Will the Prime Minister follow up on his election pledge to take over all public hospitals in Australia?

Kevin Rudd originally gave the States and Territories until the middle of 2009 to get their act together, but the end of the year is fast approaching and the public hospital system still in complete disarray and despite having had a “fair shake of the sauce bottle” – little progress has been made. This is highlighted by the the latest AMA report card which makes for very disappointing reading.

The Australian Medical Association says most hospitals are not operating at safe levels, they’re ‘underfunded and overcrowded’, patients are waiting longer for treatment in emergency departments, while elective surgery waiting lists have lengthened over the past year. That’s despite extra money coming from the Commonwealth for an elective surgery ‘blitz’ of $600 million dollars.

Dr Sally McCarthy (President of the Australasian College for Emergency Medicine) speaking today on ABC Radio National with Fran Kelly on October 15 2009

Hopefully the ‘powers that be’ will listen to the voices on the front-line such as the ‘Who Will Speak For Us?‘ group in New South Wales.

The staff at Katoomba Hospital (in the Blue Mountains, west of Sydney) – or at least some of them – have clearly had enough. In the cyberworld equivalent of taking to the streets, they’ve launched an anonymous blog to tell the public what their bosses won’t let them speak about in public – Croakey

“Things have gone insane here with computer access records of all staff being checked! Management is determined to find out who is involved and are using fear to control people.” – Who will speak for us [Source: Croakey]

AMA President, Dr Andrew Pesce, with Tim Webster of Sydney Radio 2UE Afternoons on Wednesday 14 October 2009

