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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