Health reform and our hospitals – in need of resuscitation?
When former Prime Minister Kevin Rudd and his Health Minister Nicola Roxon were criss-crossing the country to meet those at the front line of health care, many of us thought that a new age might be dawning for the organisation and management of hospital and health services in Australia.
By AMA Vice President Prof Geoffrey Dobb
When former Prime Minister Kevin Rudd and his Health Minister Nicola Roxon were criss-crossing the country to meet those at the front line of health care, many of us thought that a new age might be dawning for the organisation and management of hospital and health services in Australia. Nearly everyone formed the impression that finally we had leaders who would listen. The message that they heard again and again was that clinicians overwhelmingly want to be involved in health reform.
But what does that mean? Most of us know what it means in our daily practice. Involving those we work with, identifying and quantifying our issues and problems, collectively coming up with potential solutions, implementing change and then evaluating it to see if it has improved the quality of our service, its efficiency or its efficacy. As clinicians we know that a new treatment is subject to a well developed process of evaluation from pre-clinical studies to phase 1 through phase 3 clinical trials to show safety, efficacy and cost-effectiveness, and then post-marketing surveillance to ensure it stands up in the real world.
And yet major changes are proposed and implemented to varying degrees in our health system without any robust evaluation. Ideas that seem good at the time can on rare occasions win a Nobel Prize. Much more often they fail. Change without evaluation is change for the sake of change and simply a fashion. It is not health reform. Real reform is change based on some evidence of benefit and then subjected to the sort of evaluation that would be accepted in a quality peer-reviewed journal. Only then can it inform our practice and that of our international colleagues.
The four-hour rule is a good example of a ‘reform’ that has been embraced by the Commonwealth government for introduction to our hospital emergency departments for which the evidence base is flimsy at best. Despite a systematic search I have searched in vain for a single peer-reviewed evaluation of the implementation of the four-hour rule in England. I hear that, somewhat belatedly, resources are being committed to an evaluation of its implementation in Western Australia. So there is now pressure on State governments to meet a target without knowing the balance of risks and benefits to patient centred outcomes such as survival, complications and the quality of their health care experience.
Does it have side effects on teaching and training? Time-based targets for emergency departments may well drive beneficial change but the evidence isn’t yet there.
Much the same could be said for other health ‘reforms’ on the current agenda for our hospitals. Also, the intent appears to be a top-down approach to their implementation. The books I read on the introduction of change and reform say this needs to take a bottom-up approach, involve the workforce and be supported by adequate resources to facilitate the process.
What we are not seeing out of the reform agenda is the message that came from the Rudd-Roxon roadshows: the most needed reform in health care, and especially in our hospitals, is to have authority and accountability sitting in the same place. Instead, the proposed reforms increasingly push accountability down to clinicians while real authority remains remote. That won’t fix the disempowerment of clinicians that was identified as a fundamental issue through the roadshows and by the Garling report into New South Wales hospitals.
A measure of the appetite for real reform must be the willingness to devolve management authority and to cede control to points that are closer to health care delivery. It is predictable that bureaucrats will emphasise the risks of this reform and suggest that budgets will blow out, the outcome will be less health care delivered, not more, and the sky will fall in. But why not do it, evaluate the outcomes and get the evidence? If it works, the main risk will be to the health care bureaucracy - but reform here might not be a bad thing if it moves health employees from offices to the patient delivery end of health care.
Australia is up there with the world’s best when it comes to health care outcomes. The quality of our doctors, nurses and allied health professionals is recognised worldwide. Let’s now get the evidence to support reform in health care. If we are serious about reform, Australia has the potential to be a world leader in evidence-based health reform. I think all of us would find that an exciting outcome. Not least, it would be something other than iron ore that we could export to the rest of the world.
Published: 28 Jul 2011