Dr Pesce dicusses the Coalition plan for public hospital management boards on Radio 2SM

Monday 15 February 2010

Subjects:    Coalition plan for public hospital management boards

LEON DELANEY:    Over the weekend, Federal Opposition leader Tony Abbott talked about his plans for public hospitals, incorporating previously discussed ideas such as local hospital boards and local hospital CEOs.  This broad suggestion has been welcomed by the Australian Medical Association but, of course, some hold concerns that that might be only part of the solution and might in fact actually be ignoring some of the more important factors.  President of the AMA, Dr Andrew Pesce, good morning.

ANDREW PESCE:    Good morning Leon.

LEON DELANEY:    Well we've talked before about the idea of local hospital boards and local hospital CEOs and there seems to be growing support for the idea that that kind of autonomy will be part of the solution, but is that the whole solution?

ANDREW PESCE:    Well, no, it can't be the whole solution.  I mean, it's a solution to local management problems which have developed over the years.  And there's no doubt that the crystal clear message that came out of a whole lot of inquiries and the consultation forums that were organised by the Prime Minister after the National Health and Hospitals Reform Commission report - and the very, very clear message was that it was wasn't just doctors, it was the nurses, it was all the clinicians working in the hospital, who were suffering from low morale, and that low morale stemmed from a complete mismatch between what they wanted to do and thought they could do for their patients in the hospitals and what they were being resourced to do, and the management decisions which were leading to breakdowns on that and that was leading to poor morale.  So, the very clear message was they wanted to be re-engaged in local management of their hospitals to make the hospitals work better.

But, as you pointed out in your introduction, that can't be the whole solution because the problems go beyond just the local management in the hospitals.  It's also necessary to make sure that we get good central funding and allocation, so there's no point having good management at a hospital level if funding isn't appropriate to the service needs of the area and the hospital.  So, we do need some decision-making which allocates funding, but that should also take heed of advice from the clinicians, the doctors and nurses to make sure that it is medically appropriate and not putting budgetary control as the number one priority.

LEON DELANEY:    And, indeed, there have been concerns expressed by some that this announcement to some degree may actually distract from what could be considered the core problem, and that is chronic Commonwealth underfunding.

ANDREW PESCE:    Look, this is the problem, you see.  You say Commonwealth underfunding.  The Commonwealth would vigorously deny that and say that, you know, they put plenty in, it's the States not allocating the funding properly.  So, the central issue is that there probably hasn't been appropriate funding but we don't have a clear transparent and accountable method of funding and so the funding issue - whatever either party comes up with - has to once and for all end that blame shifting and the blame game between one level of government blaming the other for, you know, lack of good funding decisions.

LEON DELANEY:    Well, if funding is supported by the two legs being the State and the Federal legs of funding, then both legs have got holes in their shoes at the moment haven't they?

ANDREW PESCE:    Well, that's right, and I think that, you know, we have to make a decision and this is the other pillar that is necessary … I mean, the local management is a very, very important issue and at the local level for doctors it's very important that from a system point of view we really need to have that funding problem managed properly.  We need to have a resolution once and for all.
Now, the AMA has come out for a single funder because that single funder will then have the responsibility and, you know, the buck will stop with them.  It could be the Commonwealth, it could be an agency set up by the Commonwealth and States together, but with a single agreed split in funding between the States and the Commonwealth which is sort of set in concrete so no one can walk away from it.  But there are a whole lot of ways it can be done and it is as yet a solution waiting to be announced.

LEON DELANEY:    Yes, when the finger is pointed at the Commonwealth, though, it does reflect the reality that the proportion of funding from the Commonwealth has been declining over the recent years, hasn't it?

ANDREW PESCE:    Well, as a long-term trend, there was a decline.  In recent years, there has been an improvement again.  But frustratingly when the Commonwealth has announced an injection of extra funding into the system, on occasions you see that the State Governments have diminished the amount of funding they put in.  So, instead of it being an overall increase, it ends up being an opportunity for the States to withdraw some of their funding and use it for other purposes.  So that's the blame shifting - the blame game - the sort of lack of transparency that we need to end.  If a decision is made to put more money into the system it should get there and it should get to where it's needed instead of disappearing into a potential black hole.

