Friday, October 05, 2007


Replacing most of the army of bureaucrats with medical staff is the only solution but it is not going to happen. Three current articles below

The NSW public hospitals disaster is government-created

By Dr. John Graham, an emeritus honorary consultant physician at Sydney Hospital, where he is also chairman of the department of medicine

LET me say from the outset that I am not a professor of medicine or surgery. I am not a professor of nursing. I am not an economist, a bureaucrat or a politician. I am simply a medical practitioner with 40 years’ experience in five public hospitals in Sydney, two of them teaching hospitals. My comments are thus based on experience limited to NSW.

Until I entered medical school in 1962 at the University of Sydney, no medical student in Australia had been subject to an entry quota. But now young Australians have to be Albert Einstein to gain entry to any medical faculty anywhere in Australia. This is sad. To be a good doctor, one probably only needs a Universities Admissions Index of about 85 to 90 (certainly not 99 plus), an aptitude for rote learning and a passionate desire to help one’s fellow man.

When I began my student clinical years in 1966 at Sydney Hospital, student nurses lived and trained in the hospitals. Their practical skills and compassion were fantastic. Then some disgruntled soul decided to move nurse education into universities. Another big mistake. Resident medical officers also resided in the hospitals, thus enabling a far greater opportunity for learning than is available today.

Medicare, introduced as Medibank by the Whitlam Labor government, hasn’t helped either. It lets the well-off take up beds in public hospitals, which should be available for the disadvantaged. Reinstatement of a means test, or more accurately a wealth test, for classification of public-private status in public hospitals is long overdue.

During the 1970s, some huge advances occurred in the technologies relevant to diagnosis, therapeutics and surgery. As a result it was possible to treat many more patients in considerably shorter times in the available hospital beds, but that put more pressure on the public purse, especially as Medicare had made the treatment notionally free.

To cut the costs, and with little regard for the general wellbeing of the community, it was decided the number of beds should be cut. But there was no health minister with the courage to make the cuts. And so in the ‘80s the NSW Labor government dreamed up the idea of area health boards to make the cuts on behalf of the minister. These cuts, however, also required the silencing of all adversaries to the plan, and so the NSW Labor government removed nearly all the independent public hospital boards.

Next to go were the general medical superintendents who, until then, had made sure the interests of patients were paramount. And from that point onwards the chain of communication from clinicians to administration collapsed, and out the window went efficiency, morale, trust and institutional loyalty. You didn’t have to be a Harvard business school professor to know that corporate disaster for public hospitals would be just around the corner.

Governments, through their area boards, became deceptive on budgets. No longer was a hospital budget a firm commitment, and few hospitals would be given their budgets until nearly six months into a financial year. That made it easier for governments to throw all the blame on clinicians for budget overruns that were artificially orchestrated.

The health bureaucracy burgeoned with countless people who have since spent their working lives attending endless meetings, staring at computer screens and doing precious little else. As a result, much of the funding intended for patient care and for the salaries for nurses and hospital doctors had to be switched to salaries for health bureaucrats. In NSW alone more than $2 billion each year is spent by NSW Health on salaries for people who don’t heal anyone.

The reasonable expectation of young doctors that they will be granted a Medicare provider number as soon as they are qualified has also no doubt caused federal governments to put a limit on entry into university medical faculties, which brings us back to the start. It is quite outrageous that Australia should be importing doctors.

Fortunately for all Australians, the Howard Government has indicated it is going to roll back the mistakes that have been made by health bureaucrats and state politicians during the past 40 years. The recent announcement by John Howard and Tony Abbott that they wish to see nurse training reintroduced to the hospital setting is to be greatly applauded. Universities can still play their part by providing the postgraduate nursing courses in intensive care unit nursing and the like. The further announcement that a Howard Government would return a discrete community board of directors to every public hospital in Australia will bring joy to the heart of every nurse, doctor and patient across the land. This has been the single most important health initiative to be announced by any government in Australia for a half century.

By comparison, the federal Labor Opposition so far has offered only a few hypothetical platitudes that won’t cure anything before mid-2009. In fact, Kevin Rudd has amazingly offered to pour another $2 billion into a system that is patently faulty.


Nurses juggling 17-hour shifts at government hospital

A FRUSTRATED nurse at Royal North Shore Hospital's emergency department has spoken of despicable working conditions saying: "I get paid $22 an hour and have five patients' lives in my hand." The nurse - who asked not to be identified - yesterday described the situation at the hospital as unbearable, comprising 17 hour shifts, in-fighting between staff at different wards, patients being placed on top of desks and in store rooms and staff having to share basic equipment.

In an exclusive interview with The Daily Telegraph, the nurse said it was understandable the public was angry about the lack of care. "No one knows what is going on behind that door when they walk through emergency," the nurse said. "The reason why you might be waiting for hours is because there are just no beds, no doctors and even though we try and help we just don't have the time. My biggest worry is the neglect of patient care."

Embattled Health Minister Reba Meagher has agreed to review the state's emergency departments. But the nurse said it would take a massive injection of money into all hospitals before horror stories cease.

Royal North Shore has been embroiled in controversy since Jana Horska miscarried in the toilet last week. The nurse did not want to comment on the circumstances surrounding Ms Horska's case but said the triage nurses would never be able to forget the tragic night. "Those nurses left for the day and it will never leave them," the nurse said.