• TIM WEBSTER (Presenter): To discuss the AMA’s public hospitals report card, in the studio with me live, is the President of the AMA, Dr Andrew Pesce. Hi.
• DR PESCE (AMA President): Hi, Tim. Good to see you.
• TIM WEBSTER: It’s not good news, obviously?
• DR PESCE: No, here we are again. This is my first report card as AMA President. But every AMA President gets up, year after year and it’s the same story, gradually things are getting worse. People don’t need to be told. Anyone who’s gone to a hospital doesn’t need to be told it’s getting worse. Doctors don’t need to be told that it’s getting worse. But governments listen to figures, and so we do release a report card, looking objectively at performance in the hospital system. And unfortunately, it shows by any measure, all the indicators are getting worse. People are waiting longer to get seen in emergency departments, if they’re admitted. If they need admission in the emergency departments, more of them are waiting greater than eight hours to be admitted. People are waiting longer for elective surgery, bed occupancy is increasing, and it’s all not good news for the public hospital system.
• TIM WEBSTER: Yet governments, particularly states, continually tell us things are getting better. I mean, where do they get their figures from?
• DR PESCE: Look, unfortunately, statistics aren’t everything. I opened up by saying that anyone who’s been to the public hospital system understands, the doctors and the nurses who run them understand. Unfortunately the figures don’t always tell the full story. What we’ve found, and much to our dismay, is that for example, waiting lists for elective surgery don’t tell the full picture. Increasingly there’s waiting lists to get onto the waiting lists and that the official waiting lists only reflect those people who’ve been registered for their surgery. And increasingly, hospitals are coming up with ways of making sure that access to that waiting list doesn’t happen straight away and so people are waiting some time to get onto the waiting list.
• TIM WEBSTER: Yeah, look, in our report in the News, it said, despite the billions of dollars being spent by the Federal Government on this issue, nothing seems to be working. Where has all that money gone, if it’s been invested into the hospital system?
• DR PESCE: Yes, the Rudd Government announced some investment, and about – on our report card, about six months reflects that period of extra investment, and it’s hard to define where that has gone. And unfortunately that reinforces the message of why we believe that funding of the public hospital system has to be much more clear and accountable. And we believe that the mixture of some money coming from the Commonwealth and some coming from the States is leading to either party not being fully accountable for the decisions that are being made.
• TIM WEBSTER: For the expenditure, yeah.
• DR PESCE: Unfortunately, there are too many black holes where that money can go and, unfortunately, that extra money which has been injected by the Commonwealth Government hasn’t been reflected in improved outcomes and improved performance.
• TIM WEBSTER: So surely there’s a case then for hospitals to be funded federally and administered by the states, yes?
• DR PESCE: Yes, I think there is now increasing pressure to say that that’s what we should be doing. Unfortunately, this hybrid model of some Commonwealth dollars and some state dollars, and no-one knows which is supposed to be where, means that people can walk away from failures. I think there is a very strong case for a single funder and since, you know, all the funds come from the taxpayers through the Commonwealth Government…
• TIM WEBSTER: That’s right.
• DR PESCE: …it makes sense that the Commonwealth Government is a single funder, in a sense purchases hospital services. On the other hand we all recognise that the Commonwealth Government doesn’t really run a lot of services itself and that that experience in running hospitals remains with state governments. So what we think is – would be a good split, and reflect what happens in the private market of purchasers and providers of services, would be if the Commonwealth Government could be the single funder providing funds and the State Government delivering the services. But there needs to be two things to back that up, to make sure that that leads to improvement. First of all, the governments have to honestly get down and agree to national targets and they have to have a national target that they’re all committed to in terms of access to waiting lists for elective surgery, access to emergency departments, bed occupancy. There needs to be honest account accountability for all of those things, and that implies an independent auditor coming in and saying how is each hospital in each state performing to those pre-agreed targets?
• TIM WEBSTER: Look, I don’t like to be a prophet of doom but if we’re in this amount of trouble now – we’re told we’re going to have an ageing population in the next few years; the population of the country’s going to increase quite substantially in the next few years – if we’re not coping now, what are we going to be like in 10 or 20 years?
• DR PESCE: Yeah, if nothing changes, we’re going to have increasing problems. And so one thing that has to be understood is we’re not just asking for ever-increasing budgets for hospitals. We’ve defined that a lot of our acute hospital services are tied up looking after people who are recovering from their surgery and in a rehabilitation phase. And unfortunately, quite a lot of aged care patients, who could be in aged care homes but haven’t been found an aged care bed.So we’re not just asking for the funding of the acute hospital sector, but if we could use funding to open up sub-acute beds, free up the existing acute capacity in our hospitals, to focus on the people who need the acute services. So it’s not just funding the acute public hospitals, it’s sub-acute care and aged care, and investment there will relieve pressure on they public hospitals.
• TIM WEBSTER: At the basic level, do we have too many bureaucrats running this thing? Are we spending too much money on that side of public health and not enough on the patients themselves?
• DR PESCE: Look, doctors know what we need to do to look after patients. We’re always going to need to have health administrators.
• TIM WEBSTER: Sure.
• DR PESCE: But health administrators need to listen to the doctors and help doctors achieve what they want to do in the public hospitals instead of forever telling us that there’s not enough funds to do what you want to do, so this isn’t an anti-bureaucrat drive…
• TIM WEBSTER: No.
• DR PESCE: …but we need to get the health administrators focused on the outcomes in a transparent and accountable way and we need administrators. We need administrators to help deliver services to patients. But they’ve got to start listening to doctors and nurses working in the hospital system much more and have local responses to emerging needs in the local community level.
