The Australian health system has undergone a year of conflict, a volatile election, numerous taskforces and reports, tough talk and back downs. With all that, the end point in political and system terms is the same as the start point – there is not enough money in the budget to do everything everyone wants to do in health.
At the recent HITWA health informatics conference in Perth, the Director General of Health, Dr David Russell-Weisz, was explaining the priorities for the WA system in spending its annual budget of $8.6b – an amount that has doubled in just 10 years.
His first was safety and quality – and the nurturing of a culture that puts those things above all others. The second and third priorities were clinical performance and financial prudence.
In his address to a room full of techno wizzes, he kept it real. He acknowledged the serious mismanagement of the department’s ICT procurement which saw millions squandered between 2010 and 2013. However, the experience had, he said, led to greater oversight and a more rigorous contract process. Spending on technical innovation in the new world order had to have clinical and safety outcomes or it would be an empty thing.
It is inevitable – and necessary – that health should be set within a firm fiscal framework but is that shorthand for cost and corner cutting in all the wrong places and the erosion of values enshrined in mission statements framed in hospital foyers across the nation?
We spoke to three people involved in politics, training and the private hospital sectors to learn how values drove what they did and what they perceived as the greatest threats to a values-based health system.
Public health physician Prof Donna Mak and Chair of the Population and Preventive Health Domain at the University of Notre Dame has the responsibility of teaching values to medical students, a task she believes is absolutely possible given the right curriculum and support.
“Our university’s mission is to graduate doctors with both clinical expertise and the values of values of compassion, respect and service but they are empty words unless they are implemented. The curriculum is shaped by the Australian Medical Council and in its requirements for medical school accreditation is the injunction to ensure medical graduates demonstrate professional values including commitment to high quality clinical standards, compassion, empathy, respect for all patients, integrity and honesty.
“But at the pointy end, where it affects students, is assessment. What do you assess them on? Can you assess values? How do you do it?”
“There’s another influential element, which is less overt though inevitable, is the people you have teaching and working with students because students absorb culture. If you have people in the education process who embody those values then students will learn; if you don’t, then regardless of how much you put it in teaching and assessment, it won’t work.”
Learning is for life
“Given the rapid advances in knowledge these days, we can teach students the best, most up to date technical knowledge and still be sure that most of it will change in a few year’s time. What doesn’t change is the need to teach students how to think and to understand the need to keep learning throughout their career, and that includes values and behaviour.”
“This isn’t new. If you were to ask me and many established doctors what we learnt in medical school that we still put into practice today, it won’t be the factual or technical aspects of medicine, but rather our teachers’ approaches to life and work. This form of learning is very influential.”
So can you assess values? Are you going to fail someone for not displaying as much empathy as they should?
Consumers are playing an increasing role in medical training – simulated, actors or the real thing. Consumer groups are urging medical schools to give students more exposure to actual patients early so they can start developing qualities that in an older time were called bedside manner. But does every student have to be an Oprah Winfrey or a Dr Phil to be a caring doctor?
Donna doesn’t think so.
Can you assess empathy?
“Students in most Australian medical schools have patients involved in assessing students in clinical exams. Can you pass the empathy test by acting? Yes, if you are so good that patients don’t know, it may not matter as long as what you’re doing and the end outcome is benefitting people. And you might probably end up believing it yourself!”
A recent article published in The Medical Republic by US physician Dr Louis M. Profeta suggested that patients don’t care what’s happening in the lives of their doctors, what they are after is a smile, competence, reassurance and politeness and while a doctor on the day may not feel all those things, they can certainly do all those things, and in the mind of the patient it is enough.
However, Donna sounds a cautionary note that doctors in small communities don’t have the luxury of anonymity after hours and if there is dissonance between the values on display in the surgery and in their private lives, that doctor could come unstuck.
We all know medicine doesn’t exist in a vacuum. Societal and generational shifts of values permeate everything and it has always been thus. The emphasis placed on some values over others is a moveable feast and not all established values (such as bullying and harassment) should be left unchallenged.
Earning or buying a degree
As UWA and Notre Dame prepare next year to launch their MD programs, they do so in an environment where students are now consumers of an educational product rather than a more romantic notion of strivers for academic excellence. Hopefully the reality is a combination of both.
