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THE recent Four Corners exposé of the failings of rural and regional hospitals was confronting. Just like many recent stories about the drought, the program jolted urban people about the desperate state of affairs in rural towns, while for rural residents it created hope that those with power and influence may see fit to take action.
We do not seek to review the cases presented by Four Corners but rather distill what we see to be the signs of regional and rural hospitals under great strain. The program provided a reminder of the adverse outcomes resulting from this strain; it is consistent with our long experience in rural hospitals and the public health system at large.
Bed blocks cause pressure in the entire hospital system, not only the emergency departments. The blocks also affect movements to and from the operating theatres, to and from the wards and from community to hospital. In rural settings, bed blocks not only result in sick patients on corridor trolleys and chairs, they also cause patients to pile up in smaller hospitals, unequipped and unstaffed to handle very sick patients, as they wait for transfer to larger hospitals.
Stress from juggling excessive demand translates into clinician burnout, inability to maintain professional excellence, apathy and, eventually, indifference.
When morbidity and mortality audits indicate the system is failing, a culture of suppressing evidence instead of constructively addressing challenges using clinical governance only compounds patient and staff risk.
When the system is struggling to properly care for patients, it might be reasonable to ask whether that same system has the resources to train and supervise its students. While we see the benefits of an immersional approach to clinical placements for students, we strongly object to them being used as cheap labour solutions in understaffed departments.
The need for accurate, contemporaneous documentation is not disputed. However, the paperwork burden can sometimes become so overwhelming that it defeats its purpose, getting put aside or filled in mindlessly.
The old adage that a proper history is vital for an accurate diagnosis remains as true as ever, but that takes time. So too do physical examination and vital signs.
We could not help but observe some ironies in the Four Corners program.
The reporter lamented in Latrobe that there was “a lack of GP clinics in the area who are willing to bulk bill”. Setting aside that clinics are not persons, Four Corners did not offer any analysis as to why this might be. Perhaps it has to do with the rebate freeze? Perhaps it has to do with the demoralisation of general practice? Much has been written before about what is wrong with general practice presently (here, here, and here).
The Four Corners cases provided some analysis of doctor errors, and in fairness, there were some very frank opinions from doctors on how the mistakes happened and should not have happened. But we were also struck by who was NOT interviewed.
This goes to the heart of the cultural and systemic problems facing rural hospitals; senior bureaucrats and media officers run the narrative. Clinicians live in fear of their jobs and disruption to careers. The Four Corners program is only the latest chapter about the lack of trust in the system.
If we had been interviewed, our time in rural hospitals may have yielded the following responses:
- understaffing is the number one problem and seed of most of the other problems;
- the above causes pressure on rosters and over-reliance on locums and agency staff;
- there are not enough beds and this causes bed block;
- there is an inability to divert or turn away ambulances when the beds are blocked;
- administration staff are too detached from clinical care and don’t help enough or at all during busy times;
- administration staff are overly concerned about ticking boxes for their performance indicators rather than genuinely providing adequately resourced and safe patient care;
- complaints and suggestions don’t receive replies let alone actions – the performance indicators need to include timely reply to correspondence; and
- investigations that are meant to analyse systems too often end up blaming clinicians, leaving administrators untouched.
So how do we move forward?
We should stop pretending as a nation, as actual or potential patients, or as health care practitioners that we can deliver on increasing demands without being allowed the time to safely diagnose and treat. This means time to focus on the needs of the patient, take an accurate history, perform an adequate examination, consider and investigate the differential diagnosis, and properly inform the patient about the management plan.
Time is a resource that is critical for good patient outcomes and reducing error. And yet all too often it is assumed by politicians and bureaucrats that good clinical practice can be made more efficient by curtailing or omitting critical steps in diagnosis and treatment. As the ABC has shown, omissions can come at a very high price.
It is time for the health professionals, on behalf of patients, to stand their ground on what it takes to properly assess and safely treat patients. If governments want to cut taxes so that individuals have more discretionary income, meaning less for publicly funded health care, then it may be time to charge to improve safety in public hospitals, just as airline passengers accept the need to pay for their safety in the air.
Our public hospital system is under increasing pressure to provide health care, not matched by adequate resourcing, contributing to distressing accounts of avoidable and unacceptable patient harm, as in the Four Corners program. Continuing the status quo will ensure that an under-resourced and overwhelmed system will provide more reports of failure to protect patients, families and staff.
