WA News Feature Articles Will this Review Succeed?
Will this Review Succeed?
Written by Jan Hallam
Monday, 02 October 2017


29092017-SHR-InfographIn May, the Health Minister, Roger Cook, made good an election promise to hold a review into the sustainability of the health system in WA. He announced that Ms Robyn Kruk, a former Director General of Health in NSW, would be the independent chair of the Sustainable Health Review (SHR) which would be informed by both a clinical and a consumer reference group.

The infograph here shows with broad brush strokes and big numbers why the WA Government is eager to find efficiencies. However, its Terms of Reference also paints a more subtle yet not less concerning picture of patient care if the SS Health continues to steer in the direction it is heading:

Terms of Reference

“While a number of major infrastructure projects and other changes have been initiated since 2004 (when the Reid Report was released), WA’s health system continues to experience unsustainable budget growth and faces challenges associated with an ageing population, chronic disease and health inequity.”

“Health expenditure has grown faster than inflation and the economy as a whole, accounting for 52% of overall government expenditure growth between 2013-14 and 2016-17. The WA health system is the largest single expenditure in the WA State Budget representing 30% of expenditure in 2016-17 compared to 24.9% in 2008-09.”

“The growth in the cost of healthcare has not been accompanied by an equivalent increase in services to the community. This growth is unsustainable, especially in a constrained budgetary environment.”

An interim report is expected to be handed to Cabinet in December with a final report due March 2018. So the clock is ticking and the SHR has got busy with a series of forums being held across the state (last month and throughout October) asking clinicians and the public for their views on how health sustainability can be achieved.

Perhaps as testament of how hungry clinicians are for reform, there was a flood of interested health professionals prepared to work on this major review. The clinical reference group is large – with 30 people from both hospital and community medicine with geriatrician Dr Hannah Seymour the chair.

Hannah, who is also Medical Director and Clinical Lead for Information Technology at the Fiona Stanley Fremantle Hospitals Group, among other positions, told Medical Forum that the health review panel was overwhelmed by the high number of high quality clinicians wanting to be involved.

Listen to the clinicians

“That is a really positive starting point. We wanted a broad mix of people with different skills and experience to get a range of viewpoints. We’re not expecting these people to give us all the clinical ideas, we expect the forums to come up with those, but we do we want their clinical engagement and opinions on those ideas put forward,” she said.

“We don’t want to improve one area to find that the ‘solution’ makes another area worse and you need clinicians’ experience to avoid that from happening.”

“We had our first meeting recently and used the same framework we’re using in the forums; basically asking people what were their burning issues. The clinicians in the room came up with the big issues.”

They included:

  • Becoming more preventative and less reactive
  • Addressing waste and inefficiency
  • Adjudicating the tension between quality of care closer to home v high-end quality in locations that need volume to deliver them properly
  • Accountability of leadership
  • Health literacy
  • ICT system design
  • Inter and intra-government efficiencies.

It’s a well-thumbed wish-list familiar to everyone who has worked at any level of the health system. So how hopeful is Hannah that the review is going to affect real change?

“I think by having clinicians involved and having the hard conversations with all the pros and cons on the table, we have the best chance possible to implement changes that we have struggled with in the past,” she said.

Not all slash and burn

“And it’s not about cost-cutting – we don’t have a savings target. It is about doing things better. However, it is legitimate to ask that if we invest in certain things, we add value to ensure we get the best return on investment for improved patient outcomes.”

Over the last several issues of the magazine, we have had mostly hospital-based doctors involved in surgery carry on a sometimes desperately frustrated dialogue about the waste of unused and single-use surgical consumables. The system response to those concerns was typically system-heavy quality and safety speak, which can restrict opportunity for common sense and flexibility.

For Hannah, her holy grail is improvement in the pathways of care.

“As a consultant geriatrician, I’m passionate about early discharge and rehab in the community because people do better. We as a system can do better with those links between the community and the hospitals and be clearer about what hospitals do well and what can be done better elsewhere.”

Hannah sees digital innovation as critical not only to her own area of concern but for those in the scope of the entire review.

“Knowing where we are going with digital innovation is vital and it’s not all about big IT systems. We have to start working with patients and their own devices. I don’t know the answers to digital disruption but we do need to be aware where the next innovation is coming from and how we can work with it.”

Whichever focus the review takes, change will be at the heart of any meaningful implementation.

“Interestingly, I had medical students just yesterday ask me what advice I’d give them. I suggested to them that whatever path they took they would need to be really good at change. We all have to be able to adapt and change and if we can do that in a positive way we will all be happier and more productive.”

“If you told me 20 years ago that I’d be using my mobile phone so extensively in clinical practice, I’d laugh at you. Mobile phones represent a massive change and yet we have all adapted to that, so the medical profession is capable of great change, in fact, it is imperative.”

While communication is one thing, investigation of notifications is another. We believe good doctors want the bad ones weeded out but they don’t want to be part of a witch hunt or get buried in lawyers, politics or paperwork.

The national Medical Board can respond to a complaint or act on the advice of the WA Medical Board to establish an assessment panel to either examine the health or performance and professional standards of a doctor. Health consumers are represented on panels along with medical practitioners.

The Medical Board and AHPRA have undisclosed lists of doctors who are approved by them as panellists and probably as expert witnesses. Many of these people, we believe, were ‘grandfathered’ across when National Law first came in (2010). Their impartiality is as unknown as they are. Then we have expected biases of the legal assessors, chosen by AHPRA, possibly thrown into the mix.

Is there a problem, Houston?

It is important this is sorted to everyone’s satisfaction as 42% of doctors in our survey thought panellists could lack impartiality to a serious extent.

In fact, only one quarter of doctors we surveyed (n=195) were happy with the impartiality shown by AHPRA or the Medical Board in processing a complaint (with 36% unhappy and 39% undecided). Nearly all of those who were unhappy said they were concerned that unfairness will be seriously damaging to someone. Investigation is a very confronting experience.

If someone is being investigated by a panel, either the panel or the person being investigated can opt for a more out-in-the-open State Administrative Tribunal (SAT) judicial hearing – the panel usually refers because it feels the evidence before it constitutes more serious professional misconduct.

What Fair Doctors Want

Talking to doctors, they appear to want an apolitical system of investigation that is fair and timely. They want to be treated reasonably. Unlike the legal profession, their work is mostly built around trust and honesty. They do not want a return to the ‘good old days’ where those with a political bent in the medical profession could influence what the Medical Board did.

While this is a very difficult area for us to investigate, with arguments and counter-arguments at every step, we cannot understand why the Medical Board would turn to arguably the most political organisation, the AMA, for its counsel (the national Board Chair met earlier this year with “senior leaders from AHPRA and representatives of the AMA” to workshop doctor complaints).

Why? Our e-Poll responses raise a question mark over the AMA’s involvement (and we don’t think AMA members have been polled on this issue.)

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