Back to better hospitals

Doctors write scripts all the time. When Bob Gale and Robert Zemeckis wrote the science fiction story Back to the Future, they were hardly contemplating a script for fixing Australia's public hospitals. And yet the answer to a sustainable future for our public hospitals requires an element of turning the clock back.

During my 42-year medical career, I have witnessed firsthand the descent of public hospitals from a position where they were rewarding places in which to practise down to their present state of commonplace chaos, tragedy and sometimes even farce.

To restore public hospitals to what they once were – some of the most trusted and well-run institutions in the country, which altruistic citizens supported with generous donations – the dysfunctional public hospital administration of the past 25 years must be reversed.

Policymakers need to understand that the replacement of local hospital boards with centralised command-and-control area health services has obliterated the proper governance structures that were based on good communication between managers and front-line clinicians and ensured quick and effective decision-making.

Area health services are stubborn, cumbersome and remote, and they have seriously compromised the efficiency of our public hospital system. Funding is not spent optimally. Trust, co-operation, morale and institutional loyalty have been sapped. Resources have been misallocated. Taxpayer money has been wasted on the extraordinary growth of the bureaucracy.

The real bottom-line cost is that the community has forgone significant quantities of timely and beneficial hospital care.

Medicine came a long way in the 20th century, especially with the advent of antibiotics, blood transfusions, radio isotopes and the like. But the technological advances from the early 1970s on were revolutionary.

Biomedical engineers hugely influenced the efficacy and efficiency of handling a vast number of medical and surgical problems, coming up with inventions that are now commonplace tools of trade. The list of new procedures includes endoscopies, laparoscopies, CT scans, lens implants and coronary artery stents, to name but a few. By the early 80s, these advances had made it possible to achieve in one or two days in hospital what previously might have taken one or two weeks.

State politicians soon realised doctors could treat more patients more quickly, more effectively and more expensively than before. At the same time, federal politicians were promising so-called free care for all Australians in all public hospitals.

A fight loomed. Doctors and hospital boards fought on behalf of their patients and the state politicians fought for tax resources.

In round one, the Wran government in NSW dismissed all public hospital boards. Area health services were installed which, at arm's length from government and especially from the health minister, were charged with fighting round two.

The government's weapon of choice was bed cuts. The minister sat outside the ring and kept his hands clean. There was no referee. Initially, bed cuts were in fact quite plausible. But no one had the good sense to put in a sunset clause requiring an end to bed cuts and area health services once a new and reasonable status quo had been reached in the hospitals.

And therein lies the answer to all the woes facing the public hospital system today. The area health system was great for cutting down hospitals but hopeless for enabling the much overdue rebuilding of services.

We now need not just a few extra beds but beds in the right places, based on the populations being served and the demographics of each location. Hospitals in rural areas are particularly needed. And it is crucial to rebuild communication, cooperation, loyalty, morale, efficiency and plain community trust in each public hospital.

It is imperative that public hospitals across Australia once again have their own boards of directors, coupled with a dedicated hospital budget that is commensurate with a return broadly to the service levels prevailing in the mid-’80s. This will in no way interfere with networking.

Area health services can safely be abolished. Huge cuts should be made to the overgrown bureaucracy that has fed off the health dollar for far too long without adding anything to the front-line efforts of doctors and nurses.

What we now need is desk cuts, not bed cuts. The savings in NSW alone could be about $3 billion a year, which would go a long way in addressing the shortfalls in hospital funding.

Dr John R. Graham is Chairman of the Department Of Medicine at Sydney Hospital. His report The Past is the Future for Public Hospitals: An Insider's Perspective on Hospital Administration was released by The Centre for Independent Studies.