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.
I dont know the detail of the proposal and to what extent the boards will be “dominated by medical staff and medical thinking”. Isnt another problem the assumption that if you are a clinician you are qualified for the governance role of a board member? Risk management, strategy, policy, financial management, fiduciary responsibilities, the monitoring of performance all in an organisational context surely require suitably qualified people. I hasten to add that there is no reason why someone from a medical background cant acquire those skills. My point is that medical qualification shouldnt be enough. Good boards also have a diversity of talent. Hospital boards that are predominantly from one perspective may suffer from group think and not have the array of capabilities required.
The reactions to the Rudd health plan are interesting. Gavin like myself is an enthusiastic supporter of community engagement. However, unlike Gavin I have had good positive outcomes in working directly with clinicians in effecting reform at the local level. I believe the involvement of all health professionals, including doctors with their communities is central to health reform and a refocus from hospitals to primary care and health promotion can be acheived because the scale of the hospital and health networks will be similar to existing Divisions of general practice or PHCOs. Properly constructed incentives could bring these groups together into a meaningful partnership or entity.
He rightfully recognises the importance of well qualified health managers and your readers should read the SHAPE Declaration published in the Asia Pacific Journal of Health Management (2008;3:2, 10-13) http://www.achse.org.au/frameset.html. This paper, that I authored on behalf of two National organisations puts the case for principles of reform and the need for well qualified heath managers (not Bureaucrats)to work closely together at the service delivery level .
For anyone to suggest that the system works well in the face of two recent major State based Inquiries and a major National reform agenda belies belief! The system works because of the the strongly held values of health professionals, not because of the structure they work in. The challenge is to provide a structure that adequately supports staff with those values to get on with the job. Large systemic health systems will not achieve that outcome. The test will be if there is genuine political courage to take this reform forward and how the strife of interest(Sax) and the Vipers nest (Leeder) will align themselves. Lets hope they plug for community interest ahead of self interest. DSB is Health Management Program Director,UNE, Editor APJHM and a Director (community representative )of a local Division of General Practice and the views in this comment are my own personal views.
The plan seems like a great idea with medical and community involvement, I agree with the comments about the medicos. The lay people will be nominated by the party in power and will mainly consist of party hacks and others who are owed a favor.
It amuses me how many health economists in Australia dismiss medical practitioners as being ‘out of their depth’ when dealing with costs, while considering themselves expert in the delivery of medical services.
The issue is that health economists are required to portion out limited amounts of resources to each patient, whereas the medical practitioner is not usualy called on to determine the costs when trying to treat sick people. There is nothing in the Hipopocratic Oath that deals with rationing of resources, something that health economists have to deal with as part of their jobs.
I take a back seat to no one in my admiration for the medical profession, however their key core competancies tend to be on saving lives (and rightly so), rather than balancing budgets.
My recent experience within hospitals is that doctors are a law unto themselves. Everything has to fit around their schedules.
Specialist in many areas are in short enough supply that they can act like complete prats and get away with it. Partly this could be because of the money they earn relative to everyone else in the system.
They seem to have lost sight of the idea that hospitals are there to treat patients (now getting refered to as consumers a little to often for my liking). Instead they seem to think that a hospital exists as a giant publicly funded waiting room for their patients that they will see when they get round to it.
Thank you for the article and I agree – do we want a surgeon making the final decision about the medical care on offer to our communities?
This has been highlighted in the area of maternity care recently where the AMA has successfully lobbyed the Rudd Government to gain veto rights over women’s birth choices.
Thousands of Australian women do not want or need a Doctor to have the final say over their birth choice and would prefer to be cared for by a midwife but the Rudd Government has caved into pressure from the AMA. These bills now in the Senate will give the AMA control over all births in our country.
Australian Women have told the Government repeatedly at protests around Australia and with over 2000 submissions into each of the 2 recent Senate Inquiries that they want to have the final say in choices made about their health care. This includes decisions about who their care provider is and how they birth. But sadly PM Rudd and Minister Roxon have given the AMA what they want – total control.
This is sadly not surprising given how much Rudd needs the AMA’s support to make their new health reform package work.
This is a worrying trend with a trade union like the AMA now holding the balance of power over health in our country.
Michael James @ 1242pm,
On the whole, I agree with you, Michael.
Infact I am a medical practitioner who also works in health economics academia. I sort of ‘fell’ into the health economics, but find it fascinating, and as a GP who always kept costs (GP and patients’) in mind, I find it quite satisfying.
I feel, though, that a lot of health economic academics treat medical practitioners with contempt, but I agree it works both ways!
