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CLINICIAN engagement in NSW Local Health Districts (LHDs) is “deficient”, “variable”, and falls short of expectations set out in a key inquiry more than 10 years ago, according to a new report.
A NSW Auditor General’s report into the governance of LHDs, released on 18 April 2019, found that the “quality and extent” of clinician engagement in LHD decision making had not fulfilled the expectations of devolution as set out in the 2008 Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals, led by Peter Garling, SC.
“Clinician engagement is, at best, variable across the health system,” the report stated. “We found that the deep and broad engagement anticipated by the Garling Inquiry, by government policy and reform on devolution, by model by-laws for LHDs, and by NSW Health Governance Standards, has not been achieved with any consistency.”
Among the report’s several recommendations to improve LHD governance, it was recommended that the Ministry of Health work with LHDs to identify and overcome barriers that are limiting appropriate engagement of clinicians in decision making in LHDs.
Dr Kean-Seng Lim, GP and president of the Australian Medical Association (NSW), said clinician engagement was one of the key factors in improving patient outcomes.
“There has been enormous international evidence that improving clinician engagement leads to better performance both for patients and the system as a whole,” Dr Lim told InSight+. “Equally, there’s quite good evidence that disengaged and disempowered clinicians don’t produce such good results.”
Dr Aniello Iannuzzi, a rural GP located in the Western NSW LHD, said there was a feeling among doctors that LHDs did not value doctors or prioritise involving doctors in policy and strategy.
“There are the perennial problems of timing of meetings, remuneration for attending meetings and whether the meetings … achieve anything,” he said.
“To convince doctors to get more involved we need to get assurances that we can influence policy, management and strategy. In rural areas these discussions need to also take into account recruitment and retention.”
Dr Iannuzzi – previously a committee member of the Western NSW LHD and now Network Director of the Hospital Skills Program for Western NSW and Far West LHDs – said the functioning of the LHD had a significant impact on rural practice.
“Many rural GPs have visiting rights, so we rely on the LHD to run the hospitals well. Therefore, all the policies, procedures, funding, staffing … have an impact on our patients and our work.
The LHD also funds and provides many of the allied health services; doctors rely on these regardless of whether they are visiting medical officers (VMOs),” he said.
The Auditor General’s report identified several barriers to achieving adequate clinician engagement in LHDs, including the relatively fewer number of medical staff in smaller LHDs making it difficult to convene councils, geographical barriers to clinicians attending these types of forum, difficulties in engaging part-time clinicians and VMOs, and clinicians’ time constraints.
The report noted that clinicians may also have “a natural aversion to engaging with administrators, whom they see as simply the ‘holders of the money’”, and clinicians could also become disillusioned if “no-one listens to them, discouraging further participation”.
Dr Lim said in addition to these structural and geographical barriers, there were more subtle hindrances to optimal clinician engagement.
“The first element of clinician engagement is having a sense of shared purpose and shared values. The second element is that clinicians need to feel valued and empowered to achieve these shared values and purpose,” Dr Lim said. “And the third element is that there needs to be a culture of openness and recognition of the value of each member of that organisation – and this requires a level of trust.”
Crucially, Dr Lim added, a “top-down, bottom-up” approach was needed in LHDs.
“Solutions cannot be imposed from the top only, solutions need to be brought from the bottom up,” he said. “The cultural shift to a top-down, bottom-up approach is a fundamental element in setting up the right framework to allow engagement to thrive.”
Dr Lim said NSW Health could look to international efforts to boost clinician engagement, particularly to the King’s Fund in the UK, which has done extensive work in this area.
Dr Iannuzzi also outlined several key requirements needed to improve the LHD model. These included more doctors on LHD boards (a minimum of one GP, one staff specialist and one VMO); longer VMO contracts to provide job security, particularly in rural areas; greater autonomy for LHD boards; and doctors being included on interview and performance review panels for all senior managers and local hospital managers.
A NSW Health spokesperson welcomed the Auditor General’s report and supported its recommendations.
“NSW Health recognises the importance of clinicians and all staff in delivering a successful patient-centred health service and has a number of initiatives already in place to ensure effective engagement with our clinical staff,” the spokesperson said, pointing to the People Matter Employee Survey and the Your Training and Wellbeing Matters Survey, which specifically targeted junior doctors.
The spokesperson added that in 2017 a Junior Doctor Support and Wellbeing forum was held to discuss the welfare and training of junior doctors within NSW Health. A key outcome of the forum was the JMO Wellbeing and Support Plan, they said.