Dr Aniello Iannuzzi is a Visiting Medical Officer at Coonabarabran District Hospital a Clinical Associate Professor at the University of Sydney and University of New England
Dr Chris Davis FAMA is a physician and former Queensland assistant health minister.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
This clearly written description applies to many hospitals. It’s one of THE central problems of hospital based care.
I am a resident of Broken Hill, Far West NSW for the past 28 years. My article below was published by the Barrier Daily Truth 14 Sept 2019, it is regarding Broken hill Health Service.
No health professional starts a working day seeking to harm a patient/member of the public and yet harm occurs. When such harm is repeated, systemic and avoidable – then the question to be asked – is this a first world developed country hospital practice? There has been much said about the lack of funding, insufficient support, not enough Doctors and Nurses – is that the core issue? Are we asking the right questions?
I have been part of the Broken Hill community for the past 28 years; both my daughters were born in the old maternity wing of the Broken Hill Base Hospital – they are now 24 and 21 years respectively. Since their birth I have not had the need to access the hospital health service as a patient. I do not have solutions, but I have some points for reflection:
1. Law of nature is resources will always be limited. Is the estimated $150 million funding of FWLHD being appropriately utilised;
2. What is the clinical allocation vs administration/management; is the organisation top heavy?
3. Are those in clinical positions possessing the right skill set for the job. Are the medical specialties appropriate? In a regional setting – we need all rounded general physician and general surgeons far more than subspecialties. Do we have them, are they performing their jobs to levels expected;
4. Do patients who front up to casualty know the background and qualifications of the doctor who attends to them-is this information readily available on attendance or in website(s)? Are the ‘senior’ Medical Officers training registrars or service registrars. If they are service registrars should they be calling themselves as registrars in specialist training?
5. Should the wages and qualifications of senior management be published on websites? How much of fruitful & futile reporting is done at senior level? Could the recourse of futile reporting be channelled to clinical service? Futile reporting also includes duplicity of reporting – some deliberately done for funding purposes and others due to lack of communication. Such reporting obligations and conduct take away valuable resources from the coal face clinical service. For a regional hospital (this is not Royal North Shore Sydney) do we need to be this top heavy, are all those reports with colourful graphs on fancy paper necessary – what does that improve at ground level. Who reads these reports?
6. Not conducting vital observation for a patient who had fronted up several times to ED is not an issue of resource. It is an issue of competency, process/procedure, supervision – where was the due diligence. A ghastly shortfall as in the Alex BRAES case is likely to be indicative of numerous other issues. I share the community’s despair that this incident occurred in our own backyard. What are the other misses and near misses;
7. Human error always occurs. It is a question of extent and degree, how much has been learnt from the shortfall, what are the system improvements following such episodes? Transparency and accountability are fundamental;
8. Are senior medical clinicians and clinical lead of department suitably experienced or qualified in the clinical field? Are they practicing clinicians or is it just another administrative head?
9. This health service has seen numerous adverse publicity in the past. Senior administration has changed and yet the service has deteriorated. Is that a lack of intent to fundamentally improve? Is there enough checks and balances between the Board and senior management? How, why, when and who appoints the Board;
10. Our Broken Hill community is very reluctant to complain to regulators (HCCC, AHPRA) or to litigate. As a result, the human cost is astounding;
Taking the above list of issues into consideration, it is time for every member of our community to ask why we have one of the highest avoidable death rates in our country when a patient attends the local hospital. What if anything is going to be done about this shocking statistic? Broken Hill community need to act and speak as this impacts each and every one of us who call this city home. Thank you.
Great article. May I suggest you contact journalists at The Good Weekend Magazine (Sydney Morning Herald and The Age) and The Australian Weekend Magazine and suggest they do an in-depth article on the issue. The comments here are interesting and should be added too
I am GP ED . I once went locuming to a rural hospital to work in the Emergency . On a normal day there will be 3 doctors , one ED Dr ,one GP Anaesthetist and another GP OBS and Gynae Dr .
When I reached there I was told that I needed to do the jobs of the three Drs for 24 hours as they could not get any locum for the other 2 departments for the next 24 hours .Imagine the stress on me .
We called the Director of the hospital who outsource the Drs to that rural hospital and I was told that there will not be any Dr coming till the next day at 1 pm and I needed to cover the three departments and the wards on my own . Fortunately all went well till the next day and I continued to work the next day till 5 pm .
This is an example of the poor planning for Drs for the rural hospital and the stress that the Drs undergo in the remote areas.
No wonder I now don’t serve the rural hospitals anymore as there is no support and if anything went wrong I would make the headlines in the news .
Moereover when I called the director to increase my remuneration for that particular day , he refused categorically .
