The labyrinth of bureaucracy behind our country hospitals’ horror stories
After 25 years as a doctor in rural NSW hospitals, I can attest to the scandals and horror stories emerging from a state parliamentary inquiry into regional, country and remote health services: a teenager with an infected toenail dies of septic shock after being turned away three times from an an emergency department; “tea ladies” check in on newborn babies because there are not enough nurses; doctors threaten to quit en masse because their working conditions are so dangerous.
Naturally, it is the alarming stories from the front line – from the patients, families, doctors and nurses – that capture the headlines. Now we must address the causes.
Dr Aniello Iannuzzi, who is also deputy mayor of Warrumbungle Shire, giving evidence at the inquiry into regional, rural and remote health services. Credit:Louise Kennerley
Chief among them, I have come to learn, is the labyrinthine bureaucracy running NSW Health and the local health districts. The inquiry has come about because communities and health workers are sick and tired of managers in NSW Health and the LHDs stubbornly denying there is a problem.
That is why, when the inquiry came to Wellington, I testified that the principal problem is one of governance. Until that is cleaned up, nothing will improve.
NSW Health’s management structures are bulky and opaque. To progress up the hierarchy, one needs to pledge undying support to the organisation, often needing to bend personal, clinical and ethical standards along the way. When a patient or clinician at the coal face raises a concern, makes a suggestion or files a complaint, management usually activates to ignore, frustrate, bury, lose or deny. It’s like dealing with a big bank, telco or insurance company.
This explains why a CEO of a local health district or senior manager in NSW Health can be technically honest when denying knowledge of adverse patient outcomes, missing medications or the shutting of essential services. The labyrinth has done its work and protected the organisation. Plausible deniability. Spin.
It is at least heartening that the inquiry involves most NSW political parties – because the problems are chronic and systemic and have festered under the watch of Labor and Coalition governments.
No. 1 is understaffing, which puts pressure on rosters and over-reliance on locums and agency staff. There are not enough beds, which causes “bed block”, and there is an inability to divert ambulances when that happens. Administrators are detached from clinical care and managers are overly concerned about ticking boxes for performance indicators rather than ensuring adequately resourced and safe facilities. Investigations meant to analyse system failure are too often weaponised to shift blame onto clinicians, leaving administrators untouched.
To some extent these problems are encountered in cities, but Australia’s geography is cruel. When one runs out of basic antibiotics, there is not a pharmacy supplier in the next suburb or a courier the next day. When a patient drives 100 kilometres to an emergency department to discover there is only a video service, it can be another 100 kilometres or more to a town with a doctor. When a surgery or pharmacy shuts, the ripple effect on a small district’s economy and social capital is devastating.
At the inquiry we heard powerful evidence from Bathurst Council: even in such a large regional city, a lack of health workers has negative economic and social impact. Imagine what it means for a town like Dunedoo, population 750.
We’ve had inquiries before, and recommendations, yet rural health continues to atrophy and the decision-makers are never to blame.
All too often NSW Health assumes good clinical practice can be made more efficient by curtailing or omitting critical steps: making the time to take a patient’s accurate history, perform an adequate examination, consider and investigate the possible diagnoses, and properly inform the patient about the management plan. Hence we see understaffing, poor stocks of medicine and medical equipment and the promotion of telemedicine at the expense of in-person clinicians.
For those of us left in the small hospitals, we turn up to work to find new forms to complete and more data to report. Management’s priority, it often appears, is that staff attend to these tasks ahead of real patient care.
Of course, we need more money, more beds, better medicine and equipment, more staff. The states often blame federal governments for these problems. There is certainly a place for more federal money but we should not exonerate NSW Health on this account. Without better governance the money will remain poorly spent, the equipment misdirected and the clinicians unwilling to work and give their best.
While we always need to recruit more health workers to the bush, there are plenty in the bush who make a conscious decision not to work for NSW Health.
Earlier this year, senior managers of our LHD and the Rural Health Commissioner were in Dunedoo for a community forum organised by the Warrumbungle Shire Council. They suggested the Dunedoo community should be more welcoming to health workers. Oh? So it’s the community’s fault? It was nothing short of insulting and outrageous. All NSW residents should be outraged.
Dr Aniello Iannuzzi is chairman of the Australian Doctors Federation, deputy mayor of Warrumbungle Shire Council and a clinical associate professor at the University of Sydney and University of New England. He has been a visiting medical officer at Coonabarabran District Hospital since 1997.
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