“In addition, the NSW Ministry of Health in partnership with our [LHDs] and boards commenced work in 2018 on a dedicated project focusing on strengthening clinician engagement through reviewing current structures, considering new models of engagement and seeking feedback from clinicians and other stakeholders including the AMA and [Australian Salaried Medical Officers Foundation] on best practice to drive further improvements.”
The spokesperson said the NSW Government allocated $4.6 million annually to fund culture change plans for LHDs.
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….. and hence we Senior Nurse Clinicians are leaving the sector in droves. Ever increasing numbers of ‘us’ are moving into the role of Doula, whether that be with an End of Life Care or a Birthing focus. We are fortunate to be able to provide advocacy, support and guidance as well as care to those who need us sans bureaucratic BS involvement.
These generalist adminstrators are self-serving parasites whose only interests in participating in the health system is to line their own pockets and progress their own careers. These are the true bean-counters and dehumanisers who read a rule book rather than read a situation, and respond with dogma not common-sense. Plus their incomes are phemonenal for the limited skill sets they bring.
As a locum to small rural hospitals, after 25 years as a rural dr in central west NSW, I have observed a deterioration in level of patient care and very poor engagement between administrators and visiting VMOs at small rural hospitals, causing a disincentive for doctors to work at these hospitals.
Oh ! How I miss the times when we had a Matron & a Medical Superintendent running the Hospitals.
The ‘ Medical Superintendent ‘ used to be a Specialist Physician or a Specialist Surgeon or a Specialist Gynaecologist or a Specialist Anaesthetist, who was Actively working as a Clinician & would spend a few Hours a Day, working as the ‘ Medical Superintendent.’ Thie Medical Superintendent was well aware of the Clinical Needs of the Practicing Doctors .
The Matron was a practicing Senior Nurse – & was well aware of the Needs of the practicing Nurse.
Bring back those days & get rid of the CEOs & the General Managers, the Assistant General Manager, etc. etc. , who eat up a major Slice of the Health Budget & have no clue of the True Medical & the Nursing Needs.
DR. AHAD KHAN
I was a board member for 6 years and the amount of systemic anti-doctor views is frightening. If any other group were treated the way the medical profession is treated by LHD administrators there would be a significant backlash.
Although well-intentioned Garling has resulted in a worsening of clinician engagement. We have I think lost the leadership of our patients’ futures
Due to their high education levels and university access restrictions, doctors are generally smarter and more educated than most other people at any meeting. Their perspective is critical. Without the input of the doctors, clinical perspective is lost. Not all clinicians have a patient-centric clinical understanding; many doctors are challenged by this. And individual doctors don’t always share the same perspective, so around three different medical perspectives (preferably different specialties, genders, backgrounds) are needed.
However, many doctors are not good at explaining ‘why’ they have a particular perspective and why it should take priority above alternative options. Doctors must remember to explain why and how they want things to happen. Their ideas should be taken seriously.
Yet, there are many administrative and bureaucratic considerations that impede Doctors’ wishes which are often expensive to overcome (staffing, theatre availability, beds, travel, hours, parking, $$s and $$s and $$s). Compromise that does not sacrifice safety is an impossibly fine line.
In my view we should push forward for a legislation mandating only registered medical doctors to be the head of any health administration.
Sack all administrators stat!
The overwhelming majority of doctors have voted to ‘take back’ administration. Health administration is no big of a task than managing a complex socio clinical environment like ICU or even managing a single critically unwell patient.
Not being disrespectful to a genre of professions but to me it sounds ridiculous for people having next to nothing clinical experience to influence clinical decision making by virtue of some management experience or qualification. A masters in management or commerce or Ph.D or dietetics doesn’t give the right to exercise their influence (let alone affect) doctors who have immensely more educational experience, leadership skills and intellectual calibre by virtue of their years of training and the selection process. But hospital systems, private or public, think such a ‘limb’ as health management as necessary.
A simple sniff test of whether hospitals can run only with administrators or doctors will point to the non-necessity of administrators!
But such a limb as health management will be considered beneficial if and only if it establishes a symbiotic relationship with the core business drivers, the doctors. It the health management that survives on the back of doctors not vice versa! That message should strike the ignorant ceos and general manager et al like a lightning.
I don’t doubt for a second that doctors themselves cannot manage resources and monetary elements regardless of the size of the health ‘system’. The ‘system’ thinking has been too far. Time to bring it down and establish a doctors led health system.
