff to participate in decision making.
The evaluation, which I coauthored, suggests that we can strengthen engagement of health professionals in organisational decision making — not by establishing more committees, commissions and bureaucratic solutions, but by simply ensuring that managers in this important, but complex, industry have the necessary skills.
Professor Sandra Leggat is professor of health services management and head of the School of Public Health and Human Biosciences at LaTrobe University, Melbourne.
Detailed references available on request to editor@mjainsight.com.au
Posted 23 January 2012
Many thanks for your comments. I wanted to respond to Dr De Leacy. Often management is accused of being an art, with no science. But here is an example of the science. Empowerment is not just a weasel word (although I have to agree that it sometimes gets used as such with little understanding of what it is and how to foster it). Empowerment is a well-defined and validated psychological construct that the evidence suggests we need to pay attention to.
In my experience, the problem is far worse than merely having untrained managers. As Dr Ieraci points out, while clinicians are subject to clinical governance there is no real administrative governance.
The result is that I’ve seen numerous instances of not just poor performance by administrators, but also, behaviour which breeches Codes of Conduct, and is probably illegal.
The Garling report (remember?) stated that bullying and harassment was rife in NSW. There is still no real avenue to bring administrators who are perpetrators to account.
Sandra Legget is correct. My research clearly shows that managers remain unsupported and the expectations on their role are immense. They are in many cases the ’empty signifier’ to be disposed of when another reform does not work, budgets are not met or some unwelcome publicity gets the front page. The role is complex and contested between the professions. For a sensible approach to health reform and about how management needs to work with clinicians go to the SHAPE Declaration, Asia Pacific Journal of Health Management 2008;3:2, p10-13 (http://www.shape.org.au/Declaration/Feature%20DBriggs.pdf). In respect to Dr De Leacy, bias is in the eye of the beholder. I have had more than 40 years health management experience, academic roles and national roles in health management. We are not biased just committed, like many health professionals to a better quality health system. Health management will not improve managers and services are subject to the direct control of the political bureaucratic structure. There should be clear separation of funder/provider roles and more locally scalable organisations subject to greater community and health professional governance.
The high ratio of administrators in the public hospitals relative to the private sector was documented back in the 1970s, So, little has changed. I’m not a supporter of getting yet another piece of paper so that you can be an administrator as I suspect it just means you will have been trained into bureaucratic processes. What we need is people who give priority to health care and cut through the statistical rubbish. Admittedly the limit of my administrative training in the public system was as a team leader in public psychiatry, then running a very successful private practice after I got sick of non-medical, trained administrators trying to tell me which antidepressant to prescribe.
I strongly agree with Professor Leggat. Having been in hospital practice for over 45 years and seen the recurrent rounds of centralisation and decentralisation, amalgamation and disaggregation, re-reorganisation, perverse financial incentives, strategic plans ad-nauseam, the uptake of the latest management schemes sold by management consultants, and frankly silly decisions made for a variety of reasons, often political or even for personal gain, but usually out of ignorance, I think it is no wonder that there is a call for better management.
The staff of the health system are, in general, intelligent, well or often highly educated, highly motivated and good at their jobs. Some are natural organisers and run their practices, wards departments and divisions well, but almost everyone would benefit from training, or better still, learning about management theory as well as practice.
This learning should extend beyond “health management” because many of the issues in health organisations are more about organisational behaviour than health specific and it is important to realise that there are many frameworks that are relevant to organisational management.
The prevailing management style in health is authoritarian and hierarchical and intimately linked to financial control and increasingly supported by disciplinary processes. However, there are a number of other management streams, including marketing, “human resource” management, operational management, process analysis and control, quality management, strategic and change management, which can be applied to very complex organisations, such as hospitals. Even more important is an understanding of the role of knowledge and culture and the differences between the specialised professional groups that work together in hospitals and similar organisations.
A knowledge of and experience in health is clearly important, but wider general knowledge, would better prepare managers for the very complex organisations they are employed to run.
The problem has two sides. Yes, I believe we need properly trained managers in the health system. However, even when you have properly qualified managers in a health system they have two competing forces acting on them: the clinicians who constantly talk about the need for more resources to care for the patients (after all they are the core business and we must not forget that) and the health department’s corporate office saying, bring the system in on budget or you’re out of a job. To whom do you think they are going to listen?
The public hospital system has somewhere in the region of 5 times the management/admin numbers per bed compared to the private system. Maybe before management tinkers with the clinical side they need to be certain it will work. After all the clinicians wouldn’t be allowed to initiate management protocols with absolutely no evidence they would work, so why should management be allowed to effectively do the same?
Now retired, I can muse back over health. I was made Dean of the wits university in Johannesburg as a result of an emergency.
I was immediately sent on an in-depth course for personnel and business stratergies.The course was tough but proved invaluable for the rest of my carreer which was largely in management. I know that my efficacy was greatly enhanced.
Note: it was a university not a health service that drove this
Along with greater management training and expertise, I would encourage much more formal training and research in clinical governance practice. Since the concept of clinical governance was formalised, and positions became available in straegic areas of public health management, it has become apparent that much of this practice is carried out by well-intentioned amateurs. If a complex and sophisticated system such as clinical medicine in public hospitals is to be governed, should the governance system be at least as sophisticated as the system it aims to regulate?
I do understand and essentially agree with what Professor Leggat says in her article. A fairly simple proposition really. The only points I want to make however, are: firstly a concern about bias in her disclosure at the end of her piece. More so since it follows Jane McCreadie’s earlier comments surrounding bias! I hardy imagine she would actually criticise her own report!
Also, I along with virtually every person on earth have issues with the repeated hyperbole and gibberish (weasel words) that passes as management speak eg ’empowerment, enhancing capacity and implementing change’ ad nauseum etc etc. Put all those meaningless ill-defined words together, throw them in air and you can end up with limitless ill defined sentences that are supposed to sound very important to the audience. Verbal valium. This jargon immediately switches off every halfway intelligent human and is purely design to inflate the ego and perceived power of the speaker and to make the very obvious things sound really really special.
Please return to plain English Professor and your credibility would go through the roof.