The Tasmanian Hospital Fiasco

From the point of view of health and the health care system, the Prime Minister’s intervention in the Mersey Hospital in Tasmania is, at best, ill advised and, at worst, calamitous for Tasmanians and, potentially, for other Australians. It will almost certainly result in the death of North West Tasmanians.

A large number of Australians die each year as a result of avoidable ‘Adverse Events’: mistakes which would not have occurred in a higher quality system. In 1995, the landmark ‘Quality of Australian Health Care Study’ (Wilson, RM et al, Medical Journal of Australia, No 163, pages 458-471) estimated that at least 10 per cent of annual hospital admissions are associated with an Adverse Event. Up to 9000 die unnecessarily each year and many more suffer some level of permanent disability. These are not primarily the fault of doctors (who make mistakes like all of us) but of systems which have not been properly designed to avoid errors and which force doctors to work in unsafe hospitals.

This was the main reason that the Expert Advisory Group which I chaired in 2004 recommended that one large, not two small hospitals in North West Tasmania should provide comprehensive specialist services. This would allow the delivery of safe world class, not second class, specialist services.

The Prime Minister’s intervention will cement in place a system in which Adverse Events will flourish and in which Tasmanians will die unnecessarily.

There are two reasons for this. First, to provide a world class service it is necessary to have a minimum of 3-5 highly qualified specialists per specialty area and stable medical teams which work together over time. This is to avoid professional isolation and to allow the opportunity for rostering, holidays and, importantly, professional up-skilling study leave and research.

Tasmania cannot attract specialists in these numbers. The reason is not primarily to do with money, but because first-class specialists seek to practise in Centres of Excellence and it is hard for Tasmania to achieve these, even in Hobart and Launceston. In fact, the extreme difficulty in attracting doctors to Tasmania was one of the main reasons for the Enquiry which I chaired.

The second reason that the PM’s intervention is dangerous is even more intractable. The North West of Tasmania has a population of 105,000. This is too small to provide two adequately sized teams of specialists with the clinical workload to keep their skills honed to world standards. One of the clearest relationships in medicine is that as surgeons’ workloads fall the death rate of their patients rises. The same is true for medical teams. When a team has not experienced complications for some time because their workload is low, they become partly de-skilled. When complications eventually do occur, more patients die than would be expected of a team with a higher workload.

The reasons for the impossibility of two Centres of Excellence in North West Tasmania were explained to community groups in Burnie and Devonport. These reasons were distributed to all interested parties including medical associations, and were not challenged. And it is for these reasons that the Tasmanian President of the AMA, Professor Haydn Walters, described the PM’s intervention as ‘highly destructive and … quite stupid.’

In principle, the difficulty in attracting specialists could be tackled by ‘bussing in’ specialists from elsewhere in Australia. But if they were taken from Launceston and Hobart the quality of care for all Tasmanians will be jeopardised. Alternatively, specialists could be provided to the Mersey under the Medical Specialist Outreach Assistance Program (MSOAP), which assists with the provision of part-time practitioners to ‘areas of need.’

However, Devonport is not an area of need. Under the Tasmanian State Government’s plan, the Devonport community would have access to most services at the Mersey and easy access to specialist services at a Centre of Excellence in Burnie. Access to such services, under this plan, would be better than for many Australians in outer city suburbs or rural and remote areas.

It is very questionable whether a world class facility with continuity of medical teams can be sustained by part-time doctors flown in from time to time. More importantly, if the Federal Government initiative succeeded in sustaining such a facility at Devonport, it would deny Burnie the patient numbers necessary to maintain the Centre of Excellence which is currently planned for the whole North West of Tasmania. The best that could be hoped for would be the removal of Burnie’s specialist services to prevent the erosion of their quality and establishing a mirror image of the current plan: a Centre of Excellence in Devonport and the facilities now planned for Devonport transferred to Burnie.

But this makes no sense Burnie has 90 per cent greater capacity than Devonport and particularly for complex cases.

For political reasons, it is unlikely that Burnie specialist services will be trashed. It is more likely that two hospitals will be allowed to struggle for existence, providing second class medical care as in the past thus ensuring the continuation of Adverse Events (and the unnecessary deaths of Tasmanians).

The Federal intervention has also been disturbing because of the significant amount of misinformation generated. For instance, both the Prime Minister and the Minister for Health have implied that the Mersey Hospital services a population of 70,000. This is untrue. As documented in my Report, which was sent to Minister Abbott in 2004, the catchment area is 42-43,000. North West Tasmania has a total population of about 105,000, leaving Burnie with a catchment population of 62,000. With much greater capacity already, it is the obvious location for a single Centre of Excellence.

Both the Prime Minister and the Health Minister have clearly indicated that residents of Devonport will have an inadequate service, using words which allowed some to believe that the Mersey Hospital would be closed. But the State plans were to add aged services, renal dialysis, rehabilitation, a 24-hour emergency centre and high speed ambulance services to nearby Burnie. Many small population areas in Australia have a far inferior service.

The asserted lack of consultation with the Devonport population is untrue. My review twice held public consultations in Devonport and provided its proposals to the public. In the second review of services, carried out by Heather Wellington, very extensive consultations were carried out.

The Mersey-Burnie dispute has been ongoing for as long as Tasmania has attempted to plan its services. It has not been resolved because of a lack of political will. After three and a half years of planning, including two enquiries and exhaustive consultations the Tasmanian State Government finally ‘bit the bullet’ and announced its plans for rationalisation. They have been immediately overthrown.

Tasmanians will live in the shadow of this action for a long time. Comprehensive planning and political courage do not coincide in the health sector very often.

The governance structure announced for the Mersey Hospital could not set a more damaging precedent. The announced partnership between the Commonwealth and the hospital makes the Mersey immune to the effects of future State planning. Tasmania will have to plan its medical workforce, spending, emergency services, bed supply, primary health care around whatever the Mersey chooses to do. Unnecessary technology in the Mersey will breed discontent and pressure elsewhere.

According to the Prime Minister these fortified bunker hospitals may spring up across Australia adding to the funding and service confusion which currently characterises Australia’s Health Non-System. Two standards of public hospital will emerge Commonwealth and State each seeking to demonstrate their superiority at the time of the relevant election and forcing the other constituency into competitive spending. The explosive costs of a US-style hospital technology race is a likely outcome.

We can only hope that the Mersey intervention will be a one-off, random and erratic mistake.

This is more than a political question. It is a moral issue. As a result of Federal Government duplicity and the public’s gullibility, Tasmanians are likely to die.