About 10 years ago I sat on an area health service patient safety committee. This was an in-house service committee and I was the token community representative. I was astonished that the most basic methods of root-cause analysis were just being introduced after more than 150 years of public health in New South Wales. It also became obvious then that the one root-cause of significance was over-worked staff. In the years since my resignation from the committee, the burden on the staff has been steadily getting heavier.
In 1994 the lid was lifted
What is the most dangerous situation the average person can place himself in - a situation that motorcycle racers and rock climbers routinely place themselves in? It is being admitted to a hospital. That was the message that the federal health minister, Carmen Lawrence, received in February 1994. The startling revelation emerged out of a study she had commissioned. She was advised by Tito and Associates that in an average year about 14,000 hospital patients were dying unnecessarily. Tens of thousands more came out of the hospital experience sicker than they were when they went in.
On February 27, 1998, the Sydney Morning Herald headlined: “No action over hospital deaths.” That was four years after the problem was exposed! There was no firm action until June 2000 when the patient safety committees finally appeared in public hospitals. Why the action only after 90,000 had been killed? Why so much time trying to find fault in the research results (as if only a tenth as many killed is an acceptable figure!).
I think I know, because I have been there as a public health employee at middle management level. I have also been there as a health consumer representative and a support person for hospital staff who have made formal grievances: a total of 45 years. My cynical conclusion is that the first priority of a bureaucracy is not to provide a service, but to protect the bureaucratic process. Meetings have to be held, papers written and career paths protected.
(It has to be stated here that most of those who died unnecessarily were frail. The mistake pushed them over the edge less than a year or two before they were due to leave for the next world. Nevertheless, most of them went before their families expected them to go.)
Where are the disclosures?
Of the more than two million employees in both our acute and caring health services who have witnessed millions of serious adverse events during the past 150 years in New South Wales, how many have blown the whistle? You could count them on one hand. I would have loved to have blown the whistle - but I knew that the only behaviour that would have been corrected was my own.
John Menadue who wrote the Report 2000 for NSW Health claims that the root-cause of the problem is a lack of leadership. How can there be leadership if the Minister of Health can be summarily dumped by the Premier, and the Director of Health can be summarily dumped by the minister, and an area health executive can be summarily dumped by the director. How could senior management have anything other than survivor mentalities?
The system would collapse if the vast majority of public health staff on the ground did not put in the extra effort beyond that which they are paid for. They are dedicated, but they are not heroes. It is a tragedy that tens of thousands of health workers (including the executives), who earnestly desire to do a good job, are stuck in a system in which they have accepted that the choice is between not worrying or getting out. But, occasionally, there is mass industrial action.
On November 23, 2010, nurses in New South Wales staged a mass protest. To hit back at the nurses’ union, the New South Wales government has dipped into the limitless funds it has for initiating legal action. (What other reaction would one expect from survivor mentalities?)
You as a survivor
Flowing down from New South Wales parliamentary system, the members of which are themselves obsessed with their survival, there is no courageous leadership in the public health system. Management is the taking of the course of least resistance with self-survival guiding one’s every decision. It is a game of push and pull, the bluffing and the calling of bluffs. A supplier of hospital goods or services on the long list of those who have not been paid for months can expect to wait a very long time if he does not appear to be a media threat. The same rule applies to patients.
If the system in its present form is incapable of making itself safe for you, then you as a health service consumer should also adopt a survivor mentality. Where, if anywhere, does your power lie?
- Area chief executives dread a phone call from the minister demanding an explanation as to why an adverse event about their area service got into the media. It is worth noting that it is not what happens, but what the public hears about that matters.
- Have a pocket recorder with you and record everything you say to a doctor or nurse. Ensure that the staff know that you have the recorder. In an under-resourced system where choices have to be made, it is the potential trouble-maker who increases his probability of receiving priority service.
- Most importantly, if your child or grandchild is admitted to hospital, then roster a 24/7 family vigilance by his or her bedside. The sight of you there watching intently triggers a subconscious alert in attending staff.
It should not have come to this - but that is the way it is.
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