EnergyPedant @ 110pm,
Look, I agree that there are a lot of wankers in the medical profession, but that’s not unique to medicine.
Much of the difficulty is down to limited numbers of surgeons etc. There is a ‘need’ to not keep things too personal because you have to spread yourself far and wide. Having said that, if there were more surgeons etc., affability and affordability would enter a more competitive space – hopefully a sincere one!
Also, hospitals can be sods of places to work. You never know, your treating doctor may have just come from a frustrating meeting with bureaucrats that made them late and prattish.
As a clinician , surgeon , administrator of 40 years in hospital systems , both public and private in Australia , UK etc,I would disabuse Gavin of his stereotypical depiction of clinicans as administrators. My own experience of the most efficient managed hospitals , were directed by clinical superintendents ( sometimes surgeons).Space limits my , not flattering , experiences (anecdotal!) of “managers”
It continues to surprise me (but after so many years ought not to) just how thin-skinned some medics are. And in having a go at me, why blame health economists in general? Further there is nothing in what I wrote or indeed think to suggest that I believe I am ‘expert in the delivery of medical services’.
Again I have no wish in general to exclude doctors from decision making processes. The issue I was raising was about in what context we need their skills. My view is that in health care planning, we do need their technical expertise; we do not need their values.
And there is nothing in what I wrote or think to suggest that I treat medical practitioners ‘with contempt’.
I am delighted to enter debate on the issues I raised but to have comments thrown back of the likes of the above is in my view not conducive to reasoned debate.
I would add that I have great respect for medical practitioners and for the profession of medicine. For the record I come from a medical/health care family with three close relatives who are doctors, one a nurse and one a physio – and my father even claimed to have a first aid certificate from the Boys’ Brigade…
What we need I believe is a reasoned debate about power in health service decision making especially health service planning. What prompted my original Crikey comment was the lack of understanding that I perceived the PM exhibited on this issue of power. That debate needs contributions from all sides.
This may sound a little off topic but it actually suggests the difficulties devolution can bring to a practice – I am a high school teacher and have seen over the last 20 years all of the centralised practices of administering schools in terms of the wider infrastructure issues e.g. sourcing budgets (even to finding money to pay school electricity bills) and all manner of decision making passed onto principals who suddenly had to become accountants/risk managers/all manner of j o a trades without any training – suddenly there was very little time for them to be involved in the actual running of their schools in an educational sense and a lot of these onerous but necessary duties devolved further into teacher’s days – meaning the one lesson you had to plan your work for the next day/lesson disappeared into a wash of administrivia – and there’s another student or parent you can’t chase up – is this going to be a real danger with this process in the medical arena????
Shell (March 5) – agree completely with you and what you have commented on here – have encountered your comments on many occasions now quite accidentally across many web forums/comments – you do not have a stalker :o) – just someone who has great sympathy for your conviction and point of view – given the role of the AMA it is of course protecting its members interests and there is not really any incentive for them to be objective in terms of conditions/status – not wishing to doctor-bash here at all – am only referring to the AMA itself and its capacity to undermine aspects of care that it feels threaten a comfortable position.
If Croakey is to retain any sort of credibility the privileged exposure given to the rantings of Dr Mooney should be moderated a little. This piece smacks of bias and selective reporting. Something I thought Croakey was keen to avoid.
Anyone would think that health economists/ health service planners/ managers haven’t been given a fair crack of the whip at the decision making process. For heaven’s sake. Anyone who can seriously suggest that the bureaucracy doesn’t already have sufficient input into the running of health services already certainly hasn’t been spending much time in public hospitals recently. If you want a really good example of how badly it can go when the administration takes over should read the transcripts of the public inquiry into the Bundaberg debacle.
The examples that Mooney gives are all explained by poor leadership from above, bureaucrats who are too spineless to take tough decisions and state health ministers who can’t think beyond the next election.
Hi Gavin,
My comments were out of context and I apologise.
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How often do we hear polititians or senior bureaucrats talking-up evidence-based policy, only to fall back on political expediency?
Unfortunately, I find you can have a very persuasive argument in favour of A over B, but it comes to naught.
Gavin, you say:
“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.””
The current president of the AMA, I think, is relatively moderate and keen on cooperation. And there is a school of thought that there is a kind of “artificial” cap on healthcare budgets. But of course the same argument could apply to all areas. A common argument being spend less on defence and more on health. Simplistic as it may be.
I do think Rudd has the wrong emphasis; involve clinicians, but don’t rely on them to use the budget wisely.
