Who runs hospitals? Part 2

John Menadue has recently mobilised an argument that ‘No-one runs hospitals’. Modern hospitals are extraordinarily convoluted and multifaceted. They operate with high technology, undertake many intricate diagnostic and clinical responses to treat acute and chronic patients, and use impenetrable language and jargon.

Put like that, the challenges facing hospitals sound overwhelming, and they can be, but a lot of patients receive great care and leave with their condition resolved or much improved.

Although the health system gets roundly criticised every time mistakes are made, errors occur in all human endeavours, and can never be eradicated. But, largely because of their complexity, hospitals can be disorganised, some clinical units can be worse than others, or deliver unacceptably poor outcomes.

Studies in several countries including Australia have looked at why things have gone wrong. Often a conclusion is that there are breakdowns in communication and coordination between different health care providers or parts of the system leading to mishaps.

This is where newspapers focus their attention. They delight in presenting the health system as if it is constantly in crisis, and every patient is in mortal danger. The other major line taken is of miraculous cures by the next amazing breakthrough in scientific wizardry. The upshot is that clinicians are either heroes or villains. If they get it right they are showered with respect and praise. When things go wrong, litigation can be pursued and the press or the Minister for Health can attack the ‘perpetrators’.

In reality, health care is much more about the hard work of delivering good care to millions of Australians every year. The approaches developed to improve this care include introducing information technology for decision support and early warning systems, encouraging standardised treatment plans and better interaction and collaboration, networking services together more efficiently, and more and better targeted education, training and leadership programs.

Even with these initiatives, a lot of reform effort can and does fall short of the mark. Studies have shown that ‘reform’ often takes the form of restructuring, which often merely changes the boxes on the organisational chart. It changes who’s in the deck chairs, rather than promotes real change. Despite this evidence, restructuring is the common health sector response.

Despite some forward-looking people implementing ways to create better care systems, in-built problems remain. This is where Menadue’s ‘no-one’ comes in. Senior hospital managers, like their executive counterparts in other industries, spend most of their time attending to the organisation’s infrastructure services – the IT, human resources, planning, marketing, public relations and financial functions. They supervise the professionals only in an abstract sense. The ‘real’ work is done mainly by the professionals.

The professionals in legal firms directly manage their clients, university professors look after their own students, journalists cultivate their sources, and accountants engage with their customers. In health care something similar happens. Doctors admit, treat and discharge inpatients, look after them as outpatients and, in conjunction with colleagues, provide consultations, treatment and care. Infrastructure support services are coordinated by senior management. No-one person or group runs the whole organisation, but all collectively do.

So in professional organisations there is always a gulf between the senior managers who run things and professionals who do the work. But the evidence time and again shows that clinicians and managers in health care are members of different tribes. Doctors have much discretion to practice in their own way. Indeed, many are independent contractors to the hospital, and even salaried specialists have rights to treat patients privately, while using public facilities.

Most clinical practitioners and managers feel they are under more scrutiny from the media than those in other industries, and they are probably justified. You only have to watch television or read a paper to know how often health care stories feature. It adds to the pressure on the system, and means that politicians and policymakers want to get involved in problems when they arise. This makes for dispersal of accountability, such that it is not always obvious who is responsible for which part of the system, or for particular decisions. Ministers and senior bureaucrats have become more meddlesome over the past decade, and often try to micro-manage the health system.

So Menadue is right in his assertion – to a large extent, but not completely. He is correct that you cannot always confidently point a finger to the person in charge in health care. While this is true of other industries, hospitals are undeniably an extreme case.

However, that is not to say there is a total failure of command. Despite the puzzling, labyrinth-like nature of hospitals, there is a system of care, a great deal of expertise on hand for treatment, and many dedicated professionals. There are efforts to make hospitals more transparent and accessible. More and more, patients and consumer groups are seen as having the right to know about their health system, and are demanding that care and its management are improved.

Much more needs to be done. Hospitals are a heady, expensive mixture of drama, technology, professionals and sick people, all with a story to tell, sometimes locked in life and death concerns, all with big doses of public scrutiny. Overall, they pose considerable challenges to those who want to make them more streamlined and effective. Clearer accountabilities, and sharper assignment of responsibilities, along with focused teamwork, would enhance performance. We can target where to allocate the money better. We can improve quality of care, and some hospitals are doing this better than others.

We might be able to report back to John Menadue sometime in the future about substantial improvements. In the meantime there is much work to do to design better health care for patients. Menadue by his statement has implied that the health system needs a major improvement effort. It is time to accelerate that effort.

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