St Anywhere was bemused to hear this week of the Rudd Government’s plan to run it more efficiently with increased Commonwealth involvement. Up until now, many of the administrative decisions handed down by the State Departments of Health focussed St Anywhere on becoming more efficient, doing more with less, and becoming increasingly patient-focussed. Under the Commonwealth bureaucracy, apparently the Government will insist on being more efficient, doing more with less, and becoming patient-focused.

This novel and refreshing realignment will lead to unimaginable changes in how we are able to help the communities we serve.

Anyone working in any public hospital has spent at least the last 20 years shortening length of stay, increasing throughput, undergoing extensive audit of outcomes and generating endless KPIs (Key Performance Indicators) for bureaucrats who change jobs every 18 months to be replaced by interstate gurus who have moved from their public hospitals that were also failing. Effectively the Commonwealth has funded GP services and nursing home places as a national system, yet both are unable to cope with the demands placed on them. It is reassuring to know that the lessons learnt in these areas will soon be brought to bear on the acute public hospital system.

There is no doubt that waste, duplication and inefficiency exists within our public hospital system. These could be largely managed by adjusting the financial levers to give staff, hospitals and states rewards for clever practice changes. Instead, the Commonwealth has permitted the closing of outpatient clinics and a cost shift in many of the Eastern seaboard states. It has focused on surgical waiting lists and completely forgotten that it is the time from the referral to the surgeon to treat them that really matters not just the end piece of the system chain.

In the final analysis, the problem with our health system is not simply the ageing population with its obvious increased demand for services. It is also the increased number of services and treatments that can be offered. These are not only life-style interventions, such as hip replacements, but also life-saving, such as chemotherapy and emergency angiography after a heart attack.

If the system is ever to be sustainable it needs to look at appropriate indications for interventions and ensure they are applied. Many procedures are funded by our taxes. Do they all work? And how well? Few are measuring long-term outcomes.

Savings in the system can be made by reducing unnecessary pathology testing due to systems not interacting, ensuring radiology tests are appropriate in public and private sectors, reducing complex, expensive reporting processes and the management that follows and replacing them with clinically important KPIs.

Governments need to recognise that hospitals are not like factories producing a product. They are complex organisations working on the most complex of products – the patient.

*Guy Maddern is professor of surgery at the University of Adelaide. St Anywhere is fictitious, but the events and issues are real

Peter Fray

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