• TIM WEBSTER: Yeah. Look, I have to say, I mean, because I can afford private health insurance, I have it, and I have had since 1976 when I couldn’t afford it. And I’ve had a lot of operations on my legs recently in private hospital. Now, that system runs beautifully. So there’s been criticism of these hospitals being run by doctors because of the alleged vested interests. So would we not be better off doing it that way than having these very huge area health services which seem to be very unwieldy to me?
• DR PESCE: Look, you have to stand back and look at why that sector is performing so well. And it performs well for a number of reasons. First of all, it chooses what it cares for. So you know, it doesn’t look after the chronically ill, the people who don’t require any acute surgery. It’s really easy to…
• TIM WEBSTER: Well, a lot of them don’t have emergency (departments).
• DR PESCE: Well, that’s right. So, so part of, part of their efficiency lies in the fact that it’s all scheduled work and they run that very well. The other thing is, you know, they’re being funded through an uncapped system of fee for service. And even though there might be some criticism of that, it is a way of rewarding activity. And so those institutions take advantage of that and they actually can work very efficiently through the bits that will help them make money. But, you know, it would be very, very wrong to think that you can compare public hospitals to private hospitals. You’ve got to remember that that’s where we teach our future generations of doctors.
• TIM WEBSTER: Right, yes.
• DR PESCE: So, you know, there are implications there. That’s where the indigent and chronically ill who, you know, often never get better but need to be cared for, get cared for. And so, even though obviously, you know, the AMA are always seeing the health system as having two pillars. There’s the private system which does what it does well but there’s no doubt that we have to jealously guard our public hospital system and make sure it’s as good as it can be.
• TIM WEBSTER: Yeah, and obviously it’s not as good as it can be, is it?
• DR PESCE: Well, unfortunately, it’s not and I think, you know, part of it – at least part of it – a large part of it is due to lack of a good functional funding system so the funding that gets provided is transparently and accountably transferred into services.
• TIM WEBSTER: Mmm and look, you know, emergency, if you like, is the front door of the system, isn’t it? I mean, that’s where people go if they are in trouble, if they’re seriously ill. Now, if that’s not working and there’s not beds at the end of that service in emergency, well, you’ve got a huge problem and that’s pretty much what you’re saying in this report card?
• DR PESCE: Yeah, that’s right. I mean, the emergency department is obviously the public face everyone gets first contact with when they need urgent care. And we know increasingly that waiting times to get through are increasing. Now, I’ve also been involved in reviews of hospitals where there’ve been poor outcomes in emergency departments and the answer is always the same. It’s because the beds are full, the hospital is full, the emergency department is full. So people who present to the emergency department who would normally be admitted, just can’t be admitted. And because they’re not dying, they’re asked to wait in the waiting room and that’s where things start going wrong. Or they’re put on a stretcher in a corridor…
• TIM WEBSTER: In a corridor, yeah.
• DR PESCE: …or they’re kept in the ambulance which, you know, clogs up the ambulance so that it can’t get called to another emergency.
• TIM WEBSTER: Or in horrible circumstances they miscarry in a toilet.
• DR PESCE: That’s right, and everyone’s heard those stories and it’s terrible. And it makes the staff working in those departments feel terrible and it puts them under a lot of strain and morale is not high. And we need to think of that and see how we can support our staff give the care that they want to give.
• TIM WEBSTER: All makes sense to me. Now, politicians are renowned for not listening very well. Do you have the ear of the Minister? And would this report card be taken – seriously, of course – but would she say, well, okay, I’ll implement some of that?
• DR PESCE: Look, at least it demands a response.
• TIM WEBSTER: Yes.
• DR PESCE: We believe that there’s often a temptation to try and dismiss our reports. The AMA has no vested interest in this. We’re just trying to deliver the message as we see it. It only reflects, as I opened up by saying, that what everyone out there who’s visited a public hospital…
• TIM WEBSTER: We all know, that’s right.
• DR PESCE: …knows, and what the doctors and nurses who work day to day know, that things are slowly getting worse. We’ve put some numbers and figures together to try and document that. It demands a response from the State and Commonwealth Governments and it’s a challenge to them.
• TIM WEBSTER: Okay. Now, finally, if there is a solution – and I know it’s a much bigger problem than one solution – would it primarily be for us to say, okay, this X-billion dollars we spend on health goes to this one entity and from there it filters down to everywhere where it’s needed? Would that be it?
• DR PESCE: I believe – yeah, I think there are a few necessary strategies required. First of all, we need very clear funding and a single funder is the most clear funding you have.
• TIM WEBSTER: Okay.
• DR PESCE: We then need all of the States to come together and agree on benchmark figures that they are going to achieve. We then need those states to decide how they’re going to get local input from the clinicians – the nurses, the doctors, the people who work at the coal face…
• TIM WEBSTER: Absolutely.
• DR PESCE:…and how they’re going to deliver those services. And, to be frank, whether it’s at a hospital level or  an area level or a regional health authority level, that can be left to each state as long as the targets are met. And we need an independent auditor to come in because we can’t trust the waiting list figures. It’s not…
• TIM WEBSTER: No, they’re very rubbery, aren’t they?
• DR PESCE: Well, it’s not – it’s just not acceptable that the institution being audited, audits itself. So we need independent auditors to come in. It could be the Commonwealth Auditor General, it could be anyone, but we need independent auditors to come and verify the targets that have been agreed to are being met or not met.
• TIM WEBSTER: All right, thanks for coming in.
• DR PESCE: It’s a pleasure, Tim.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Many recent blogs have discussed or linked to articles about patients who have died in ED waiting rooms. Thanks to SymTym for some other examples – from Sacramento, and more evidence of problems with ER waiting times in the US. There is even an erudite weblog to help health care providers shorten waiting times and improve patient flow.

