It's Make Or Break Time For Public Hospitals


It is three years since Vanessa Anderson presented to the emergency department at Royal North Shore Hospital with head injuries sustained from a golf ball. Last year, Jana Horska’s tragic miscarriage in the waiting room toilets kept the large Sydney hospital in the media spotlight.

These incidents triggered a spate of inquiries into the NSW health system. Hospital staff were delighted to hear of the safe arrival of Sarah Louise Horska on 13 October. Meanwhile, the report of the Garling Inquiry into Acute Care Services in NSW Public Hospital, due to be released tomorrow, is almost as eagerly anticipated.

It has been a busy year for clinicians in 228 public hospitals across NSW. Presentations to Emergency Departments have been up by 4.5 per cent, with nearly 1.8 million people, equivalent to 30 per cent of the population of NSW, requiring emergency treatment. Hospital admissions have been up by 2.9 per cent, while the number of available hospital beds has declined. Physical and human resources are spread thin.

Staff continue to do more and more with less and less, resulting in risks to patient safety, rising workplace stress and dwindling morale. Many of our precious public hospital clinicians are voting with their feet, seeking employment in the private sector or outside the health sphere altogether.

In my specialty, emergency medicine, the workforce is at breaking point. Things are usually too busy for me to take a meal break — and sometimes even a toilet break — at work. I often do not have adequate time or space to assess my patients as thoroughly as I would wish. I am concerned that I might make mistakes under pressure.

A recent survey found that nearly half of all doctors in NSW Emergency Departments have seriously considered changing specialty or finding employment outside clinical medicine within the next five years. Emergency Department overcrowding impacts on patient safety, quality of care and staff burn-out.

Research has demonstrated that patients who are treated in crowded departments experience delays to assessment and definitive treatment, and have mortality rates 20-30 per cent higher than patients seen during less busy times. Across Australia, Emergency Department overcrowding is responsible for about 1500 extra deaths per year.

This astounding statistic does not count events such as Jana Horska’s miscarriage, nor measure the impact of events like this which are undignified and distressing for patients and health professionals.

Over the last 10 months, Mr Peter Garling SC and his team have visited many hospitals across NSW, hearing a catalogue of complaints about patient care, management strategies, workplace culture, staffing, budgets, infrastructure, equipment, transport, telecommunications and training. The team has met with key stakeholder groups, often more than once. Reading through the transcripts, I am certain that Garling and his team are intimate with every problem currently facing the NSW public hospital system.

Clinicians across NSW have high expectations for the findings and recommendations of the Garling Inquiry. His intervention is widely perceived to be the last chance to save the ailing public hospital system, to turn around the steady exodus of highly trained clinical staff, and to improve patient care outcomes.

What do we hope for? Personally, I wish to see some brave decisions made. If we are to face the challenges posed by the ageing population, we need to significantly change the way we do things.

We need urgent workforce reform. We need to create new roles to deliver effective care that addresses increasingly complex patient needs. We must think beyond existing professional boundaries. We need efficient systems to train health professionals throughout their careers.

We must acknowledge that every service cannot be safely provided at every hospital. Specialist care is best provided at a small number of specialist sites, ensuring critical mass of expertise and equipment. Some hospitals should have their role changed. Some should close altogether. Communication and transport networks should be developed which allow patients to access appropriate care in a timely and safe fashion.

We need to devolve the administrative hierarchy to allow clinician managers to have control over the day-to-day running of their services. Clinicians support a move to funding models based on the number of patients seen or procedures performed.

We need to have an honest discussion with the community about the futility and indignity of providing high-level care to frail, elderly people and patients with terminal illness. We should deliver compassionate end-of-life care, and should involve patients and families in decision-making early, through advance care directives.

In the meantime, we need to open more acute beds to take pressure off frontline staff until these measures have time to impact.

The problem is that we have all been here before. There have been several recent high-profile hospital investigations in Australia, including the Walker Inquiry into Camden and Campbelltown Hospitals in 2004, yet little has changed at the coalface.

This time, we need an independent panel, consisting of senior clinicians, academics, politicians and community-members, to oversee implementation of Mr Garling’s recommendations, according to a strict timetable.

This time, we cannot afford to fail.

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