Public Health System 2000 Survey Results

The Survey

The Public Health System Survey was carried out by the AMA (WA) in November and December 1999 through the Clinical Staff Associations of Teaching Hospitals and was distributed through them to full-time and sessional Senior Medical Practitioners.

The purpose of the survey was to give clinicians an opportunity to respond to a variety of issues to assist the AMA in representing their concerns to Government.

The survey was broken into four distinct areas:

1. The Public Hospital System
2. Service Delivery Models
3. Salary Packaging
4. Health Administration Performance

Overview

The survey highlights the concerns of clinicians about the state of the health system. These concerns include:

1. Lack of consultation, eg. advocacy of clinical streaming as part of the 2020 process.
2. The importance of institutional integrity and commitment.
3. The abolition of public hospital centres of excellence as we know them and replacing hospital based acute service delivery with clinical streams without considering other options.
4. The need to address fundamental problems such as: funding, macro management and the deteriorating state of capital and equipment.
5. The adverse effect on the commitment and morale of the health industry staff by continued change which lacks evidence of improving the system.
6. The need to address problems through an evidence based approach.
7. The need for genuine clinician involvement.

The AMA (WA) has been lobbying the Minister and assisting clinical leaders in securing appropriate medical input and achieving reform of benefit to patients. Meetings have been scheduled with the Minister to discuss results of this survey and options. Members will be informed of developments as they occur.

The AMA would like to thank everyone for participating in the survey, and would welcome any further input from members.

Principal Findings

• Public hospital system problems in order of importance are: (1) Funding; (2) Ministerial/Departmental leadership; (3) Capital infrastructure and equipment; (4) Hospital Management; and (5) Structure of clinical services.
• Structure of clinical services and hospital management are performing well given the resources available.
• Overwhelming rejection of: (a) the dismantling of hospital managed services; and (b) the introduction of clinical streaming other than in very limited areas.
• Support for the development of further inter-hospital cooperation.
• Medical and Nursing staffing levels inadequate.
• Equipment is inadequate.
• Patients waiting too long.
• Consultation on change inadequate.
• No consideration of alternative models.
• Doctors would resign or reduce public hospital commitments if Government reduces current benefits of salary packaging.
• Strong regard for hospital managers.
• State Government and Bureaucracy not performing well in health area.

Key Results

Section One: Public Hospital System

1. Staffing levels for both medical and nursing are inadequate (59% and 66% of responses respectively).
2. Equipment is inadequate according to 59.3% or respondents.
3. Funding limits are prohibiting "best practice" to varying degrees according to 96% of respondents. (Sometimes: 57.5%; Usually 27.2%; Always 11.3%). Comments throughout the survey emphasised the significance of this problem:
   • "Can only provide immediate care; goals for future care impossible to accommodate."
   • "The interests of patients are largely looked after but provision of appropriate staff and equipment could ensure that they are always looked after and facilitate improvement of care."
   • "Excessive waiting time."
   • "We are not able to perform surgical site infection surveillance with the current resources. We are even struggling to provide nosocomial bacteraemia surveillance data."
   • "Being over budget is constantly used as the excuse not to buy new equipment. Constant pressure being applied to use the cheapest drugs etc."
4. Patients are waiting more than clinically appropriate. (Sometimes 56%; usually 21%; always 6.2%). Comments highlighted problems with long outpatient times, overloaded clinics and "relative degradation of the position of the teaching (or tertiary) hospitals in the health system."

Section Two: Service Delivery Models

This section was designed to give medical practitioners an opportunity to express their attitude to proposed changes to the management of service delivery from institution based to clinical streaming.

1. 92.4% believe consultation to date has been inadequate. Comments emphasised a perceived lack of "genuine consultation."
2. Only 5.5% felt that consultation had been adequate.
3. 64.7% could not see any advantage in clinical streams. 12.4% felt that advantages of clinical streams outweigh their disadvantages. 22.9% did not respond to this question.
4. Only 2.9% felt there had been adequate consideration of alternative models.
5. Only 2.2% considered the implications of further change to the current system had been assessed in a comprehensive way.
6. Only 2.5% felt there are appropriate audit and evaluation mechanisms in place to assess the effect of integrated clinical streams.
7. No respondent (0%) felt the transitional costs of restructuring had been determined and would be budgeted separately; i.e. bureaucratic change could be at the cost of clinical services.
8. Only 4.7% felt that implementation of integrated clinical streams will lead to improvement in service delivery.
9. Respondents were asked a series of agree/disagree questions on the removal of institution-organised service delivery and replacement by integrated services. Results were:
   • 83.6% of respondents felt that integrated clinical streams were an unproven experiment.
   • Only 5% supported integrated clinical services across all services.
   • 84.4% favour further evolution/development of institutionally based clinical services.