It would be nice to say that similar issues are not happening in Australia – but unfortunately we are not immune to catastrophic administrative policies which destroy hospital capacity and we too are seeing similar problems throughout Australia.

In Western Australia there are substantiated reports of patients dying in tertiary adult Emergency Departments, having been kept waiting for many hours. These cases never made it to the press – due in most part to the compassion and empathy with which the Emergency staff explained why the hospital system was suffering such problematic delays.

An example of a tragic incident involving an Australian ED is the death of a 30 year old man -who presented to the ED suffering ‘epigastric pain’ – he died following a cardiac arrest having been delayed for four hours in the ED waiting room. This is a tremendously sad incident, made all the more unpalatable by the typical political and bureaucratic response from administration and government. The typical response to such ‘incidents’ is that they are ‘not a system problem’; ‘are wholly unexpected’ and ‘unpredictable’.

Administrators say on the one hand that EDs are safe (despite being dangerously overcrowded) and openly praise the staff for their commitment; yet on the other hand ‘blame’ the same staff for making mistakes (without any evidence or real information) when situations arise as a result of overcrowding, access block and poor management.

Of course the people making these comments have no idea what actually happens in the Emergency Department or what really happened in the tragic cases outlined above. They simply tow the party line; cover their own political butts; plead ignorance to published and peer reviewed journal articles and seek solace in the Confederacy of Dunces.

In reality the evidence is plain to see, easy to read and possible to fix. But ‘head in the sand’ leadership persists – and we face the same metronomic attitudinal problem of treading water in the pullulating and growing megalopolis that is the Emergency Department

• Association between hospital overcrowding and mortality
  • Peter C Sprivulis, Julie-Ann Da Silva, Ian G Jacobs, Amanda R L Frazer and George A Jelinek
• Increase in patient mortality associated with ED overcrowding
  • Drew B Richardson
• Dying risk up 30% in Perth hospitals
• The deepening crisis

For those who work in our EDs the frustration is palpable; tolerance at an all time low and empathy has surrendered to obloquy. Patient assessments are done in the waiting rooms, triage areas and on ‘ramped‘ trolleys – and it is now routine to trawl these ‘holding zones’ to define those most seriously at risk of imminent harm. On a recent such ‘reconnaissance’ I managed to ‘redefine’ the spatial positioning of two patients, one with hyperkalaemia (>8) and ascending paralysis; and a second with progressive TEN. I now find it difficult to leave the front line of triage, my vantage point to the appendiceal neoplastic sprawl which now defines our ‘extended’ treatment area.

Yet, our reason for entering this profession was to care, to cure and to console – please afford me the opportunity of returning to this role and continue to adhere to the principle – Primum non nocere – above all do no harm.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Australia has a great climate, beautiful beaches and relaxed lifestyle – but it is not immune to administrative bungles, bureaucracy and middle management. Thanks to Oz eMedicine for updating me on the latest way for Australian physicians to unite and overcome the latest challenging issues for emergency physicians in Australia. In the setting of the current health care crisis – the Victorian branch of the AMA (Australian Medical Association) have provided a blog – Doctors 4 Hospitals to allow physicians to air their comments anonymously.

Hopefully the erudite will respond and action will ensue.

I encourage and support positive action to encourage doctors to stay within the system – however dark the days may seem.

http://doctors4hospitals.blogspot.com/

We are not alone when it comes to doctors being ‘at odds’ with administrators as Kevin M.D. recently commented. This scenario is not only being played out ‘nationwide – in the US‘ but ‘globally. Every day the ER visits increase and the access block ramifications increase exponentially.

Doctors are at odds with administrators in this California hospital. The administrators simply calls the physicians “whiners”, and are ignoring the reasons behind the exodus of physicians.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog