Opinion
Funding alone is not the magic bullet in fixing Victoria’s hospital crisis
John Wilson
Former president of RACPHow do we know when our healthcare system is past the tipping point? Recent failures in service delivery exemplified by ambulance ramping, delayed elective surgery and reduced mental health services raise red flags and suggest we have already crossed that point.
Weeks after hospitals were told their budgets would be locked in and there would be no top-up spending, Premier Jacinta Allan conceded on Tuesday the state government would “add more funding” if needed. While the seeming reversal is positive, details remain scant and breaths bated until budgets are finalised in August.
The Victorian public hospital system is in crisis.Credit: Luis Enrique Ascui
Many assume there is a straight line between funding health and high-quality service delivery. But this myth is quickly busted when one observes a well-funded hospital lacking any of the essential supporting elements – appropriate policies, good leadership or a healthy culture.
When arguments are made for simple funding increases, health economists point to the law of diminishing returns, and they are right. No amount of funding will improve service delivery if we cannot find nurses to fill positions under current conditions. The proviso, of course, is that available funding is directed to the right place – to the conditions for paramedics and nursing, to staff rather than to those with much higher salaries and less visible performance.
It is anachronistic that hospital boards are expected to behave with the scrutiny and performance of commercial enterprises, yet have limited options to raise revenue.
Many readers might be surprised to know that hospitals take hundreds of millions of dollars in private practice income from their medical staff through donation schemes. Contracts require staff to optimise billing from Medicare for their private practice activity in favour of hospitals. Still, exploitation of medical staff continues in other areas. Some hospitals have failed to abide by contractual enterprise bargaining agreements for medical staff, leading to action against them in the courts.
If we really want to fix our hospital system with the resources available, it’s time to put our collective effort into optimising policies, leadership and culture. While none of these are mutually exclusive, there has been insufficient focus on how these key factors produce the best health outcomes.
Policies abound in the healthcare sector, regulating everything from training of staff to auditing of unit performance. But how do we judge their effectiveness? For example, we are operating in the wake of the COVID-19 pandemic, where policy-on-the-run was the order of the day. The hangover effect is that we are sensitised to risk, and enact expensive preventative strategies such as working from home, isolation of staff exposed to viruses, and mandatory staff vaccinations. At the same time, our hospitals still have ventilation and heating systems that may not adequately prevent the aerosol spread of viruses.
A burning example of policy needing revision is the operation of 29 primary care clinics, originally opened to relieve pressure on emergency departments. Funding pressure and a shortage of clinicians are reported to be pushing the venture into unknown policy territory.
When it comes to the importance of leadership in healthcare, too many confuse it with management. Years ago, leadership expert John Kotter succinctly described the difference between the two: the former are elected, have vision, inspire others and challenge icons; the latter are appointed, follow protocols, are risk-averse and adhere to budgets.
Both are important, but the latter can attract resentment, which does not promote a positive culture. We are seeing in the Victorian health system a metamorphosis of keen clinicians to jaded administrators who lack the charisma of leaders.
Culture traditionally comes from the top. Given the constraints on funding and the organisational stresses that subsequently flow, the healthcare workforce looks to its leaders for their response. So far, we have seen hospital chief executives asking employees to “turn off the lights” when leaving a room. Others have forecast freezes on appointments and projects. Clearly, messaging is of prime importance. This lack of positivity has a ripple effect, both deterring talent from entering the system and greatly impacting retention rates.
There is another vital component in the healthcare system: you, the future patient. At some point, every person becomes a participant. Everyone is responsible for the care of their bodies, and the community at large is responsible for the rise in inappropriate over-use of state-based health services. It is incredible that public hospital activity before COVID-19 increased by 20 per cent in five years, while the population increased by 13 per cent. It is unbelievable that paramedics are called to attend to headaches, toothaches and constipation.
While it is true that the cost of living has dramatically increased and that few GPs can afford to run clinics that are fully bulk-billing (Medicare Benefits Schedule-funded), the misuse of public hospitals for simple care is more than we can afford.
It is time to look at the distribution of resources more carefully, slash the red tape to renew our policies, then think twice before wasting both public hospital time and the heartbeats of healthcare workers.
Professor John Wilson is a past president of the Royal Australasian College of Physicians and has completed a master’s degree from King’s Business School, London.
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