Re­form built by look­ing and lis­ten­ing

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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.

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