Clinicians' comments on service delivery reflect a very deep concern over Government attempts to dismantle institutional management. The comments also reflect a strong attachment by clinicians to their institutions and the importance of such commitment to the health system. The clinicians say they recognise there is a potential to further improve the system by adopting an approach based on appropriate consultation and evidence.

"The excellence of institutions tends to depend upon the loyalty and devotion of staff, sometimes over and above reasonable contractual obligations. Whether this will be so if clinicians are integrated into a broader service, or whether they will just do a job of work, seems questionable."

"Loyalty to institution has been a positive force promoting clinical excellence. I am concerned that loyalty will not readily transfer to an integrated clinical service."

"ICS will prevent replication of some services. Hopefully it will prevent inter hospital politics and rivalry."

"Inter hospital and intra hospital competition was espoused and even encouraged by State/Hospital bureaucrats (i.e. purchaser/provider artificial markets) over the advice of clinicians. The credibility/goodwill towards political point scoring and ambitious bureaucrats with the latest structures has been exhausted. Fostering goodwill and motivation in healthcare workers would likely achieve a better productivity result."

Section Three: Service Delivery Models

This section was designed to check the clinician's understanding and potential response to any endeavour by the Federal Government to reduce the current benefits of salary packaging. The level of awareness was very high and the responses send a clear message to Governments of the need to review current proposals.

1. 8.4% indicated they would resign if benefits were reduced.
2. 30.5% indicated they would reduce their public hospital commitments to the minimum required by their contract.
3. 15% said they would reduce their contractual commitment.
4. 36.4% will claim for entitlements they currently do not claim, resulting in increased costs to the state.
5. 27.3% said they will also seek compensation. Note: The percentages exceed 100% due to overlapping questions. The responses indicate, however, that the majority of affected clinicians will take some form of action.

Comments on this section included:

"Much of our effort goes unrecognised and unappreciated unfortunately."

"Compensation for the loss by any means available - in particular, no further unpaid overtime/callbacks. Possible drop back sessional commitments."

"I will become disadvantaged by staying at (Name of hospital deleted), and so will many others."

"Negotiate with hospital for compensation. It will be impossible to retain current staff and attract new staff, since the already marked difference between private sector salary and public sector salary will be even further widened."

Section Four: Health Administration Performance

Responses to this section were extraordinary with strong recognition and respect for hospital management but very poor ratings being achieved for the state government and the bureaucracy.

It should be noted that some respondents did not reply to all questions and percentages represent responses to individual questions, not to the entire sample.

1. 45.9% believe the Commonwealth Government is performing at an average or good level.
2. 79.7% believe the State Government is performing below average or at a poor level.
3. Performance of the state opposition was fairly evenly balanced with 45.9% believing it was doing a good or average job and 54.1% believing it was doing a below average or poor job.
4. 85.6% believe the Metropolitan Health Services Board is performing poorly or below average.
5. 76.2% believe Hospital Administration is performing at a good, average or excellent level. Comments included:
   
   • "The main problem is that a great deal of funding contributes to an administrative culture of continuous change as the people who actually do the work are paralysed by uncertainty of future support."
   • "The State and Commonwealth Governments are involved in designing and avoiding cost shifting. Both seem to be reducing expenditure in real terms. There is a relatively new State Minister. The Commissioner is invisible. The Metropolitan Health Service Board is a monstrous totalitarian innovation."
   • "Appears to be a lack of political will and funding to ensure good service. By squeezing the system the politicians and administrators will make the medical profession responsible for rationing health care, thereby putting the onus on Doctors rather than HDWA or politicians for the poor service."
6. Public Health System Problems - in rank order:
   1. Funding
   2. Ministerial/Departmental
   3. Capital infrastructure/equipment
   4. Hospital Management
   5. Structure of clinical services
   Comments included:
   
   • "Resources are stretched beyond a reasonable limit. We have become apologists for an inadequate underfunded public system with declining standards and falling morale. There is virtually no goodwill left in the clinical staff and hence most are looking t o alternative employment in the private sector. Indeed, it is hard to see why anyone would stay working in the public system beyond the satisfaction of teaching the junior staff."
   • "It is essential that a decision which is supported by clinicians be made very soon. This plan must have stability and therefore must have bipartisan political support. The chronic under funding of hospitals, the lack of consultation and the perception that no plan will outlive the government of the day has almost totally eroded any interest in, and commitment to, any plans of any type developed by the Health Department and the Metro Board."
   • "Nothing will be successful in sorting out the problems of the Public Hospital system unless the problems of medicine and health, public and private sector, are addressed in a comprehensive way."

