public health

27 Nov 2008

It's Make Or Break Time For Public Hospitals

By Clare Skinner

skinner-hospitals

In emergency departments across NSW the workforce is at breaking point, writes Dr Clare Skinner, on the eve of the long-awaited Garling report on the state's health system

It is three years since Vanessa Anderson presented to the emergency department at Royal North Shore Hospital with head injuries sustained from a golf ball. Last year, Jana Horska's tragic miscarriage in the waiting room toilets kept the large Sydney hospital in the media spotlight.

These incidents triggered a spate of inquiries into the NSW health system. Hospital staff were delighted to hear of the safe arrival of Sarah Louise Horska on 13 October. Meanwhile, the report of the Garling Inquiry into Acute Care Services in NSW Public Hospital, due to be released tomorrow, is almost as eagerly anticipated.

It has been a busy year for clinicians in 228 public hospitals across NSW. Presentations to Emergency Departments have been up by 4.5 per cent, with nearly 1.8 million people, equivalent to 30 per cent of the population of NSW, requiring emergency treatment. Hospital admissions have been up by 2.9 per cent, while the number of available hospital beds has declined. Physical and human resources are spread thin.

Staff continue to do more and more with less and less, resulting in risks to patient safety, rising workplace stress and dwindling morale. Many of our precious public hospital clinicians are voting with their feet, seeking employment in the private sector or outside the health sphere altogether.

In my specialty, emergency medicine, the workforce is at breaking point. Things are usually too busy for me to take a meal break — and sometimes even a toilet break — at work. I often do not have adequate time or space to assess my patients as thoroughly as I would wish. I am concerned that I might make mistakes under pressure.

A recent survey found that nearly half of all doctors in NSW Emergency Departments have seriously considered changing specialty or finding employment outside clinical medicine within the next five years. Emergency Department overcrowding impacts on patient safety, quality of care and staff burn-out.

Research has demonstrated that patients who are treated in crowded departments experience delays to assessment and definitive treatment, and have mortality rates 20-30 per cent higher than patients seen during less busy times. Across Australia, Emergency Department overcrowding is responsible for about 1500 extra deaths per year.

This astounding statistic does not count events such as Jana Horska's miscarriage, nor measure the impact of events like this which are undignified and distressing for patients and health professionals.

Over the last 10 months, Mr Peter Garling SC and his team have visited many hospitals across NSW, hearing a catalogue of complaints about patient care, management strategies, workplace culture, staffing, budgets, infrastructure, equipment, transport, telecommunications and training. The team has met with key stakeholder groups, often more than once. Reading through the transcripts, I am certain that Garling and his team are intimate with every problem currently facing the NSW public hospital system.

Clinicians across NSW have high expectations for the findings and recommendations of the Garling Inquiry. His intervention is widely perceived to be the last chance to save the ailing public hospital system, to turn around the steady exodus of highly trained clinical staff, and to improve patient care outcomes.

What do we hope for? Personally, I wish to see some brave decisions made. If we are to face the challenges posed by the ageing population, we need to significantly change the way we do things.

We need urgent workforce reform. We need to create new roles to deliver effective care that addresses increasingly complex patient needs. We must think beyond existing professional boundaries. We need efficient systems to train health professionals throughout their careers.

We must acknowledge that every service cannot be safely provided at every hospital. Specialist care is best provided at a small number of specialist sites, ensuring critical mass of expertise and equipment. Some hospitals should have their role changed. Some should close altogether. Communication and transport networks should be developed which allow patients to access appropriate care in a timely and safe fashion.

We need to devolve the administrative hierarchy to allow clinician managers to have control over the day-to-day running of their services. Clinicians support a move to funding models based on the number of patients seen or procedures performed.

We need to have an honest discussion with the community about the futility and indignity of providing high-level care to frail, elderly people and patients with terminal illness. We should deliver compassionate end-of-life care, and should involve patients and families in decision-making early, through advance care directives.

In the meantime, we need to open more acute beds to take pressure off frontline staff until these measures have time to impact.

