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.