Professor Gavin Mooney, health economist and regular Croakey contributor, writes:
“In at least one regard the statement at the National Press Club from the PM shows an astonishing lack of understanding of the health care system, its ethics and its power base.
I do not deny there are good bits in what he said but here I want to look at just one. He suggests that we must fix the problem that ‘too many of our local clinical leaders are not adequately involved in decisions about delivery of health and hospital services in their local communities, when they invariably know best’.
Of course the AMA welcomes the idea of local networks/boards. These will be dominated by medical staff and medical thinking.
Is that so bad? Well there are a number of problems here.
First an ethical problem. The task of clinical doctors is to do the best they can for their patients. Medical ethics supports this. That is what I want from any doctor who is treating me. However if sitting on a local hospital network board, a surgeon will have to weigh up her demands on hospital resources with the demands of a psychiatrist. That is a different and conflicting ethical issue as compared with the ethics of decision making about individual patient care. The individual ethics of medicine come in conflict with a more social ethic. It is unfair, inappropriate and inefficient to have that dilemma in one person – much better to separate the roles.
Second, a distribution of power issue. In any local board when a surgeon and a psychiatrist face off against one another over resource allocation decisions, who will win?
Third, another distribution of power issue. In any local board with a surgeon, a nurse, an administrator and some lay person facing off against each other, who will win?
Fourth, yet another distribution of power issue. Devolved and decentralised power as envisaged by the PM sounds good. But it is not devolved and decentralised to the local people which is what ideally ought to happen.
Fifth, yet another distribution of power issue. The power of the AMA will be strengthened as it will not devolve power to local areas and the countervailing power that currently exists, albeit weakly, at state level will be gone. And the AMA does not use its power ‘objectively’. Here in the West at least, it seldom pushes for more resources for health care or even for hospitals. The push is for more money for tertiary hospitals.
Sixth, the issue of competence. Clinicians are good at treating, and are trained to treat, patients. There is enormous confusion or at least lack of understanding in the PM’s statement when he argues that in decision making at a local level ‘our local clinical leaders… invariably know best’. I am stunned that the PM can confuse decision making in patient care with health service planning.
Seventh, hospital and health service management. The PM took a populist swipe at ‘bureaucrats’ as he rollicked his way through his speech. Just think what it must be like to be a hospital manager hearing the PM’s speech. Essentially he argued that clinicians should be managing the system rather than distant bureaucrats. That really does a lot for morale among health service managers! Health service management could be better but the place to start in improving it is to recognise that health service management is a highly skilled job requiring highly trained people. It does not need amateurs in health service management who may double up as highly trained clinicians.
This is all very worrying. Most good doctors want to concentrate on what they are good at which is treating patients. The power of doctors is great and it is greater the closer they are to decision making. But there is a need for the PM to recognise that there are limits to the areas of competence of doctors.
Some relevant examples from my own experiences.
1. I was commissioned by a Chief Medical Officer (who was still working as a part time clinician) to liaise with a group of doctors to work out which of three surgical units should be closed because, to keep all of them open, was inefficient. We provided the answer but there was no closure. The CMO was too close to the rest of the local medical fraternity to make such a ‘hard’ decision.
2. Commissioned to try to rationalise surgical waiting lists in a major hospital. More than half the surgeons refused to provide data on their waiting lists to the hospital CEO. So the study could not be done. Such problems will be worse if clinicians are on local hospital network.
3. Asked to look at priority setting in a suite of hospitals. Good study – until we needed to get the chief oncologist to play ball with data etc. He refused. The study stopped as no one seemingly could force him to play ball. If clinicians on local hospital network, this sort of ‘blocking’ will arise again and again.
4. Discussion with very senior manager at state level on priority setting. He was working to set priorities. How? By asking clinicians what they wanted. And resources? Budget limits? These would be brought in later! If that is the thinking at state level, at level of local hospital network?
Deeply disturbing – and no wonder the AMA is gleeful! The President of the AMA apparently thinks that ‘the government may also be willing to remove the “artificial” cap on hospital budgets, that doesn’t allow them to always deliver necessary services’.
Ah yes ‘necessary services’ and to hell with the cost! The AMA are up and running in this clinical world where money grows on trees.”
Post Script: Croakey was also struck by the PM’s casual dishing of bureaucrats – especially as he is going to be relying on them to progress and implement his health reform package. There is going to be years of work involved in this, assuming he wins the political battles. Another Croakey contributor commented yesterday that: ‘bureaucrat’ is the odious word for clever, hard working public servants who put in long hours trying to save ministers (& even Prime Ministers) from themselves.