There is no bigger issue facing the Australian health system than what to do about public hospitals.
Public hospitals provide 60% of the hospital care needed in Australia each year and treat the majority of the oldest, sickest and most complex patients. They also consumed $28 billion in 2007–08.2 This represents approximately 40% of federal and state health spending, or just under one-third of the total amount spent on health care in Australia.
Despite the ever-increasing sums that Australian governments pour into public hospitals each year, waiting times for elective surgery grow even longer. Emergency departments continue to be clogged with patients forced to endure long waits on trolleys in overcrowded corridors before being admitted to a hospital bed.
Until there is major structural reform of the governance, funding, and delivery of taxpayerfunded hospital services, the public hospital system will continue to monopolise and lock up billions of valuable health dollars in the least productive segment of the health sector.
But despite the scale of the so-called ‘hospital crisis,’ governments throughout Australia remain in denial about the poor performance of public hospitals. When yet another disaster hits the headlines, the standard response of health ministers is to blame red herrings such as ‘underfunding. The real problem, which politicians are understandably reluctant to admit, is the way they have chosen to run public hospitals.
How public hospitals should be administered is the subject of Dr John Graham’s monograph. It provides an insider account—from the perspective of a medical practitioner with more than 40 years of experience in NSW hospitals—of what the author describes as the ‘disastrous reorganisation of public hospital administration of the last 25 years.’
Dr Graham’s policy advice is straightforward, but he presents more than the case for why each public hospital should once again be run by an independent board of directors with full responsibility for the entire hospital budget. He also provides a telling account of the health policy upheavals of the last 25 years and the deleterious impact the establishment of Medicare by the Hawke federal government has had on the quality and quantity of the hospital care received by Australians.
As Dr Graham explains, only the less well-off received treatment in a public hospital without charge prior to 1984, while those who could provide for themselves were expected to get private health insurance to cover their hospital bills. Once the era of ‘free’ hospital care began, many formerly self-reliant people dropped their private cover and state governments were forced to bear the cost of the ‘free’ care promised by the Commonwealth.
The states’ predictable response was to control spending and ration the services that public hospitals delivered by closing large numbers of hospital beds. But before beds could be cut, the tried and tested administrative structure that had ensured the good governance of public hospitals had to be dismantled. Local hospital boards were summarily abolished around the country in the 1980s and 1990s and replaced with the Area Health Services, which continue to administer numerous hospitals within a geographic region.
Once public hospitals had lost their financial and administrative independence, the rot set in. Dr Graham amply demonstrates this by detailing the resulting waste and inefficiency.
Huge amounts of taxpayer’s money have been misallocated to pay for massive and unnecessary growth of the health bureaucracy. Funding is no longer spent effectively in hospitals because there is nobody in a position of authority on the ground anymore.
The massive government expansion into the health sector has resulted in fewer and fewer health dollars out of ever-increasing hospital budgets reaching the frontline. Dr Graham shows just how high has been the price of ‘free’ hospital treatment. The real bottom-line cost incurred by the community is the significant amount of timely and beneficial hospital care that has been forgone.
Dr Graham’s monograph makes the important point that prior to the mid-1980s, public hospitals were of government—their governing boards were constituted by an Act of parliament— but they were not part of the government. Instead of being dependent on government and the funding allocated by health departments as they currently are, public hospitals were strongly connected to the community and were a vibrant part of civil society. These connections started with the broad membership of their governing boards, extended to the generous citizens who made donations to support their work, and flowed right down to the numerous volunteers who donated their time and effort in service of the local hospital.
The ranges of issues Dr Graham discusses pertain to the impact of big government growing ever bigger. But what makes this a unique and perhaps unusual publication is the first-hand experience brought to the topic. Most importantly, we told what it was like when hospitals were not mismanaged from remote and centralised bureaucracies. The decline of public hospitals into their present state of disarray and torpor is proof, if further proof is needed, of what happens when dynamic, self-improving, and self-determining parts of our society become subject to the dead hand of statist domination and bureaucratic command-and-control.
Dr Graham also recounts the history of his medical home—Sydney Hospital. The story of Sydney Hospital over the last four decades is a case-study of the way hospitals once functioned under autonomous boards. Graham argues that one of the key advantages was the way problems were quickly and effectively solved. As he shows, these highly accountable governance arrangements are a world away from the highly bureaucratic arrangements of today. Micro-managing hospitals from afar has only ensured that decisions take forever to be handed down and are frequently flawed in conception or implementation or both.
This monograph is a timely intervention into the health policy debate. A government policy wonk recently told me that he could understand why market-based or ‘demand-side’ hospital reform (such as a competitive system of voucher-style hospital funding4) would improve public hospital efficiency. But he just could not get his head around the need for ‘supply-side’ reform to achieve better outcomes. He was puzzled why anyone would think it is better to go back to the future and re-establish the local hospital boards abolished two decades ago. His questions have now been answered.
Drawing on his vast experience, Dr Graham explains why the only future for public hospitals is to reclaim the best features of their past and reclaim their freedom from the clutches of the bureaucracies that have stifled them to the detriment of the health and welfare of the community.
Dr John R Graham graduated in Medicine from the University of Sydney in 1969 and has practiced as a consultant physician in Macquarie Street, Sydney, since 1973. He has had an uninterrupted association with Sydney Hospital since 1965 and has been Chairman of the Department of Medicine at Sydney Hospital and Sydney Eye Hospital since 1997.