I am now a full time GP in town and gave up the locuming in the rural Emergency .
I am an “over paid locum” who was once a Rural Generalist earning less than the local Plumber.
The two organisations with the most “push” in the field, did and continue to do nothing in trying to get a decent rebate for my skill set, thus I left the system and returned to the same job at double the rate as a locum.
Might I suggest the time has come for all Rural Generalist’s to leave the system and force a rapid rethink by those who control the purse strings.
Same story country wide, need to have an emergency levy to Medicare to pay for widespread improvements in rural medical staffing and conditions.
Get medical staffing right and medical students will start to want to train and work in rural places if the same or better money and conditions are offered as well. I have been saying the same comments for years, next to no research gets performed in rural hospitals either. It’s the great blind spot of Australian health. A dollar spent rurally is worth three spent in the oversubscribed city, where we are seeing diminishing gains of having heaps of city GPs and specialists where we are starting to over service and over investigate.
It’s a shame it takes a four corners investigation to highlight the current state of crisis in our rural
and regional medical services. It will never be possible to staff rural hospitals with specialists, more efficient and transfer to tertiary hospitals for critical patients needs to be a priority in solving equitable access to care for rural communities. Open the lines of communication with specialists. Make transfers quick and easy. In my experience air ambulance transfers have taken more than 24hrs for STEMI and stroke. Often retrieval is diverted or unavailable or there are ineffective communications. No wonder the rate of avoidable deaths is three times higher in our rural hospitals. Timely transfer is imperative and should be staffed by a ED/ICU retrieval not just paramedic. Rural generalists have incredible skills and should be further supported in their roles and skilled in immediate care and prep for transfer. An incredible amount of health dollar is wasted on over paid locums who are not invested in communities. Money needs to be spent supporting rural generalist in their careers and lives. Rural GP’s can thrive if their training, career and family lives are supported financially. Make a rural generalist career as well paid as an specialist in a city, provide incentives and you will see excellent trainees making career and lifestyle choices that include rural communities. Invest in safe effective transfer to specialist care. Invest in people who want to stay and work as a valued member of a community not just a forced stint by an overseas trained doctor.
Oh how very true. Understaffing the ED overnight despite multiple expressions of concern. Staffing with inadequately trained nurses overnight in ED ( a midwife on a Saturday night – ALONE – you really think that’s appropriate?). Having arguments about the suitability of Px for ward vs flying them to the capital city (you REALLY think the post-thrombolysis guy can go to the ward?) Nurses refusing to assist with the management of particular patients because they don’t think the px requires two cannulae for transport, or sedation for the RFDS journey. And on and on and on. And don’t get me started on payment – no locum fee increase in almost a decade.
Also at the heart of the problem is true medical leadership. The senior medical practitioners rarely have time beyond their clinical work and even more importantly are never provided with the appropriate administrative support to run their departments safely. They are usually beaten down by the non clinical staff (administrators) who think they know how to run the show, they do not!
These terrible outcomes are more to do with system failures rather than to the caring clinical staff.
Telemedicine is a bogus when it comes to treating really sick patients. Nothing will equal a fully trained and qualified specialist onsite. For example- Video magic can’t intubate no matter how much you wave the wand from the comfort of the metropolitan couch!
A thoughtful paper thank you. I thought the cases pn the Four Corners program presented were not directly related to rurality (as the commentator above has noted). Moreover, there was little or no discussion of the difficulties of extending resources to rural facitlies/districts and not much on potential solutions to this problem such as very active telemedicine.
Just ask the simple question of how many rural /regional hospitals have truly trained and qualified Intensivists holding FCICM ? Hardly a handful. Metropolitan hegemonist Intensivists running cheap city icus with overseas substandard nontrainee registrars harm these regional centres enormously – they get their “numbers” sorted with these regional sick patients . And aeromedical retrieval teams have their heyday in playing ping pong with sick patients for their pecuniary interests. The bean counters medical administrators have to suck their share out. Add to it the medical indemnity industry – these are all setup against the real doctors that want to stand for patient safety. It’s a big joke. Unless a national intensive care authority is setup and run like civil aviation safety authority- with a national register for critically unwell (not the superfluous databases in vogue now), sick patients in regional centres are very very unsafe. So are the really qualified Intensivists in these sites – bullied and tortured to the extreme.
a number of the cases had nothing much to do with rurality… they were errors that could have happened anywhere.
The actual rural issues of enough and consistant staffing, distance and complexity of transport to higher centres were not well enough hightlighted .
At the moment if you stand on your ground they will crush you.