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HEALTH CARE administration claims to improve accessibility and quality of care delivered to the community. The composite roles of human resources and financial management, cost accounting, data collection and analysis, strategic planning and marketing, among others, aim to provide “top quality and highly effective patient care”.
However, administrators in our hospitals and clinics have also been accused by the media of being costly and bureaucratic. Australia’s federal Department of Health employs 4500 non-clinical staff at an average salary of $222 000 each, according to The Australian. Although 15% (in England) to 25% (in the US) of health care budgets in the advanced economies are consumed by health care administration, the Organisation of Economic Co-operation and Development contends this to be “wasteful, [making] no or minimal contribution to good health outcomes”. There is no link between higher administrative budgets, better quality care, life expectancy and other health indices (here and here).
In 2015–16, over 10% of Australia’s gross domestic product ($170.4 billion) was spent on health care, with a sizeable proportion funding administrative services.
Let me strongly state that I am not referring to frontline administrative staff who assist in registering patient details and facilitate non-clinical aspects of health care, allowing clinicians to free up precious time to look after patients better. Skilled administration assistants trained specifically to manage medical records requirements are crucial to the patient journey. Moreover, deploying medical scribes that record episodes of care in real time enhances efficiency of acute care and allows the doctor to clue in on subtle yet important nuances of a consultation without being distracted.
Dr John Graham, a senior Sydney physician, claims that “huge amounts of taxpayers’ money have been misallocated to pay for massive and unnecessary growth of the health bureaucracy”. Importantly, “fewer and fewer dollars out of ever-increasing hospital budgets reach the frontline,” potentially contributing to worsening care, hospital congestion and clinical staff shortage. The time is ripe, Dr Graham says, to reclaim the public hospitals’ “freedom from the clutches of the bureaucracies that have stifled them to the detriment of the health and welfare of the community”. Although some necessary administration lubricates the complex machinery of health care, Dr Graham contends that “current governance arrangements … are stacked against quality, efficiency and effective administration”.
The Director of the Centre for Independent Studies Dr Jeremy Sammut rails against the “army of clerks warehoused in the bureaucracy who ‘don’t do any work’”. When 20–40% of state health department employees occupy administrative or non-clinical roles, and with conflicting priorities, relationships with their clinical colleagues, namely the doctors and nurses doing battle at the health care coalface, are often strained. Is it any wonder that there is anecdotal evidence that overworked doctors and nurses have a dim view of those who manage them?
The inclusion of clinicians, more so if they have undergone management training, delivers improved and more efficient health care. It could go a long way towards healing the corroded trust that has made fractious the relationships between doctors and their non-medically trained managers.
It could also mean that new care pathways and medical equipment would be far less likely to be instituted without discussion. So much goes on without clinician involvement – apparently simple decisions about equipment and costs can be disruptive and potentially life-threatening. For me, a situation such as having to get used to a new pleural catheter on the hop when a previous set worked well could be something of the past. Situations such as this are not just annoying, but the new medical equipment’s unfamiliarity may pose risks, for example, to the patient with a large pneumothorax that needs urgent drainage.
Health administrators and clinicians face the mountainous challenge of reinstating the “responsible autonomy” around which clinicians regain empowerment and are permitted high levels of clinical autonomy underpinned by accountability. This pivotal shift may help to alleviate the high levels of mutual distrust – the “them and us” binary between clinicians and the managerial line to whom they report.
There is a long way to go to find a peace accord between clinical staff and their managers if we want to avoid the “close a bed, open an office” syndrome.
In the era of evidence-based medicine underpinned by proven health benefit, it is staggering that up to a quarter of health care budgets in advanced health systems are wasted in funding a health administration sector, when there is no evidence of it resulting in cost savings elsewhere nor any benefit in terms of patient mortality.
I’d argue that constraining bureaucracy will free up money for clinical care of patients and free doctors and nurses to do their jobs better, without the impeding oversight of those for whom we hold scant respect or attention. Turning back time and re-empowering local hospital boards with community representation, as with local schools managed within broad guidelines by interested community members, could be the critical first step back towards reinstituting non-centralised hospital management boards that better respond to the needs of patients within its catchment area. Aside from gaining community trust, it’ll certainly constrain burgeoning management and consultancy costs associated with the ineffectively wasteful behemoth-sized health services districts now found Australia-wide.