This commercialisation of universities which has been building for a number of years has shifted the balance of responsibility and, it can be argued, changed the emphasis on some values. If students are now consumers, it goes without saying, they have rights and after forking out close to $100,000 for a post graduate degree via HECS (double if university fees are deregulated and unspeakable if you are full-fee paying) do those rights extend to insisting on graduating?
Unless terms and conditions are clearly stated at the commencement of such an educational contract, universities can find themselves in tricky legal waters. If we extrapolate further could it be possible for universities to accept some liability if a recently graduated doctor finds himself or herself before the Medical Board?
These thorny questions are not for a dystopic future but for a complex present and answers are needed.
The Hospital Administrator
Kevin Cass-Ryall is Operations Manager for Ramsay Health in WA and SA, the publicly listed company that in WA owns and operates Hollywood and Glengarry Private Hospitals, Attadale Rehabilitation Hospital and has the state contracts to operate the Joondalup and Peel Health Campuses. It’s national and international footprint is also large.
The company was started by Paul Ramsay in Sydney in 1964 and now operates 223 hospitals and day surgeries in Australia, France, the UK, Indonesia and Malaysia and was listed on the ASX in 1997.
Paul Ramsay also became one of the country’s great philanthropists and before his death in 2014 had inculcated the simple yet effective value of “People Caring for People” at the core of his business model.
Kevin has worked for the company 22 years and in the early days worked personally with Paul Ramsey.
“He was an inspiration. He was a humble man, a very respectful man and he taught me and all who came into contact with him that health care is about quality, relationships and reputation. If we got those things right, we would be successful.”
“Treating others how you would like to be treated; putting yourself in the other’s shoes; looking after people; being honest; doing the right thing. I can still hear him say that.”
Keeping legacies alive
Those values are Paul Ramsay’s legacy to his highly successful company but now he’s gone, who is the protector of the flame? Well, it would seem everyone who works for the company.
“We call them the Ramsay way values and they are a part of all the orientation in all our hospitals but it’s up to us who have been around for a while to see that the culture of caring continues. Any organisation that wants to be successful needs to have a strong, positive culture and not just a bunch of words on the wall.”
“All companies have values, whether they live by them or not is another matter, but I believe Ramsay does, which doesn’t mean you don’t make unpleasant or tough decisions, you do, every day, but it the way you go about it.”
“Mutual respect is crucial and free exchange of ideas critical and, in tough financial times, that means being innovative. The best way to be innovative is to engage your people. If you don’t have that trust and respect you don’t have that exchange of ideas either.”
“The innovators are not senior management, they the people doing the work who know how to do it slicker.”
“It’s not rocket science. If we treat everyone, regardless of roles, in accordance with our values of care and respect, people will respond positively.”
Roger Cook is long-time Opposition spokesperson for Health and an aspirant for the role of WA Health Minister after the March election. He believes strong values and sense of purpose are central to any successful organisation or system. They are the bedrock in challenging times; if ignored, an organisation will fail to reach their objectives.
Patients must be put first, is his mantra while waste is the enemy.
“Hospital staff are being hounded to save money and create efficiencies but look at mountains of waste in the system every day… around procurement, management of equipment and supplies. They see their colleagues being sacked in the name of saving money. That is in direct conflict with the reasons they come to work, which is to provide care,” he said.
“Workers will respond to that call to arms if it is accompanied by a strong value statement and action around why it’s necessary to do so in the first place. When people monitoring the system outnumber those in service positions, that sends mixed messages to people on the front line about the extent to which they are valued and the extent to which the organisation is following its stated values.”
Waste, silos and bureaucracy
Roger sees the new devolved health services as a positive step in breaking down silos and red tape.
“I think they have the capacity to deliver real efficiencies and devolve decision making to the frontline and that has to be encouraged. Part of the problem we have had in WA, as it and the need to control the quality and costs of services have grown, decision-making has become centralised and that can undermine people who are in the best position to make a decision on the distribution of resources,” he said.
Devolution should also help reconnect the primary and secondary arms of the system which have for so long been working at odds with each other.
But is budget belt tightening (the health budget is now 26% of the entire state budget) the most serious threat to values?
“It is certainly one of the challenges but it doesn’t have to be a limiting factor,” Roger said. “If we think cleverly about a system that is more integrated and that embraces the opportunities presented through digital disruption we will make head way.”
“There are huge opportunities to create a lean, responsive integrated health system. It is simply a matter to have the political will and good faith to undertake the process and that whole discussion has to be underpinned by strong values.”