The problem is that we have all been here before. There have been several recent high-profile hospital investigations in Australia, including the Walker Inquiry into Camden and Campbelltown Hospitals in 2004, yet little has changed at the coalface.

This time, we need an independent panel, consisting of senior clinicians, academics, politicians and community-members, to oversee implementation of Mr Garling's recommendations, according to a strict timetable.

This time, we cannot afford to fail.

Discuss this article

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Jonah Bones 27/11/08 11:53AM

Small Victorian country town with 2 part time semi retired doctors , one and a half full time doctors and 2 other doctors in an outlying towns expected to cover the needs of the only hospital covering a large area , with the Summer influx of tourists about to begin , most of them not realizing that there is no emergency department.
More times than not the doctor also goes unpaid as the patient is transferred to a city hospital more capable of processing paperwork quickly , under medicare first in gets paid.
Great system all up.

revilo 27/11/08 9:51PM

Thank you Dr Clare for an erudite, informative and well written piece on the perilous state of many of our public hospitals.

The reference to Advance care optons is something noone can afford to be ignorant of.

So often distraught relos and friends have conflicting views of what the ‘loved one" "wants", "would do if…" "sincerely believes". Just write it down in the form of a living will with a trusted authority, and then there is no doubt what one’s wishes about DNR etc. really are.
I would’nt give up on Medicare or regional hospitals just yet though.
Remember the established clique are still mainly appointees under previous regimes. It takes a long time to turn around ships of state.
The federal govt has given itself leave to go into deficit.
Garling will undoubtedly advise what should be done, and who should do it.
Then as the Nike ad says, they should "Just do it!" :)

ianpetransky 29/11/08 12:41AM

Thank you for this article. As you say, the Garling report is an opportunity to make the health system better. I hope that the NSW government take on board the enquiries findings and look to implement the advice. Providing a better service may mean that some hospitals close. When this offers better health care provision and best use of resources then “the bull should be seized by the horns”. Too often a hospital closure is mentioned and as soon as local opposition occurs, government backs down without defending its position and so wastes scarce resources.

I equally welcome your thoughts on advance care directives as end of life issues are all too frequently discussed at a crisis point in the acute care setting. At such a time it is difficult to spend the time and offer the appropriate support to patients and families. Advanced care directives should be discussed with everyone entering a nursing home. This discussion should not stop at resuscitation decisions but consider whether transfer to hospital or administration of new therapy (including antibiotics) is appropriate. Any patient interacting with cancer services should also have the opportunity to do this. We should be adding quality to peoples lives and not continuing life because the environment where a free and open discussion is allowed was never created.

I am looking forward to reading the Garling report and seeing the implementation of its findings.

Gazbo 01/12/08 11:17AM

Great starting point for discussion Clare. There is much in your thoughts that needs further analysis. While not every hospital can be everything to a community, ( we can’t have neurosurgical facilities in every country town) we have not yet reached community consensus as to what a community can legitiamely claim as a right to healthcare. These general discussions need to take place before any specific decisions are made in relation to closures. When our communities understand the interconnectedness of our healthcare system ( keeping small emergency departments open in the city for example impacts on workforce in regional Australia ) perhaps there will be a better acceptance of the need for closures.

jhaines1 14/12/08 8:47PM

In America, incoming patients sign an advanced care directive before admission so everyone knows the patients wishes in the event of the patient’s need for ongoing acute or critical care. There’s nothing really preventing patients in Australia doing the same.

Hospitals are clogged. Restructuring of the health system over the last 30 years have left the system with too few beds. The aged care system needs more beds. Community based care needs more staff and more resources. The community needs more education on prevention of illness and the treatment of minor illness at home. We need to solve the shortage of doctors and nurses, easily said not so easily done but the biggest problem with staffing now seems to be retention, rather than recruitment. There needs to be a re-empowerment of staff to improve staff morale. These are huge tasks requiring a planned and strategic effort by those managing the health system. It also requires a commitment to resources being directed to public health services, a challenge for all levels of government.