INTENDED Submission to Health System Royal Commission - 17/5/05

• Qualification
• Intended Submission
• A: Deficiencies
• B: Challenges
• C: Context

Introduction

A Royal Commission was initially reportedly to be established to conduct a broad ranging inquiry into problems associated with Queensland's public health system [1].

This was triggered by problems at Bundaberg Base Hospital where a doctor (nicknamed 'Dr Death') who had been de-registered in the US for negligence was employed, and allegedly injured various patients [1]. He was also reportedly employed by the University of Queensland in training medical students [1, 2]. However, as there are numerous other problems in Queensland's health system which have caused public concern, the Royal Commission was reportedly to be given broad terms of reference to examine the system as a whole.

It was then reportedly decided that a ($3.75m) Commission of Inquiry would be established with narrower terms of reference (focused on recruitment of doctors overseas, the role of the Queensland Medical Board and medical practices at Bundaberg Base Hospital), and be paralleled by a ($1.25m) Review of the health bureaucracy (which would focus on staffing and resources - and 'put a shudder through sections of the bureaucracy' in the premier's opinion) [1]. 

Numerous other investigations into aspects of the situation are also being undertaken [1].  In particular the Crime and Misconduct Commission (CMC) is to examine Queensland Health's response to complaints about 'Dr Death' - in terms of whether there were reprisals against those who complained and the adequacy of Queensland Health's procedures for dealing with complaints [1].

The basic thrust of this (intended) submission is that none of the investigations which have been established seem to have terms of reference that would allow them to get to grips with the source of problems in Queensland's health systems.

The present author (whose CV is available on this web-site) has no personal medical or health system expertise, and moreover has no inside knowledge of Queensland's health system.

Rather this (intended) submission is based on published reports and prior study and experience of factors in the health system's public administration environment, which seem likely to be the primary drivers of systemic failings such has those that have been suggested to exist within the health sector.

Problems Affecting Queensland's Health System

There have been allegations of increasingly serious deficiencies afflicting the health system as a whole for several years. Some of these are outlined in Attachment A to this (intended) submission. It refers to apparent inadequacies in: governance; management; resources; and medical practices.

There are also various emerging and ongoing challenges which Queensland's health system will have to deal with (such as population aging, higher cost technologies, chronic diseases affecting younger persons and others outlined in Attachment B) at the same time as existing deficiencies are corrected.

It had been suggested at least as early as 2002 that (a) Australia's health system was likely to be in crisis by 2005 [1] and (b) Queensland's health system was fatally damaged [1]. Moreover it is alleged that unions confidentially warned Queensland's Premier in September 2000 that problems in the health system were so severe that a royal commission was likely to be required [1].

Systemic Defects in Public Administration

There is no doubt that ensuring quality in health services is a difficult task - because of the complexity of the issues to be managed. Health systems worldwide seem to struggle with, and universally fail to prevent, significant numbers of injuries to patients as a result of medical errors. Sophisticated efforts to address those challenges have been under way in Australia [1]

However based on the reports cited in Attachment A, substandard medical practices (which triggered the establishment of the Bundaberg Hospital Commission of Inquiry and the Health Systems Review, and are apparently to be the only focus of the main Inquiry) seem to be only a relatively minor, and derivative, part of a bigger problem.

This is because, despite factors such as constrained funding, a lack of overall organizational effectiveness seems likely to be the main factor in the concerns about Queensland's health system because:

• a severely defective organizational culture (characterized by intimidation and secrecy) has reportedly been officially recognized to be a feature of Queensland's health system [1];
• in normal health systems the breakdown in the standards of health practices are not as severe as appears to have arisen at Bundaberg Base Hospital;
• limited resources are unlikely to be the main problem, because the state's health system operated with a relatively low level of resources by national standards for decades without any overt crisis. Moreover:
  • overall public spending has increased quite rapidly over the past decade (see Queensland's Budgets);
  • despite large additional state funding to cut surgery waiting lists, the numbers of operations performed declined and waiting lists grew [1];
  • there are indications in Attachment A of unwise use of resources - such as over-investment in a major hospital building program and under-spending on staff to match that investment; and of imbalances in the types of staff employed;
• there has been no real requirement to seriously consider professional competence in making 'senior' Public Service appointments (see Ombudsman's reasons for an explanation of how this follows when appeals against SES appointment are banned); and
• even with the best of intentions, the political system on its own must intrinsically be unable in making 'senior' appointments to recognize the types of abilities needed for real professional competence or credibility (see The Growing Case for a Professional Public Service for an outline explanation). Unfortunately the intrinsic difficulty in politically recognizing real professional merit is compounded by:
  • the traditional lack of leading-edge inputs into Queensland's public policy debates by competent, independent institutions (see Queensland's Weak Parliament); and
  • the below-world-standard competencies which often prevail in leading Australian organizations. For example, it has been pointed out that: (a) persons with international experience and skills are frequently unable to gain positions in Australian businesses because they are regarded as a 'threat' by existing managements [1]; and significant Australian innovations are often only able to be recognized overseas [1].

