Is there room to improve the quality and efficiency of healthcare (whether in Queensland or other parts of Australia)? No doubt.
Is there room to reduce wastage in healthcare? Indeed. The Institute of Medicine has in fact just released a report, Better Care at Lower Cost, estimating that about 30 per cent of US healthcare spending in 2009 was wasted. Notwithstanding that the US spends more on healthcare than we do, many of the report’s themes are familiar (some NYT pieces on the report are here and here).
But the answers to these next questions are not yet so clear: Will the staff cuts and restructuring of Queensland Health improve the quality and efficiency of healthcare, and reduce waste? And what will be their consequences for patients and, more broadly, population health?
Hopefully, researchers will work out ways of providing some rigorous answers to these questions in the months and years to come.
More widely, it seems a Health Impact Assessment of the Queensland Budget would have many issues to address – not least the effects upon the health of individuals, families and communities of the job losses. (On related themes, it would also be useful to know the health impacts of NSW Government cuts to public schools and TAFEs).
Meanwhile, the articles below raise plenty of concerns about the nature and impact of the Queensland upheavals. Read on for:
• Queensland Health: Unthinking one day. Thoughtless the next
Philip Darbyshire, Professor of Nursing at Monash University, writes that “caprice and political whim have again replaced any principled, evidentiary and health outcomes basis for making decisions about the health services and staff we should either fund or lose in tough financial times”.
• Are massive workforce cuts the answer to rising health costs?
Daryl Sadgrove, CEO of the Australasian College of Health Service Management, writes that slashing wages is a ‘quick and dirty’ way of putting downward pressure on costs, and although it works as an economic solution, it fails to recognise that there is more to the business of healthcare than economics.
• Links to further reading at The Conversation and Commonwealth Parliamentary Library
Queensland Health: Unthinking one day. Thoughtless the next
Philip Darbyshire writes:
Post Queensland budget, it is truly ‘game’ on in the public health cuts contest.
In the red corner, the public sector health industry remains wedded to the credos that no public sector service job can ever be ‘un-created’ lest the sky fall in and that the only acceptable employment movement is towards ‘more resources’.
In the blue corner, the Coalition’s zero sum game sees the public service as an ideological bête noir, fattened by Labour, whose numbers can be ever more ‘courageously’ reduced while touting the mirage of continued ‘quality’.
Between this Scilla of jobs-for-life entitlement and Charybdis of slash and burn vengefulness lies an alternative approach that puts the public before professional self-interest or political ideology.
What we are likely to see, however, is yet more shameless shroud-waving from the professionals and tub-thumping from the politicians. Where, we should ask, are the guiding principles or sound rationale that might usefully determine why some services or staff should either stay or go?
The problem is that with such a blunderbuss, unquestioning approach to cuts, we will never know. The old union mantra of ‘last in, first out’ looks a positively sophisticated criterion in comparison.
Instead of a dialogue on the proven merits and demonstrated health benefits (or lack thereof) of particular services, we see lazy ‘just make the cuts’ orders from on high combined with a fixation with ‘Front-Line’ services so fetishist it makes ‘50 Shades of Grey’ seem understated. It is as if the concept of teams and teamwork in health care were a foreign country. Imagine a footy coach revealing that his finals’ strategy is to cut the number of midfielders and defenders but leave the forwards intact.
A near universally accepted political truth in any country is that its health budget is a bottomless financial pit that funds a system that is essentially, as Vern Hughes notes, “built around the interests of disparate providers and practitioners”.
The health budget could be doubled tomorrow and in a year or two, the professionals would be complaining about ‘underfunding’ and would have discovered a raft of new ‘underserved populations’ all requiring the creation of their own ‘tailored’ health empires without which they will surely ‘suffer’.
The opportunity that has been missed in this sorry saga is to ask tough but legitimate questions of our health services that focus on the effective and demonstrably beneficial, as opposed to the merely existent and self-perpetuating.
Queensland and every health authority could ask all staff and services four Kipling-esque ‘serving questions’. I liken them to Four Horsemen of the Apocalypse for obvious reasons. How they are answered speaks volumes about the value or deficiencies of a service and thus whether it should be retain, reformed or rejected.
‘What do you do all day?’ When people recite their position description like an HR-bot or simply list tasks that they undertake, alarm bells are already ringing and the razor blade is being fingered. Conversely, when staff and services describe their activities showing how they change lives, improve health or reduce the burden of illness, things are looking upwards.
‘Why do you do it?’ When you hear, ‘Because that’s what we’ve always done’, the alarms sound more like tinnitus. When a service can show you the solid evidence basis for what they do, when they can show how they compare with the world’s best, when they can show how involved consumers and enthusiastically engaged staff are central to their development, you know that this is probably the last place you should be looking for cuts.
‘How could you do it better?’ If the response is ‘Don’t you know how busy we are, or how short-staffed we are?, or worse, ‘Don’t you know who we are?’, then amidst more ringing than a campanology workshop you will be polishing up your Chopper Read techniques. However, hearing detailed accounts of how the service melds passion and systematic approaches to constantly looking for better ways to work, inviting review and evaluation, sharing success and failures and joining forces with other key service, academic and patient/consumer groups, you know that you are in the presence of greatness that only a fool would destroy.