Dr Joseph Ting is an adjunct associate professor in the School of Public Health and Social Work at Queensland University of Technology in Brisbane.
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The disconnect must be abolished between clinicians and those non clinicians who make decisions affecting clinical practice. eg the change in catheter without consulting the user (doctor); It is not helpful to say that doctors must practice medicine only, because the non clinicians make decisions in isolation that affect patient care;
this means that they manage the doctors and patients and not the doctor managing the patient. Whreas they should be secondary to the patient’s needs;
Well said A.Prof Ting.
It seems to me that the next step in solving this insanity is defining exactly and specifically which jobs are lumped under the term “health administration”. Naturally, as stated, some admin jobs are indispensable- such as ward clerks, departmental secretaries, med record workers, and payment officers. However (as a hospital specialist witnessing the exclusion of the majority of medical experts from ‘executive’ decision making), one wonders about the exact role, remit and function of jobs such as ‘executive head of people and culture’ (to give one example). Seriously, what is added to the single goal of Healthcare – the relief of suffering of our fellow citizens in the face of illness and psychosocial distress – by this type of administrative role? Defining exactly what lies under the term “health administration” is key – to make discussions on this crucial topic less vague, and to hone in on specifically those roles which are truly superfluous to patient outcomes, rather than targeting essential people like our secretaries or ward clerks. People in any health system usually mean well and are not trying to harm patients, but when bed numbers per population have dropped over time, one does wonder increasingly strongly about the return of the ‘hospital board’. Finally, I ‘d agree with the comment above, re the endless stream of ‘instant delete’ memoranda emailed to clinical staff by the administrative sector – a staggering amount of crap on “strategic direction” and myriad pointless announcements streams into inboxes every day, rain or shine!
I think he means he wants doctors to be able to decide how they do things and what equipment they use in public hospitals just like they do in private practice. we buy for our 10 dr clinic what we want to use, and the three doctor owners/ partners also oversee the budget in consultation with 1 manager. we don’t have much trouble with unfamiliar changes to most things. Only seems the brands of dressings change with the purchasing decisions of the supplier. Surgical instruments, printers, other machines we buy what we want from where we want without anyone telling us we cant. Meanwhile our small rural public hospital next door no longer even has a suture kit so if an inpatient cuts themselves we cant sew up the wound in hospital! This in a hospital that decades ago used to have 16 instead of the current 15 beds, did midwifery and all sorts of trauma but now due to bureaucratic decisions cant even let us put a couple of stitches in! We no longer do iron infusions in the hospital because they wont stock ferinject which takes 1/2 hour in our surgery. they stock the older ferrum H which takes 4 hours and they try to insist the doctor not the nurse sits there for the first 1/2 hour! Just a couple of examples of the mad bureaucratic decisions from distant unaccountable bureaucrats who seem to go out of their way to make life difficult for us. I think they enjoy this sense of power over doctors. Is it envy?
Administrators don’t make the electricity and the hospital engineer or electrician (when there were such things) kept the backup generator going and dealt with any power supply problems. Yes a purchasing officer and paymaster are important but how many of them. The two anonymous admin people above should realize that there is the need for administrators but the main issue is that the system is overmanaged with superfluous and usually well intentioned people with little or no medical knowledge spending too much time creating bureaucratic BS that wastes all our time. Just look at some of the memoranda and notices that appear in hospital tea rooms or pigeon holes nowadays! The sad thing is the way so many administrators will not communicate with their medical underlings from whom they may learn something. The QA that the administrators get involved with is often meaningless stuff done with ACHS accreditation in mind which does not address the real quality issues which are much more complex and cannot be solved with paperwork but can be addressed by education (costly) and better facilities.
