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A PROPOSAL for doctors to be involved only in clinical practice and standards in local hospital networks as part of the federal government’s health reforms has infuriated the AMA.
The discussion paper ― Lead clinicians groups: enhancing clinical engagement in Australia’s health system ― proposes that lead clinicians groups will focus on providing the “right care, at the right time, in the right location, by the right provider”. (1)
It says the priority of clinicians groups should be to “promote evidence based clinical practices and standards, safety and quality improvements, and more effective (and efficient) care processes”.
AMA president Dr Andrew Pesce (pictured above) says the discussion paper is contrary to the intended clinician role in the National Health and Hospitals Network (NHHN) reforms announced by former Prime Minister Kevin Rudd in May last year.
Mr Rudd had told the AMA’s national conference that clinicians would guide local hospital networks in “service planning and the most efficient allocation of clinical services”.
Dr Pesce said that, in its response to the discussion paper, the AMA would advocate that the proposed New South Wales model to the NHHN reforms be adopted federally.
NSW plans to establish hospital clinical councils that will allow clinicians to be involved in management decisions impacting on public hospitals.
The councils will provide leadership and advice on health service performance, quality and safety programs, models of care and clinical standards, budget management and planning.
Dr Pesce said the AMA had made it clear to the federal government and the Department of Health that doctors must be involved in decisions made at the local hospital level about resource allocation, service planning and provision, and patient care.
“We need to have transparent and accountable processes for doctors to have a say on how their hospitals are run,” he said.
“Specifically, doctors should be involved in decision making about funding for infrastructure, staffing and training with their hospital to ensure it is allocated efficiently and equitably.
“But the discussion paper falls well short of proposing a mechanism for ensuring that doctors have a meaningful say in how health care is delivered in their local community.”
Dr Pesce told MJA InSight that the AMA was looking for positive ways to ensure that lead clinician groups had more input into hospital and health service management.
He said the NSW model provided a good template for how clinician groups could work.
However, he said the discussion paper seemed to indicate continuing tensions between the federal government and the states over how the hospital reforms would work.
– Kath Ryan
Posted 31 January 2011
Take a walk through a Victorian hospital. Where wards once stood, offices prevail. The system is drowning in bureaucrats. Time for a cleanout – there just isn’t enough money to support them.
Regarding the criticism that “few doctors have formal health management qualifications” I must ask whether such qualifications are actually meaningful – given the abysmal decline of our health system going in parallel to the increase in “managers”.
From a bird’s eye view it appears that the managers are the problem, not the solution – at least as long as they keep doing what they are doing at present, namely inappropriately and without qualification interfering with clinical decisions.
Japan is one example where doctors call the shots in hospitals and where it works – the second example is the country where I worked before coming to Australia, – Norway. No surprise that they usually rank second in WHO statistics, just behind Japan. It is high time to dump the ideology in this discussion and look at the cool hard facts.
Evidence-based medicine is all good and well, but will not deliver it’s potential if it is constantly hampered by evidence-ignoring ideology-driven politics and management.
To manage effectively requires moderate knowledge of the area managed, so adequate scrutiny of information is more likely to be effective, including knowledge where to get further help from reliable people and who those are, using a knowledge network one can rely on. Playing power or favourites does not work.
Any trained, good mind can diversify and extend into other areas, including management, even doctors can do that, but we all need to understand that information and skills change and improve, so if we act in a role we need to understand the needs.
Basically truthful evaluation, honesty and doing it for the common good, particularly for the ill, under-informed and disadvantaged are required by both doctors and administrators, at hospital level, board level and political level – nothing less is good enough. If we all act thus, trust and cooperation are more likely to ensue.
I agree with Basil that few doctors have either the training or the ability to manage large organisations and see beyond the individual patient. Those few that do will find full-time management poorly rewarded and thankless in comparison to specialist clinical practice – plus much more frustrating.