‘How do you know that you make a positive difference to people’s health and lives?’ If you hear platitudes about our lovely staff, their tireless efforts, the shiny new facility, or how ‘fully committed’ we are to blah, blah, blah, then you will be so alarmed as to think that you are in the belfry with Quasimodo. Music to your ears, however, will be the near reverence for evidence that shows proof of health outcomes, e.g. that this service is in the top ‘X’% of services worldwide, perhaps for successful remission, for avoiding cross infection, for increasing vaccination rates or for creating stellar satisfaction levels among parents of children with disabilities. Such a service is not a bloated drain on the public purse but a national asset to be treasured. You put that razor away and move on to the mediocre and ineffective.
For the health staff concerned, these job cuts are bad news indeed. Worse news for the health service is that caprice and political whim have again replaced any principled, evidentiary and health outcomes basis for making decisions about the health services and staff we should either fund or lose in tough financial times.
Queensland Health: Unthinking one day. Thoughtless the next.
• Philip Darbyshire is Professor of Nursing at Monash University, Adjunct Professor of Nursing at University of Western Sydney and Director at Philip Darbyshire Consulting Ltd. Read his blog or follow him on Twitter.
• Declaration: Philip Darbyshire has undertaken paid speaking engagements for various services within Queensland Health.
Are massive workforce cuts the answer to rising health costs?
Daryl Sadgrove, CEO of the Australasian College of Health Service Management, writes:
I would like to officially announce ‘austerity’ as health care’s middle name. Although the title ‘health-austerity-care’ (as it will now be known), has only just been announced, its impact is already bringing governments to their knees.
So why do we need austerity measures? Well, basically the baby boomers are about to cause an unprecedented spike in health service utilisation, and our system hasn’t been designed to accommodate it. In fact over the next two to three decades the population over the age of 65 will double. Considering the 65+ age demographic contributes to over 80% of total healthcare demand, we know that demand will at least double, with dire projections suggesting it could quadruple.
So, is Queensland’s decision to put downward pressure on healthcare costs rational?
I believe there is some method to the madness, but the approach leaves a lot to be desired. If we continue ‘business as usual’, the rising costs associated with our ageing population will consume every state budget within 20 years.
Yes, you heard right, if we don’t transform the way we deliver health care quick smart, state governments will soon have no money for water, no money for schools, no money for roads, nothing; the cost of healthcare will consume every last penny. Considering this, you can begin to understand why state governments are taking such radical action.
However, are massive workforce cuts are the answer?
The simple answer is no. Slashing wages is a ‘quick and dirty’ way of putting downward pressure on costs, and although it works as an economic solution, it fails to recognise that there is more to the business of healthcare than economics.
When the government and treasury made this decision, I wonder if they considered what impact this might have on quality and safety? I wonder how many lives was it acceptable to lose to make this saving worthwhile? Did they factor in the cost of the long term societal and community impacts? Did they account for the loss of productivity and higher workforce turnover? Or the impact on organisational culture? Did it cross their mind that it might be difficult to reorient the system towards a more cost effective preventive model when the entire preventive health workforce has been axed?
Does the government have a plan to mitigate these risks, or was this decision as blunt and shallow as it appeared to be?
Unfortunately health-austerity-care measures are not only confined to Queensland. I recently returned from Tasmania where a similar number of their health workforce was cut over the last six months. The only difference being that Tasmania only had a workforce of 12,000 to start with! An already flailing Tasmanian health system has compounded the challenges they face by cutting 25% of their health workforce. Of course this might save money in the short term, but what about the long-term sustainability of the health system?
If blunt and short-sighted policies are the best the state governments can do to enhance the sustainability of our health system, then we are in for some tumultuous times over the next 20 years. It is simply impossible to avoid serious and long lasting consequences when you decimate a workforce in this way.
So what would good leadership look like in these situations?
Good leadership would begin by having an honest conversation with the community. If the community understands the gravity of the challenge we face, I believe they would support us and find solutions. At the moment the public have not been informed that we face an impending crisis in health care, nor are they aware of the urgency for change.
Secondly, I believe the government needs to create a ten-year change vision for health services and communicate the vision for buy in. This is essential if our governments have any hope of wanting the public to understand and support their actions, otherwise all they will get from the community is anger, frustration and confusion; has anyone seen any evidence of this lately?
Once good leaders have created an urgency for change, established a strong vision, and developed a coalition of support, they need to empower broad based action. Often that means getting out of the way and trusting the community and the health system to come up with sustainable and innovative solutions.
The role of government should be to remove obstacles wherever they can by doing things such as reviewing legislation and regulation, and generating public support. Governments need to create an environment conducive to change, rather than driving change down people’s throats. They should invest more time into recognizing and rewarding success, as opposed to sacking experienced leaders within their departments for system failures typically not within their control.
Great leadership would see governments create quick wins, and then build on the change before incorporating the changes into the culture by articulating the connections between the new behaviours and organisational success.
Great leadership is achievable. In fact the model outlined above is drawn from the most widely used leadership model in the world called ‘Kotter’s 8 step model for leading change’ – a simple but effective leadership approach taught in many ACHSM leadership courses.
So while austerity remains the dominant discourse in health care, let’s hope the practice of great leadership does too.
• The Conversation covers the Queensland Budget
• The Commonwealth Parliamentary Library investigates public sector job losses across the country