LEON DELANEY:    Yes, over the weekend, the Telegraph also published concerns about public hospitals turning away expectant mothers because their maternity wards are full.  This is a problem that's becoming increasingly more significant, isn't it?

ANDREW PESCE:    Well, look, yes, and the real underpinning of that is that the baby boom … we've seen an increase in the birth rate in this country over the last three or four years, which has sort of caught the forward health planners by a bit of a surprise. It just was that no-one saw it coming.  So even without anything else, the increase in the number of births which are taking place in a system which is under some budgetary pressure, and not necessarily having much room to expand to take account of the increase number of births, is putting the system under pressure.  And then you've got the recent position to change the safety net arrangements underpinning obstetrics, which means that it possibly may be a small but significant shift of women from the private maternity system into the public system - and so we're now having, you know, quite significant issues being raised at all public hospitals which have maternity in them, in that how are they going to expand to take up this extra capacity.

LEON DELANEY:    Yeah, that Medicare change means that people who might have been able to make use of that Medicare rebate safety net measure to access the private system, now will have that avenue closed because they can't afford it?

ANDREW PESCE:    Yeah, and without sort of wanting to re-enter the debate on whether it was the right thing to do or not, it just shows that sometimes when you think you're making a decision which is going to save money in one part of the health system, it actually just transfers cost to another part and you actually don't get any real cost saving at all. 

It's estimated that, you know, the safety net changes will mean that the Government will save about $800 per delivery in the private system by the withdrawal of the safety net support for that part of the pregnancy care.  But if one extra patient goes into the public maternity system, that costs the Government $3500 to $4000, so you can see that it doesn't take - it won't take too many women transferring from the private to the public system for there not to be any net savings at all, and funding is going to have to follow presumably from the private system into the public system and there's no financial gain to the Government at all.

LEON DELANEY:    And in fact it could actually be a false economy completely?

ANDREW PESCE:    It could be.

LEON DELANEY:    Yep.  Also last week, quite significant concerns raised once again about Hornsby Hospital.  We are given the revelation that a nurse had actually seriously injured her arm in a fall as a result of water on the floor from a ceiling which has been leaking for so long now that people have given up on trying to get it fixed.

ANDREW PESCE:    Look, that's just terrible.  Just think about what that means both for patient care, I mean if that's happening to staff working there, there are implications for patient safety as well. But you know, the morale, just think of those people who are quite dedicated, they could probably be making more money working in the private system but they have a commitment to the public system and they're just not getting the support that they deserve.  The simple things like that and it's all because there's so little slack in the system that necessary maintenance work isn't been done.  You know, this needs to be addressed.

LEON DELANEY:    It certainly does, but this hospital in particular seems to be such an extreme example of decay in the system and it's so bad that the problems have been known for quite some time.  The politicians have said; yes we're onto it, we're going to fix it, but nothing ever happens.

ANDREW PESCE:    It doesn't seem that anything happens.  If they're doing things, it's not adequately addressing the problem, so that's one example, and it is a long-term problem.  Hornsby's been in the paper for years.  It's obviously something that has to be turned around to make sure that we don't keep having Hornsbys in the papers and in the news, so this just shouldn't happen and we need to fundamentally address the long-term failings of the way that the public hospital system is being organised to make sure it doesn't happen.

LEON DELANEY:    The only possible message we can take away from that situation is that (a) the Government doesn't really value the wellbeing of patients and their healthcare, and (b) doesn't really value the services provided by medical professionals?

ANDREW PESCE:    Well I'd add (c).  I think the most important thing is, unfortunately, the people who are making decisions in the Government are too far away from the problems of the coalface and they need to listen to the doctors and nurses who are working there every day and there has to be a mechanism for the feedback that they're providing to impact on the decision makers who are maybe six or seven bureaucratic levels away, and are getting paper reports and not really appreciating  how significant these problems are.

LEON DELANEY:    Yeah, absolutely.  Thanks very much for your time today.

15 February 2010

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