Who stole our health system? The one taxpayers have investing in for 40 years, that especially older taxpayers must remember — doctors in white coats, treated as gods, nurses in uniforms, caps and capes, always cheerful. Hospital porters, cleaners and kitchen staff were working-class men and women, often the most recently arrived migrants, who were helpful at translation for non English speaking patients.
Patients’ wounds were re-dressed four hourly. Golden staph (MRSA), VRE and other super-bugs were virtually unknown. Nurses could actually touch a patient without gloves on. You could rest and recuperate from your operation, and not be rushed out the door. You may have met people from all over our society in hospital as social admissions, because there was bed space for them and they needed the clean up and feed up. Matron was known to everyone, patients and staff, and on her daily rounds she remembered each patient’s name, condition, diagnosis and prognosis.
For many people that system still exists, in their minds at least, which is why they are so surprised to encounter the system as it is now. The old system was like the Titanic — it had its luxuries, but was always sailing towards a financial iceberg. Changes had to be made: rationalisation, reorganisation, restructuring, productivity and efficiency drives, downskilling, privatisation and contracting out. What we have now in the system is the end result of all of these initiatives over the past 40 years.
But what is really driving the system now is the "health as business" approach. Business managers with budget prerogatives, often non-clinical staff, are the new gods in the health system.
Clinicians may have professional power, but not budgetary power, and it is the latter that matters if you want something done. The nursing unit manager who has a dirty ward is held hostage by the independent contractor, who is responsible for ensuring that their staff arrive and perform to a satisfactory level. The contractor, intent on making a profit, may only have the minimum staff on for the hospital. If even one of those staff take a day off sick, there is no budget for a replacement. Corners are cut, patients and their families complain.
The nursing and medical staff may be embarrassed by the state of their workplace, but they have no power to change it — other than by making it an industrial issue. But then you need a sympathetic and active union at both branch and Head Office level. If the officers that lead that union are otherwise occupied, your issues fester for years, unresolved and getting worse.
The problem with the "health is a business" approach is that you are dealing with people who are often in a very fragile state. It’s not easy to quantify a patient’s emotional, mental and physical health in calculable units. But doctors and nurses have to deliver to patients a professional standard of care that meets the patient’s needs, whether or not that care can be measured and delivered in calculable units.
Nurses are taught ethics in university, and one of the important parts of that program is reconciling their professional ethics with the demands for resource allocation — often a dilemma that requires sophisticated reasoning to reach an ethical outcome.
But patients, often unaware of the demands placed on staff by limited resources, want a caring nurse or doctor who can relieve their pain and distress. Patients want a comfortable clean environment while they are in hospital. Some bring their own — I was impressed by the family member at Royal North Shore who brought his own mop into the hospital to clean a patient’s room. Is this the way of the future? (Don’t give the business managers ideas!)
Patients want to eat edible, culturally appropriate food. It is common to see patients of diverse ethnic backgrounds eating food brought from home by their families, rather than the hospital-supplied meals.
With the health budget now threatening to take over the whole of the NSW State Budget by 2030, financial control is no doubt going to be the name of the game. But the health system is about the health and illness of people. It is not all about budget priorities and bottom lines.
If doctors and nurses have to consider their professional ethics in the context of resource allocation, maybe business managers should be required to consider resource allocation in the context of the professional ethics and standards of health practitioners. That may mean more flexibility in budgets and less cost cutting. So be it, if what we are trying to achieve is quality of care and safe patient care.
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