Moreover the lack of organizational effectiveness in the health system is likely to be a reflection of general weaknesses in Queensland's system of public administration, rather than of factors that are unique to Queensland Health. This is indicated by the parallels between reported concerns about the health system (see Attachment A) and problems encountered elsewhere in the state public sector such as:

• an unbalanced focus on financial outcomes at the expense of functional effectiveness - which was also seen to be associated with failure in development of Queensland's electricity distribution system (see Failure of Queensland's Electricity Distribution Network);
• blaming subordinates for what appeared to be systemic problems, and an overall loss of organizational effectiveness (in the Families Department) which was also associated with the breakdown of the child protection system (see Review of CMC's Child Protection Proposals);
• bullying of staff - which is anything but unique to Queensland Health (see History of the Growth of Public Service Bullying. The latter stresses the relationship between bullying and the breakdown of the Westminster tradition). Moreover it has recently been suggested to the author that in one Queensland agency, which has not yet been the focus of public attention, the level of bullying (often of subordinates with experience or a depth of knowledge) has grown to 'almost frightening' proportions.

The core of current health system problems is thus likely to be the declining effectiveness of the overall administrative systems through which public resources are used in Queensland.

In this respect it is worth considering that the consequences of eliminating the Westminster tradition of a politically independent and professional Public Service are likely to include:

• a working environment where staff are forced to pay more attention to whether policies and programs will be popular with key interest groups than with whether they will work in practice;
• appointment of 'senior' officials skewed towards those who are politically compliant at the expense of those who are technically skilled - as the latter are more likely to be seen as 'difficult' because they point out limitations in political assumptions from time to time, while 'yes men' have to be more skilled in political gamesmanship;
• a consequent reduction in technical competence in advising about, or carrying out, the complex practical functions of government;
• a lack of effective leadership of public agencies;
• ongoing evaluation of staff performance in terms of appearances (eg the ability to bluff superiors by expressing stylish policy rhetoric) rather than in terms of practical experience and capabilities;
• the rapid growth of purely 'process' functions (which politically-compliant 'senior' officials are comfortable with) at the expense of the technical functions required to perform the agencies' operational roles;
• a predisposition for agencies to fail in their intended function, and for 'senior' officials to have to find someone else to blame;
• an inability to recognize or really value professional competence in others;
• inappropriate training of junior staff;
• a loss of credibility of 'senior' staff with subordinates who have greater technical experience or knowledge - which leads the 'seniors' to (a) feel threatened and (b) use bullying as a management technique;
• poor morale and working conditions.

Many of these symptoms are reflected in reported concerns about Queensland's health system.

These problems are associated with defects in the operating environment created for staff to work in, rather than with the failings of individuals.

They thus can not be resolved by 'putting a shudder through sections of the bureaucracy' (ie by a 'witch hunt') because the history of Queensland's 'reforms' in the 1990s shows that the result of a 'witch hunt' is to reinforce the position of 'yes men' and displace those with the professional / technical skills required for organizations to be effective (see Towards Good Government in Queensland).

The 'witches' who would probably be 'hunted' out are likely to be the people whose capabilities are most desperately needed to re-build an effective organization.  Moreover the bullying management culture 'in' the bureaucracy, which has now given rise to political concern, is a direct result of bullying 'of' the bureaucracy by the political system.

The bullying of the bureaucracy by the political system is in turn largely a consequence of poorly considered theories about economic strategy and public administration which have impacted on Queensland over the past 15 years. These even broader contextual difficulties are outlined in Attachment C.

Implications for Health System Inquiries

Given their terms of reference, it appears that neither the 'Overseas Recruitment / Bundaberg Practices' Inquiry nor the 'Staffing / Resources' Review nor the CMC's 'Response to Complaints' Inquiry will be positioned to propose the types of changes in the overall public sector environment that might enable Queensland's health system to become more effective.

In particular:

• the proposed terms of reference for the Bundaberg Hospital Commission of Inquiry into medical practices seem too narrow. The Australian standard related to managing health risks (AS/NZS4360) requires assessment of factors in the context that can give rise to risks [1]. For reasons outlined in this (intended) submission, such an assessment is impossible without evaluation of the biggest risk factor arising from defects in Queensland's system of public administration as a whole - which the royal commission is reportedly barred from considering [1].
• problems affecting Queensland's health system can not be understood (much less corrected) by the Health Systems Review which deals with management practices within the health system in isolation. Such an approach can at best identify 'band aid' options;
• the CMC's inquiry into Queensland Health's response to complaints about 'Dr Death' (eg into whether staff making complaints were bullied) can not fix the problem by suggesting changes to Queensland Health's complaints procedures or by charging individuals with misconduct, as such problems have their origin outside Queensland Health.

