No-one runs hospitals: John Menadue at RACMA meeting

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Addressing the inefficiencies and inequities of our health system requires system change, rather than just more money.

In this presentation to the the February 2008 meeting of the Royal Australasian College of Medical Administrators, CPD Chair John Menadue addressed the fundamental structural conflict between clinical and corporate governance in our hospitals and suggested ways we can move towards solutions which achieve both medical and organisational excellence.

The full text of his speech is available here and below.

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Dr Clare Skinner
Emergency Registrar RNSH
Hospital Reform Group

John Menadue perceptively describes the
fragmentation of clinical and corporate management that underlies so many of
the problems facing our public hospitals.
Unfortunately, fragmentation extends much further in healthcare: we have historical professional and
disciplinary boundaries which impact negatively on teamwork and workplace
culture, often affecting delivery of clinical services where they are needed
most; we have professional training systems which fail to recognise their
fundamental relationship with workforce shortages, and thus their impact on
clinical quality and safety; we have fragmentation of health representation,
with powerful groups, representing the interests of the few, often openly
disagreeing in public; and we have a failure to bridge the philosophical divide
between those who see prevention as the answer, and those who provide acute
services in hospitals or in the community setting.

Allowing clinicians to do as they please is
not the solution. We need to employ the
now considerable evidence about health service delivery and start making brave
decisions together. When treating
patients, we clinicians must consider ‘the bigger picture’, it is not good
enough to assume that this is the job of health economists and managers. To do this, we need thoughtful policy, legal
support, a mutually respectful relationship with management, and the goodwill
of the community. A good start would be
some sensible discussion around appropriate provision of services to the frail
elderly. Those clinicians with a talent for management must be nurtured, for
they are key in forging links between the population-based perspective and
individual patient care.


Paddy A. Phillips
Acting Chief Medical Officer, SA Department of Health
Professor and Head, Department of Medicine, Flinders University
Director, Division of Medicine and Related Services, RGH

I agree with what John has written. Modern health care has evolved rather than been designed. Everyone works to
optimise their own segment whether it be the states vs federal governments,
hospital vs community practitioners, one profession vs another profession.
Understanding that teams linking across boundaries achieve better outcomes than
individuals working in silos is fundamental. So, mutual respect, trust, and
jointly agreed goals, across managerial, legislative, and professional
boundaries become foundation values for a health system to work better. Asking,
and listening to those who do the work is integral to building respect, trust
and goals. Bottom up leads to change much more so than top down.


John Dwyer
Chair of the Australian Healthcare Reform Alliance
Professor of Medicine at the University of NSW

Doctors are
totally frustrated by management efforts to save money by rationing their
services. Artificial Christmas closures, limited access to theatre time, the
closing of beds (indeed whole wards), restriction of out patient activities…
all distort models of care and in all cases is driven by budgetary pressures.
Few major hospitals have an Executive Director or General Manager capable of
making significant decisions. These must be referred up an endless chain of
managers to the CEO. For this reason Clinicians have fruitless meetings with
their executive team when urgent decisions are required. Real decision making
is an "Ivory Tower" phenomenon.

Doctors can and do manage large budgets and the model in Sydney of having the Director of a program
assisted by a nurse and business manager (such as I had at POW where my budget
was $80 million) worked well. All that has disappeared with the centralisation
of services in the new huge area health services that blight NSW.

NSW health has hired consultants to work up recommendations for improving
"Clinician Management connect". How genuine are these efforts?


Kerry Goulston
Emeritus Professor of Medicine, University of Sydney
Chair, Greater Metropolitan Clinical Taskforce
Member, NSW Health Department Health Care Advisory Council

Clinical Staff are certainly leaving, but many are also staying in Public
Hospitals – though without their previous drive and commitment. Instead, they put their energy into their private practice or a Private


Dr Brendan Murphy
Chief Executive Officer
Austin Health

In general the picture presented in this speech is perhaps gloomier than reality, certainly in Victoria, but it doesn’t hurt to highlight the issues, all
of which have a lot of truth.

I would say that not one health minister has PUBLICY acknowledged that we can’t have all that we want in health.

In the comments on inappropriate use of resources, I think it is always relevant to also bring up the vexed question of futile end of
life care. Most major Intensive Care Units, at any one time, have one or two actively treated patients who are clearly dying with no prospect of recovery.

I am not sure that I agree with John about Hospital Boards, at least not in every jurisdiction. Certainly the experience you describe is what seemed to happen in NSW, but I am not convinced that it got any better in NSW when the Boards were effectively abolished. The Board model is working reasonably well in Victoria – the key issue is to have a skills based Board, a health service of sufficient size that the Board owns the issues, and at least some autonomy from government so that they
feel they have some autonomy of direction. Our Boards, in general, are very concerned about quality and safety (for example I have been allowed to get onto my Board a senior surgeon and academic physician, as well as strong financial and risk management people). I agree that a Board that is very political or interest group focused does not work, but I certainly sense that our model in Victoria is much better than NSW.

I totally support your call for greater clinician involvement in management. It is very difficult but it does work.


The Canberra Times covered John’s speech in an article entitled Let clinicians run hospitals, Menadue says.


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