I work in a major public hospital in Sydney where the Director of Clinical Governance is a dietician and the current Patient Safety Manager is also a dietician. I respect my allied health staff and our system cannot run without them, however how can they truly understand and address the major clinical issues and safety issues and solutions without a medical background. In the whole floor of the Executive Unit there is only one Doctor – the Director of Medical Services – who is a FRACMA – and not an active clinician.
Far West LHD (FWLHD) is an absolute nightmare – I believe the money will be better spent in reducing the size and scale and giving funds to community services and General Practice. Key FWLHD Board members were sacked by the Minister – but many of the ill practices continue and the new title holders are no better (it is a workplace culture issue). The former Medical Director of FWLHD was named in the Royal Commission into institutionalized sexual abuse – but administrators looked the other way and said we have replaced one man. I agree with lack of transparency, institutionalized workplace culture of deceit that is in practice. There is deliberate no local GP or hospital specialist representation in the FWLHD. VMO GP are expected to work honorary – perhaps a deliberate attempt to keep away community engagement. Yes – there should be a Royal Commission into the culture of nepotism and power corruption.
The article quite clearly uses the generic term ‘clinician’ which I presume means ALL health professionals offering clinical care?
Disengaged is an understatement in my view. Doctors in such LHDs are exploited, harassed and harmed by the administrators. The hue and cry of promoting rural and regional medical workforce, especially that of getting specialists to these LHDs, fails to take into account the turmoil such specialists and their families have to go through because of value lacking, money minded and corrupt LHD administration. Good clinical outcomes are vehemently opposed by these ignorant idiots. Because it exposes the low quality practitioners these administrators employ – people without Australian training or experience who will never complain and work as slaves. No I would not recommend any self respecting specialist, especially if you have a fellowship in Australia, to go and work in these systems. Particularly those who work in critical areas such as ICU, ED and Anaesthesia. One you will end up having a worse PTSD than those who serve in frontline combat positions! Two the thankless ignorant mob including General Managers, self styled unqualified bully directors and substance abusing nurses will affect you and your family with every possible disciplinary proceeding there is under the sun if they even have the slightest of inkling that you could be a whistle blower. Worse still they could physically harm you. Corruption to the core. A Royal commission is necessary to look into this mess.
The elephant in the room here is that there has been a power struggle between doctors and professional healthcare managers ever since the latter appeared on the hospital scene 40 or 50 years ago. The managers believed that they should be the top dogs, and they systematically set about reducing doctors to ‘healthcare providers’ or, worse still, ‘human resources’, with little or no real power. And notwithstanding Garling, they have no intention of letting us regain it. Is there any wonder doctors are ‘disengaged’?
For doctors to be involved at any level requires the feeling that what you have to say is valued. Doctors can supply many solutions to problems. But it is a waste of my time and energy to continue to be involved if nothing is taken on board or nothing changes.
Doctors time is also valuable and as such remuneration has to came into it.
I left my Position as a Director of Nepean Division of General Practice when there was the mooting of the formation of LHDs – it was called then appropriately as the Division of GENERAL PRACTICE, as GPs are the Lynchpin of Primary Health Care .
I could foresee this coming.
I agree 11% with John Graham’s Comments :
A return to every Public Hospital having its own hospital board on which all directors give their service pro bono is actually what is required if governments are to maximize the outcomes for health provision within hospitals. (Ref. “The Past is the Future for Public Hospitals” Centre for Independent Studies Policy Monograph #102, 2009)
DR. AHAD KHAN
speaking from the perspective of as GP in a small rural community near a regional hospital, I think an obvious reason for our disengagement from activities that encourage co-ordination/liason with the public system is the inherent difference in our funding models. i.e. that GP is based on fee-for-service, and the Public System is not. My experience of public system initiatives is that projects mangers are blind to this. GP is struggling to stay viable, so why spend extra unpaid hours filling in the gaps in the system?
So.. to all the public project managers/beurocrats…that while we all wish to work for the good of our patients, please acknowledge that GPs have a right to get paid for it – just like they do!
The situation is getting worse and worse. Most LHD administrators have never known a time when doctors were engaged or involved so they have no idea what we can contribute, this makes it hard to convince them that engagement by senior doctors is needed.
You are asking doctors to vote on the wrong question. The question should be “Do you agree that the Local Health District governance of Public Hospitals has been a failed experiment?”
A return to every Public Hospital having its own hospital board on which all directors give their service pro bono is actually what is required if governments are to maximize the outcomes for health provision within hospitals. (Ref. “The Past is the Future for Public Hospitals” Centre for Independent Studies Policy Monograph #102, 2009)