Dr Ting is spot on and his comments long overdue. Having worked at the tail end of an era when Hospitals were run by Senior Doctors and Senior Nurses I am in total agreement with Dr Ting because I have since seen it evolve as Dr Ting describes. There is nothing pejorative about using terms such as bureaucracy because it is the truth and those who object are in denial. The Hospital system can be run more efficiently, more effectively and more economically by Senior Doctors and Senior Nurses as they always were. As for the “gap in understanding between clinical and administrative staff”, the truth and reality of the matter is that the bureaucracy does not understand clinical medicine. Nor do they understand what is necessary for optimal patient care as Doctors and Nurses do. Unfortunately, the bureaucracy, having not gone through the ranks of training and exposure to patient care as Doctors and Nurses do, they are not on the same page as Doctors and Nurses. This, in itself explains the “gap in understanding”. If the bureaucracy were to be reined in as suggested by Dr Ting and run by Senior Doctors (and I would add Senior Nurses), the millions of dollars saved by slashing the cost of wages alone for the bureaucracy could be funnelled into the wages of nurses and necessary medical equipment needed for optimal patient care. For example, increasing the wages of nurses would for the first time in many years value their contribution to healthcare and they would come streaming back into a health system that they had abandoned because of the poor pay and working conditions they had endured. Furthermore, beds closed to fund an expanding bureaucracy can be reopened and staffed by these same nurses streaming in and also by the increasing numbers of new Australian graduates instead of their jobs going to foreign medical graduates. The reality is that in NSW at least, there have been no new hospitals in the last 40 years, and if some of these hospitals have expanded in size, it would not have been to the same degree as the bureaucracy. Dr Ting is spot on and has only scratched the surface of the problem of health care. His views need to be seriously considered.
I have got the impression over the past few years that Australians are falling over themselves to break new ground and discard old values which threatens the very fabric of our society.
How pleasing at last to hear a voice of reason which wants to cut off the parasitic growth of bureaucrats and return medicine to clinicians.
Just do it -Fire them all. Put the hospital doctors board in charge of the budget and only employ people who work such as nurses, doctors, essential clerical staff such as ward clerks, cleaners, security staff. etc.
You would see morale improve, costs drop like a stone and output go up.
It’s sad to see such misinformed comment. I assume Dr Ting wants to work in a system where the electricity runs out, there are no supplies and he doesn’t get paid. And that he’s happy to work in a system that is weak on quality assurance. The major problem I think we have with the Australian health care system is that it is undermanaged. It is neither acceptable nor ethical that only half of the patients with high blood pressure are treated properly. This is a quintessential management failure which would not be tolerated in other sectors. Doctors generally make poor managers, unless they are trained in this skill. Doctors should concentrate on what we do best, which is patient care.
Coincidentally the same material was covered just last week James Delingpole in The Spectator: “…(in) the NHS, only about half the 1.4 million employees are actually doctors or nurses. The rest – on their inflated salaries… are monitoring patients’ racial profiles, or organising diversity seminars, or devising targets – or devising clever ways to avoid being penalised for not reaching those targets…”
there has been an explosion in the numbers of health bureaucrats since I graduated in 1971, so that in the public hospital system in SA we have more administrators than doctors and nurses, and it is getting worse. Similar things have happened in the NHS in the UK. We now have hospital managers and multiple layers of bureaucracy determining medical and nursing practice. Doctors have progressively been excluded from decision making in the system. The horrendously expensive new Royal Adelaide Hospital was designed and built with minimal medical and nursing input and it is now not fit for purpose. Not sure how this can change–the bureaucracy is self perpetuating. At the same time health services for the uninsured public have gone backwards.
Dr Ting does little to close the gap in understanding between clinical and administrative staff, with pejorative use of terms like bureaucracy, quoting obviously incorrect average salary information and poor insight into what is done by health administration. I agree there is a lot of frustration and concern with the level of dysfunction, but I think this should spur us to work together in ways that enable all of us to achieve our goals. If clinicians can not acknowledge and recognising the valuable role administration plays in public health to secure funding (in competition with non-health ends) and to distribute funding (often inadequate) to the least worst result then we are unlikely to be moving forward anytime soon.