Reform built by looking and listening
MOST inquiries end up making worthy recommendations which, like New Year resolutions, become ghosts within a month. The recently announced special inquiry in NSW to look at acute care services in public hospitals has a comprehensive set of terms of reference that includes a mandate to look beyond our public hospitals to the way we care for sick people who are not in hospital.
The inquiry is headed by Peter Garling SC, who explained its scope at its first meeting on Thursday this week. Garling made clear that his interest is in major system change, and that individual complaints are to be handled by other, existing agencies.
It’s impossible to know whether this inquiry will follow countless others into some bureaucrat’s ‘‘ file and forget’’ drawer. But three guiding principles should help to prevent it from disappearing without trace.
First, it would help greatly if the NSW Government would guarantee to take the findings of the inquiry seriously, responding to each recommendation within a specified time. Gaining political will to effect change is critically important. With the growing demand for care from people with serious and continuing illness, and a steady growth in our population in general, political leadership of a high order is required.
Success will require the active support of powerful professional groups, including doctors, with attitudes often heavily freighted with self-interest, as well as genuine concern for the well-being of patients. Discerning and acting upon the difference requires a sharp eye and a strong arm. Reforming the way in which different health services are provided by different hospitals can beat up a perfect storm, especially if the community has not been involved from the beginning.
Logic suggests that greater specialisation among hospitals would be a good way forward. Public support for change and lasting improvements will depend on a broad understanding that change may improve a service, breaking the common assumption that reform is synonymous with deterioration.
Second, the interpretation of the terms of reference should be broad.
The inquiry was a response to cases of fatal hospital mismanagement, culminating in the tragic case of 16-year-old Vanessa Anderson, who died at Sydney’s Royal North Shore Hospital in November 2005 after being treated for a head injury caused when she was struck by a golf ball.
Reviews by the NSW deputy coroner, Carl Milovanovich, pointed to treatment and communication errors. Research conducted into quality and safety in health care shows that these errors usually indicate deeper problems that underlie mistaken behaviour by individuals.
Like symptoms, these tragedies should be assessed and whatever immediate actions are needed to prevent them from reoccurring should be put in place. However, reflection on the meaning of these symptoms — to form an accurate and complete diagnosis of the underlying disorder — is also important. Why has a serious communication problem arisen? Why is there a shortage of hospital beds? The terms of reference allow the inquiry to probe these larger, systemic difficulties, and the opportunity should be taken.
Third, the inquiry must join with efforts now occurring federally to reform health care. In the past 10 years the private sector of Australian health care has expanded, largely through multi-billion dollar public subsidies for private health insurance. Private hospitals have offered more beds for elective surgery, but there has been an underinvestment aimed to relieve growing demand for the public hospitals’ emergency services. The number of public beds has remained stable, drastically restricting the sector’s ability to provide adequate services to all emergency patients.
Insights from the state committee of inquiry could contribute usefully to the federal reform deliberations. In the run-up to last year’s federal election, proposals were advanced for the Commonwealth to take over public hospitals unless they became more efficient. Little was said about how these efficiency gains could be achieved, but it was implied that hospitals should do more with less.
What was missing was evidence that those rattling the sabre of ‘‘ more efficiency or else’’ understood the linkage between hospital and community, and the inefficiency that follows when hospitals are left to fill the gaps in community services. Research in NSW has shown, for example, that if community care for people with chronic problems is deficient, then these people will require twice as many admissions to hospital as those who receive strong support.
Such support, while it does not come for nothing, is not as expensive — and frequently far more humane and less disruptive to the patient and his or her family than admitting a patient to hospital. It follows that one can achieve greater hospital efficiency not by turning off more lights, skimping on replacing equipment or understaffing, but by ensuring community support services are up to speed.
Let us not forget, in our concern for fixing what must be fixed, that at present hundreds of thousands of NSW citizens receive good quality, safe care from our public health system each year from dedicated doctors, nurses, and, behind the scenes, health service managers.
That is the strength upon which reform can be built. By taking these people into their confidence — talking and listening — reforming politicians can engage a huge army of support. Likewise, the community that uses these services can be called upon, by the right voice, to help.
Creating a better, more responsive, safer, and more efficient health service need not be a lonely vigil. Stephen Leeder is co-director of the Menzies Centre for Health Policy and a professor of public health and community medicine at the University of Sydney.