My view – also with more than 25 years in NSW hospitals – is that good managers should manage, but must be guided by rational advice from senior clinicians. They also need to leave their hands out of clinnical decisions.
What disappoints me most in the last decade of state health system management is the apparent disdain for clinical judgement. In the rush to “standardise”, what has been achieved is “dumbing down.” The most risk-averse approach “wins” – which only encourages inaction. Those of us who are prepared to (indeed, trained to) make high-level decisions in the interests of patients are held with disdain by many “process managers.” Only today, as a senior consultant in an acute specialty, I have been told that training in the “DETECT” system is “mandatory” for all medical and nursing staff. The most basic approach to a patient with abnormal vital signs is to be taught to EVERYONE? The KPI is number of people trained – not the clinical outcomes! More disdain for medical skill…
I fully support the concerns by Dr Pesce and others who have contributed to feedback. The management of hospitals and preventive health has been taken over by persons with a smattering of health training, others with arts and psychology or/and social science degrees (not even science training) who claim to be better than trained psychiatrists or health management specialists – and see what has happended? The health service has become a dumping ground for jobs , especially jobs for the boys and girls and favourites of political parties. Local politics takes precedence when selecting staff, and often even doctors with postgraduate management training are overlooked in the greedy grab for higher paid health management jobs by bureaucrats without any health training. I agree, get the doctors back as team leaders, senior executives/ managers and decision makers! and transfer the allied health workers to serve the public after training in customer service supervised by doctors.
I have worked in the public hospital system for 25 years and still wonder about the reason why doctors think they should run hospitals. In my experience it is a rare medico that has the capacity to see the big picture when it comes to the allocation of limited health care resources. In fact, most are extremely protective of their own turf (and income) and very few have formal health management qualifications. Provide advice on clincial practice standards, quality of care and policy development, most definitely, but if they want to be taken seriously when it comes to hospital management, get some formal training.
Horst Herb states it well. Japan has it correct. Having been intimately involved in trying to have a smidgen of influence over my Department when I was a Director, I now realise that the only way that we, as a profession, will be able to do anything useful is when we have the ultimate decision-making power in the health services operations. All other committees, advisory boards etc are really just exercises in “patronising tokenism”.
Before I quit my last attempt at working in a public hospital, I was severely chastised for using the following signature block on all correspondence:-
“Homeless, powerless, uselessly qualified Director of Nothing Much!!”
It was unfortunately entirely truthful and the non-medical bureaucracy were not amused!!
In Victoria doctors who are employees of the hospital can’t serve on the board of the hospital they work in and to be a VMO and have admission rights you need to be an employee. They will not accept any other arrangement. Hence to be on the board of a hospital you need to live and work in another part of town or the country. Subtle isn’t it? These plans for the advisory boards of local hospitals were developed by the same people with the same thinking as the Victorian model so why would we be surprised they have marginalised the doctors? We have already raised this issue in Victoria and have been told quite clearly that no changes are intended.
This is predictable, and should be no surprise. When Clinical Expert Panels (which were multidisciplinary) were developed by Queensland Health, following the Bundaberg Inquiry, it was not long before some of these became effective in developing systems of clinical coordination and resource allocation. It was not long before the role of these panels was challenged by the bureaucracy, who pushed for these roles to be stripped from the panels. Doctors and nurses may not be skilled in policy development, but they do have a realistic view and are aware of the real priorities and advances in health care. Much health policy that is developed by bureaucracies is unrealistic, ignores the real issues and is simplistic, counterproductive, politically oriented and wasteful. This needs to be corrected.
The world’s best performing health system (at least the health system with consistently top ranking in WHO statistics at a cost well below what Australia spends) – namely Japan – has it mandated that hospitals MUST be run by doctors. Over there, bureaucrats exist to do the bidding of the doctors, and not the other way around – it works. Why not for a change copy something that works, instead of trying to shoehorn changes into our system that are already proven not to work, like PHCOs? Doctors need to get back in control of the health system in all it’s aspects, and bureaucracy must be decimated.