Reflections on the Bundaberg Hospital failure

I believe that the current problems in Australian hospital systems have their roots in the “reforms” of the 1980s: the development of corporate structures and managerialist management systems.4,5 Corporate structures devalue clinical involvement, alienate hospital communities, diminish humanity, and result in a burgeoning corpocracy. The managerialist approach produces staff and bed shortages, long waiting lists and excessive bed usage.6 It concentrates on business plans and targets, and negative short-term financial objectives, producing perverse economic activity; managers are rewarded for “quick fix” solutions. This can result in inaction and deferral of work. For example, there are concerns about waiting lists for surgery and delays with specialist referrals.3,6

The period since the 1980s has also seen considerable politicisation of public services in Australia.7,8 This can result in bias, inappropriate appointments and excessive use of secrecy and spin.

Good systems are designed deliberately to produce high quality work.9 By eliminating waste, delay and the need to redo substandard work, they achieve long-term cost effectiveness. All good hospital departments have leaders who are clinically competent, but they must also be just, transparent, energetic and committed. They have the ability to transform their staff into effective teams. Team “ownership” results in people working to improve systems instead of merely using those systems to further their own ends.

When I was a junior resident medical officer in Townsville Hospital in 1960, the hospital was of intense interest to the local community, and this “ownership” was a strong incentive to hospital staff. In addition, the Medical Superintendent was a competent and active general surgeon. The hospital made remarkably efficient use of the resources available to it. I don’t remember there being any waiting lists.

Contrast this with present-day public hospitals — they are likely to be isolated from their communities, lacking in humanity, costing more and doing less,10 and run by executive staff with minimal clinical knowledge.

There are other problems besetting Australian hospitals. For example, many have been slow to adopt safe systems. New intravenous device technology has been demonstrated to reduce the risk of needlestick injury.11 Many hospitals are yet to define and mandate best practice for the use of intravenous devices — the major source of hospital acquired bacteraemias.12 Although the immediate costs of such initiatives may be considerable, the treatment of a potentially preventable blood stream infection that endangers life can cost tens of thousands of dollars, and an injury with a contaminated needle may lead to chronic illness, substantial economic loss and potentially shortened life.

In addition, hospital systems have not capitalised on the advantages of information technology. Communication and the dissemination of knowledge are vital in the complex dynamic systems that are modern hospitals, and this requires efficient communication systems.3 Yet, hospital IT departments can become corporate empires dedicated to the control of computer hardware and software — they often seem to do more to inhibit communication than to facilitate it.

Although the Morris Inquiry was clearly essential, its base cost has been estimated at about $6 million.2 In addition, compensation of those who may have been injured, and repair of those injuries, is likely to entail a substantial financial burden. Ultimately, this money has to come from the pockets of taxpayers and the Queensland economy, and is therefore unavailable for treating patients or educating children. This is quite apart from the moral and personal costs involved, and the damage to staff morale when a job is either not done or done badly.

So, what can be done? Unfortunately, the culture of the managerialist corpocracy is so deeply embedded in public administration in Australia that no quick answer seems likely. And, according to the late popular historian Barbara Tuchman, when something fails, it seems humans are inclined to believe that the solution lies in doing it twice as hard.13

One thing that could be done now is to make central offices behave like coaches rather than controllers and judges. Good coaches are able to mould effective teams, they are expert at dealing with poorly performing players, and they themselves are expendable if the team persistently underperforms. In addition, really good coaches think of the longer term. Politicians and senior staff in central offices need to relearn the motto of the schools some of them attended: “cui servire est regnare” — to serve is to rule. Quality is always positive; we can only ever do better by having better systems and by learning how to make better use of them. This requires careful systems analysis and systems optimisation.9 A fundamental requirement is trust, and this demands justice and transparency.

However, if we are to improve the quality, safety and economy of hospitals in the long term, we need an “idea whose time has come”, to quote Victor Hugo (http://www.geocities.com/Paris/LeftBank/9640/otherq). Like Maynard Keynes, who found a way to end the Great Depression, we can only hope that succeeding generations will be able to see more clearly the reality of things as they are. To create an enduring and worthwhile hospital system, public administration has to move beyond corporate structures and managerialist management approaches.