General Comments

The following additional comments from the survey give a summary of your say on issues affecting the health system.

"It used to be an honour and a privilege to work in a teaching hospital, now it is a tiresome chore, which I put up with because I enjoy my work, but the conditions under which one works leaves a lot to be desired. The cause of this change is multi-factional but generally is neglect by the Government and a lack of vision by those bureaucrats who ran the Health Dept over the last 10-15 years. Parochial hospital based interests haven't helped either."

"The major problem is that band aids have been applied to health far too long. We now have wound breakdown and the surrounding skin is necrotic - the band aids won't stick!!!!"

"....... The chains of responsibility from the Health Department and the MHSB appear to have been deliberately broken to distance those organisations from the debacle in the hospitals. These two organisations act without accountability or public scrutiny and are not in the feedback loop to assess damaging effects of their interventions within the hospital system. The Minister gets advised by them and no one else. It would be difficult to devise a better system for wrecking the fibre and morale of workers in the hospitals. Is this perhaps the tacit intention?"

"(Speciality deleted) needs long term planning and a commitment to that long term plan. Various state governments shelve the problems by commissioning reports that are very rarely published, far less acted upon. We also need a budget that builds in depreciation and replacement for our expensive items."

"There probably is enough money in the system but it is being wasted. However, the standard of care is good. Governments are trying to lower the expectations of their constituents."

"I do accept that an integrated service is necessary in order to deliver some levels of care to patients in the community. It is obviously inappropriate to expect neurosurgery to be performed at Meekatharra. I am very concerned about the disempowerment of peripheral services by an integrated service. I feel that in order to produce quality care, it is necessary for the individual doctors or teams to feel responsible and to coordinate care delivery to patients. Integrated clinical services disempowers the medical delivery of care and will lead to deterioration of care at all levels."

"There is no leadership. (...............) The Health portfolio has one of the biggest budgets but is lowly ranked in Cabinet. The MHSB is a disaster."

"Although I have not been consulted about these changes, I dread the usual exercises in pseudo-consultation which involve telling me why the changes are good and demonstrating no interest in my 15 years of experience in the public system, including ten years as a specialist."

"The Board (..............) does not have their staff's interest at heart - only the bottom line figure. They are too responsive to Government interference with too little input from the people who actually spend the health dollar."

"No plan, no leadership, no consultation, no decisions. These comments apply to all organisations in this State apart from Hospital Admin. MHSB has no idea as to what goes on in a complex hospital setting. They can't make logical decisions. They need to CONSULT and LISTEN."

"I can't understand why all hospital managements don't get together to unite to stop these useless and costly exercises. Unity is strength."

"It seems there is plenty of money to work on most of Perth roads at the same time but none for health."

"Some disciplines are suited to ICS, some are not. These decisions should be made after a consultation process not before!! Whilst I understand that the government is systematically trying to disembody the public hospital system and in particular disempower the teaching hospitals, there may be other ways to do this."

"I feel that the most competent and dedicated of doctors with considerable clinical experience are unlikely to be interested in administrative positions midway through professional lives, at least generally speaking. The concept of empowering clinicians, is then, suspect."

"In my speciality a single state unit based on one site is the only responsible option from a professional, teaching and research point of view, not to mention cost effectiveness."

"The lack of clinical membership of the MHSB starkly points out the inadequate and apparently deliberate lack of input from the provider of care. The move to denigrate institutional loyalty will inevitably bring about a deterioration in service and patient care."

"Obviously, communication and consultation on these issues is abysmal. The arrogance and ignorance breathtaking. Where is the leadership? Health Services leadership now consists of flotsam and jetsam, the cream has/have soured and gone to a better future."

"Why is the CEO of our hospital not allowed to be a hospital employee, supporting the hospital, rather than a Board employee. He has a conflict of interest, supporting the Board rather than our institution."

"Most doctors, be it GP's or specialists, are in the community working hard for little reward. Sessional and VMOs prop up the system."

"Global performance of the 'health management' at a State level is appalling. There is a long history of 'plans for health' that have cost vast amounts of money, have never been fully introduced, let alone evaluated. What is needed is less in the way of large scale disruptive change and more problem oriented analysis and then corrective measures."

"I have resigned. I am extremely concerned about the level of commitment from Government and bureaucracy."