There is a situation in Hobart where a private hospital acquired a PET scanner, hoping it would be used by the adjoining Royal Hobart Hospital too. Only to find out that clinicians at the RHH considered it more “cost-effective” to send public patients to Melbourne, than to the private hospital round the corner.
The final outcome being that the RHH now has a PET scanner too – two PET scanners in Hobart within 100 metres of each other!
I believe health economists have a role in the education of medical practitioners, so that terms such as ‘cost-effective’ are applied correctly and health economics outcomes are used properly to inform critical decision-making.
I am a clinician and a director of medical services in a medium sized public hospital. I have training in medicine and administration. I was pretty much on-side with what Gavin said up until his post about doctors that “in health care planning, we do need their technical expertise; we do not need their values”. This type of silly statement simply stops people talking to each other.
Some decades ago I sat opposite a health service planner/economist discussing the number of cots we would put in a special care nursery to be built. She planned to limit the number in view of cost, and said “we can’t save all of them”. She was only partly joking, and clearly saw that this was an area of excess. The male nurse in charge of the nursery and I said, “yes we can. It doesn’t matter how many cots we build, we will ventilate and keep all the babies who we should, even if we hand bag them and spend our days off here”.
To suggest that you can plan any health service without reference to the powerful culture and strongly held values of the clinical workforce is just dumb. That is why I agreed with Gavin’s initial, perhaps more carefully thought out opinion piece. Recognizing that there are power plays and competing values does not then mean that you can dispense with the values of people you disagree with.
‘It continues to surprise me (but after so many years ought not to) just how thin-skinned some medics are.’ Prof.
They are not the only ones are they? If you don’t like dissension, then don’t put up any opinion that has a response facility…?
Medical economist. That strikes me as a contradiction in terms- but that’s just me!
‘ 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!’ Croakey.
I don’t give one damn for the ‘morale’ of HSM’s! I care about the quality of patient care, and it IS lamentable.
I am not stupid, I am fully aware that hospital have to be run on a ‘cost effective’ basis, much as that disgusts me in terms of the economist rationalist philosophy. However it is necessary. God knows funds are needed for political projects that serve as a monument to those who waste tax-payer dosh to instigate projects that will serve as monuments to their time in office.
We must face the consequential reality that health/education/and even non-statistically rationalised employment must scratch for a buck wherever it can.
But its gone too far.
It would in my opinion, be a rather pleasing change for medical professionals to have some input into how their hospital is run. To have MAJOR input into how their hospital is run.
A compelling argument can be put up on BOTH sides to justify why or why not.
Only one side has been put up here.
This is in no way an endorsement of Rudd/Abbott/or Auntie Nellie’s cat. What it is is an acknowledgment that what we have currently is not working,-and has not been working for a damned long time! The situation is getting worse-so much for medical economists!
We have to do something.
One of the biggest problems in the health system at the moment is the number of clinicians promoted to management roles because they are good clinicians – but they have no training in any management skills – for managing people, money, resources or competing priorities. The same often applies to non-clinicians put in management roles – they may be excellent at policy development or writing ministerieal briefs, but not at managing such huge enterprises as hospitals.
I went to a talk last year where I was told that in the health sector which is approx $900b industry, only 30% of people in positions of management have any management training. That would never be allowed to happen in the private sector.
I have worked in the health sector in a range of capacities for a v long time and have seen so many passionate, skilled, dedicated people burn out or leave for the private sector because of the frustration caused by incompetent or malicious managers.
I agree it is vital to have clinicians involved in or providing input into decisions that will affect their clinical work, but we need people with the skills and experience to manage all aspects of a large organisation, who can harness the skill and energy of all the hospital staff and channel that through good systems which reward competence not bullying and boys clubs.
To William, sorry I did not make myself clear. I am not dismissing clinical values to replace them with mine or health economists’ more generally. I have been on (and on and on…) about the need to get informed citizens’ values into play in setting principles and priorities in health care. I thought on this occasion I’d stop beating that particular drum but in retrospect that was maybe a mistake.
The issue of the importance of equity, the question of the relative importance of prevention versus treatment, more resources for the poor, cancer versus heart disease are to my way of thinking to be determined according to informed social values not medical values. They need to be based on sound medical technical judgments.
That was what I was trying to convey but I misled William and probably others.
Certainly I would welcome debate on these issues. In essence to me the key question here is whose values are to count in establishing the principles on which we build the Australian health care system and in setting the priorities within it?
Sorry that last comment was intended primarily for HospitalCat not William.