"People don't realise we are working 17-hour shifts, sometimes twice a week. By the time you are reaching your 16th hour you are scared you are going to make a mistake. "You are arguing with your colleagues and then you have to fight with the ward up the other end just to get a bed."

There are 100 nursing vacancies at Royal North Shore, with staff leaving faster than they can be replaced. If those jobs were filled, John Tague says his elderly mother may not have "suffered in hell" on her deathbed. Mr Tague, of Pyrmont, sat with his 85-year-old mother Elizabeth, who died of heart complications, around the clock because he was not confident of the care she was receiving. "You would call for attention but it could take up to an hour sometimes," he said. "I had to remind nurses to give her her medication. Sometimes there wasn't someone senior enough on shift who had the authority to change her medication. You could see there just weren't enough nurses."

Mr Tague's mother was placed in a store room at night because she was suffering from hallucinations and was disturbing patients. He said while individual nurses were not to blame, pressure on staff caused some to have appalling attitudes. "There's an expectation that Royal North Shore will be an excellent hospital but the reality is vastly different," he said.

Opposition health spokeswoman Jillian Skinner said the Government could not persist on refusing a full inquiry. "It's pointless holding a review into all emergency departments . . . a full, independent inquiry is needed into Royal North Shore," she said.


Don't blame the medical staff

By Dr Phil Huang, an intern at Royal North Shore Hospital. Dr Huang sounds like the sort of doctor everyone would like to have

I have just finished four evenings in emergency at Ryde Hospital, part of the North Shore network, with minimal sleep over the long weekend. I am a mere intern, fresh out of medical school, driving with a learner's licence, but driving nonetheless. Recent events at Royal North Shore Hospital and its aftermath have brought tremendous sorrow into my life. Sorrow for the mother who miscarried, sorrow for the hospital and sorrow for our health profession. What is more unfortunate however, is that the event has become a platform for politicians to campaign while the real problem disappears into the background. There is no doubt that what happened to Jana Horska was a tragedy. Miscarriage at any stage is a harrowing experience and you do not need medical training to appreciate that.

We live in a time of medical miracles. Heart attacks can be prevented and stopped as they are happening, degenerating hips are replaced with synthetic ones, cancers can be beaten into submission through chemicals. But we are helpless in effecting change in the early period of pregnancy. There are no absolute predictors for which pregnancy will proceed and which will terminate. Such is the nature of conception. Mothers are usually fit and healthy. Telling them that something may go wrong is exceedingly difficult.

For better or worse, our emergency departments are designed for emergencies. Patients are categorised by severity and reversibility. It is unfortunate but necessary. Patients who may die from a easily reversible condition are given priority over patients who we are helpless to assist. In an ideal world, Ms Horska would have been placed into a bed and protected from the ultimate horrors that ensued, but hospitals in their current form cannot provide that. We as health professionals have no control over who receives a bed. Guidelines and codes determine which patients receive a bed.

The attempt to categorise human suffering has led us ultimately to this destination. Having spent all my student years at Royal North Shore Hospital and feeling like I was part of a family, I have watched it degrade over the past five years. It is no secret that many hospitals are underfunded and under-resourced. Budgets are exceeded each year and the response by the bureaucrats is to give less. This will encourage less spending over the next financial year as workers attempt to be more fiscal at a cost to patients. Thus reports of budget "blow-outs" are often misrepresented because hospitals have less to work with each year. Hospitals are not businesses and yet are managed as such with boards and chief executives. Patients are not profits and yet economic models are applied in attempts to manage them. These are the cards we are dealt everyday.

There is a belief that we practise medicine for financial gain yet, any doctor working in today's health system will laugh when this is suggested. I am not implying that doctors are scraping the poverty line and most do live quite comfortably. But the sacrifices made to attain that level of comfort come at the expense of their own families and their own lives. Thus the real reward in medicine lies in the ability to help another even if there are difficulties in expressing this undeniable truth.

I was completing a research masters at Cambridge when my professor discovered I was finishing to pursue medicine. He laughed and tried to dissuade me. "What would you rather, Phil?" he asked in a typical pompous British accent. "To affect the life of one? Or the life of millions ?" I chose the life of one. The doctors, nurses and health workers I have encountered at North Shore and elsewhere have served to confirm my initial decision. I can confidently say that most I have encountered hold the above ideal true. This ideal is what brings my colleagues and myself into work every day, to face abuse from patients for an article they read that morning, to go through shifts of 14 hours or more without breaks and to find increasingly that we have less to work with. This ideal and its current state forms the basis for my compulsion to write and make an impassioned plea.

As the hype settles and the blame game takes its turn moving around the board, I hope the real issue resurfaces. What happened with Ms Horska is the tip of the iceberg of faults that exist in the health system and not just at Royal North Shore Hospital. Inquiries and articles blaming doctors, nurses and health workers may satisfy the anger of the mob, but it will never effect change.

In a period of prosperity, the resources of hospitals and universities have dwindled. Politicians will debate the foibles of my colleagues and seniors, shifting blame and providing a smokescreen to the truth. I love my job and medicine in spite of the system and I can attest that many of my colleagues feel the same. Yet the current system has drained the passion away from so many, turning them apathetic as they are blamed for actions beyond their control. The media have tremendous power and effect. Effect that can be directed towards change and empowering individuals. Effect that is lacking in current stories about blame and fear.


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