Newman’s attacks on our health system will hurt the poorest and sickest #keepourdoctors
TO quote a great conservative leader at a time of crisis and change: “It may not be the beginning of the end but it is, perhaps, the end of the beginning.”
There is crisis and change for manufacturing, refugees, public servants. The last is a slow burn but potentially far more consequential for Australians, particularly those in need. South Australia will be the next battleground and it’s clear that experience elsewhere is being monitored – particularly Queensland. For the drivers in the smart state, the “end of the beginning” might be considered to be neutralised opposition in the largest and most complex public sector – health.
So far it has been a bloody business, with the elimination of thousands of jobs a year ago. The strategy was to go in hard and fast; change laws to eliminate legal recourse and ensure that those refusing to “co-operate” were financially disadvantaged. Most of the casualties were in non-frontline sectors such as population health, and non-clinical positions that were deemed unnecessary and, implicitly, unproductive, if not lazy.
The Newman government was prepared for a short period of disquiet but was confident that it could tough it out – which it did.
Since then, services have been restructured and relocated as the chill breeze of austerity and accountability blows relentlessly across the health landscape.
Of course, there is unfinished business and what is in progress now is a radical reconfiguring of clinical services.
The strategy is again to go in hard and fast and assert absolute control over the clinical workforce so that the reins can be tightened at will.
To that end, the first group to be targeted are medical specialists. The logic is obvious: deal with the apex and the rest will follow.
Of course, there are dangers and opportunities in that strategy and doubtless they have been weighed up.
Medical specialists are, on the one hand, powerful, but on the other poorly organised (for instance, by comparison to nurses). They perform critical functions within Queensland’s public hospital and healthcare system, but are unlikely to abandon patients in need.
Doctors generally have potent arguments in support of clinical autonomy to ensure best patient care, but that can be dealt with by shifting the discourse from effectiveness to efficiency.
And then there is the esteem in which specialists (and the medical profession in general) are held in the community: they are highly trained, skilled, hard-working and often carry onerous responsibilities. The pre-emptive solution to neutralising these attributes has the additional benefit of inserting a wedge between medical specialists and the rest of the clinical workforce (for whom, of course, the blade will fall later); that is, by framing the issue around remuneration and responsibility: money and morals.
So, the packages that have long been in place to attract and retain senior practitioners by Queensland Health can be represented as greed. And a sure winner was the conveniently released report of the Auditor-General into 88 of the state’s 2800 senior medical officers just as this dispute is peaking. Those problems identified in the report have largely been dealt with. But what is being contractually pressed on Queensland’s medical specialists as its after-taste lingers has implications not only for their working conditions (where, when, what and how they do it, and their rights should they object) but for patient care.
As perhaps only the most obvious example, specialist services will be controlled through key performance indicators driven by the interests of the system. Doctors’ abilities, then, to put care before cost in clinical decision-making and to engage in collateral but critical activities will be constrained.
Rather than being made by a professional with whom a patient has a relationship, those decisions will fall to administrators. And perhaps those administrators’ decisions will be appropriate – but the public should consider with whom they would wish for such decision-making to be vested in relation to their or their families’ care in a time of need.
Perhaps the efficiency arguments will be marshalled to address those objections. However, I believe that the most significant consequence will be for the quality and morale of the specialist medical workforce (and subsequently for other health professionals). When I came to work with Queensland Health more than two decades ago my income fell, but I was attracted by the challenge of the job and joining an innovative, energetic team blooming after three decades of inertia. I was proud to work with the Cape York and Torres Strait Regional Health Authority and felt privileged in my role in indigenous health.
I know I am part of a (dwindling) cohort of doctors from that time in the north who share those motivations and feelings. Since then, much has changed. Queensland Health introduced inducements to attract and retain doctors (as has occurred across Australia) which have benefited me and for which I am grateful.
In 2008 I was designated as a pre-eminent medical specialist, another measure to attract and retain senior specialists. Again, I am grateful.
If those measures increased the critical mass of specialists, they should be considered a success; but they were not the attraction for me or the colleagues with whom I work in remote settings. One thing that has unquestionably changed is our identification with and pride in the system in which we work; that resignations en masse are looming is testimony to that disaffection.
Even if that does not occur, the relationship between doctors and patients will change.
And that will extend beyond specialists as other professional groups are brought into line; already in remote communities the turnover of temporary staff and agency nurses compromises care. As I have written in this paper previously, the greatest negative impact will be for those most disempowered and least visible – for prematurely aged, indigenous residents of remote north Queensland struggling with chronic disease, for the homeless mentally ill in Brisbane or Mount Isa, for young girls at risk of lifetime reproductive damage through unrecognised or inadequately treated sexually transmitted infections, and for many more. For them the public system providing expertise through trusting relationships is critical.
That’s what is at risk.
Of course, the response to my commentary will be “sour grapes”. Well, there is certainly a sour taste in my mouth, but as I am at the tail-end of my career in indigenous health, it is not for remuneration lost but for opportunity squandered as capacity built up over two decades is deconstructed.
Ernest Hunter is a medical practitioner in north Queensland.
Source: The Australian