Furthermore, if the source of problems in Queensland Health lies in the inability of Queensland's political system un-aided to identify the types of abilities needed for real professional competence or credibility, it will be impossible for any of the Inquiries to prove this - because only persons with high levels of such abilities are likely to be able to tell the difference (see The Effect of Public Service Politicisation which commented in 1999 on the former Criminal Justice Commission's difficulties in doing anything about Public Service politicisation).

Solutions

In order to rebuild an effective health system, it is the present author's suggestion that:

• the origin of many problems should be recognized to be outside the Queensland health system (as suggested above), and to relate mainly to defects in the Public Service's operating environment, rather than originating in the failure of individuals or a lack of resources;
• renewal should not be viewed as a process which is separate from ongoing operations and ongoing responses to strategic challenges (eg those outline in Attachment B). Separation would be likely to result in a failure over several years to deal effectively with those ongoing issues;
• high priority should be given to creating:
  • a system of civil institutions able both to take the lead in stimulating changes within health functions (affecting both the private and public sectors), and also to provide high quality inputs to public policy debate; and
  • an effective system for real professional accountability in making senior appointments  - as suggested in Accountability of Queensland's senior public servants. A Public Service which can complement elected government by providing a focus on the practical effectiveness of policy is also a vital part of Australia's democratic system of government; and
  • a process for 'truth and reconciliation' - as otherwise past officially-sanctioned injustices are likely to indefinitely delay recovery;
• a 'build-on-what-works' change process similar to that used with reasonable success in Queensland's public sector in the 1970s (see Outline of Changing the Queensland Public Sector) would be preferred to the 'tear-it-all-down-and-start-again' methods used with disastrous results in the 1990s (see Queensland's Worst Government).

There have been various other suggestions about how current problems in Queensland's health system might be corrected eg

• more strategic use of resources, rather than more resources [1];
• focus by governments on meeting emerging challenges, rather than on funding arrangements [1];
• institutional changes [1]; and
• better management information systems [1].

All such contributions are likely to have merit - and the present author is in no position to judge. However none is going to make any difference until the operating environment genuinely values effective performance - rather than merely pretending to do so to the extent needed to gain political applause.

If reforms are not put in place which allow public agencies to be effective, there is a risk of a serious worsening of Queensland's system of public administration. Corruption, some signs of which are mentioned in The Growing Case for a Professional Public Service, could rapidly grow as various individuals conclude that no one is serious about agencies' nominal tasks so they might as well look out for themselves.

April 2005

Attachment A: Public Allegations of Deficiencies

Amongst the deficiencies which have received public comment are those related to: governance; management; inadequate resources; and poor medical practices:

Governance deficiencies include

• federal system [1], and especially duplication of functions [1];
• defects in Queensland's political system (eg weak opposition; government tactic of publicly identifying with the victims and dealing with problems in ways which have the effect of blaming those in the system even though the latter were not responsible for systemic weaknesses) [1]
• lack of government interest in systemic reform. Commonwealth wants to adopt new funding arrangements, while states just take the money and run. No one deals with implications of population aging, expensive technology and growing service demands [1];
• misleading government information about surgical waiting times [1, 2, 3];
• unwillingness / inability of Queensland's health minister to answer hard questions in parliament [1];
• Queensland Health's refusal to notify police of sexual abuse of children which undermined attempts to reform the child protection system [1];
• need to reform Medicare [1];
• establishment of a privacy regime whose main effect was to protect Queensland Health and hospitals from litigation as a result of mistakes [1];
• medical indemnity crisis which makes it relatively hard to staff regional hospitals [1] - and failure to understand that this would force closure of private practices and throw a heavy burden onto the public system [1]

Management deficiencies

• management problems in Royal Brisbane Hospital's leukemia ward [1, 2]
• maladministration [1];
• bullying of staff [1, 2, 3, 4, 5], especially of those who highlight problems [1];
• a culture of intimidation and secrecy, which has been of concern to the Health Minister [1]
• fear of retribution against staff who point out problems [1];
• preventing staff responding to federal survey seeking to identify problems [1]
• relatively very large numbers of non-medical staff [1, 2, 3];
• management emphasis only on costs, as those who run the health system have no medical knowledge [1, 2];
• poor working conditions and quality of care (eg associated with understaffing, high staff turnover, poor management, and lack of penalties for failure) [1];
• despite large additional state funding to cut surgery waiting lists, the numbers of operations performed declined and waiting lists grew [1];
• deficiencies in regional hospitals due to centralization of services [1];
• departmental officials did not mention problems with overseas trained doctors to minister in briefings - though previous minister had known [1];
• an official inquiry into an overseas psychiatrist filed to find evidence that he had been convicted on various sexual offences [1];
• there were many mechanisms to prevent what happened at Bundaberg Hospital but all of them broke down [1].

Resource deficiencies

• a perceived 'unsalvageable funding crisis' facing hospitals (Ware M., 'State's free hospitals under siege', Courier Mail, 23/8/99 - which quoted an earlier government report)
• lack of state funding [1, 2, 3, 4, 5];
• lack of federal funding [1, 2];
• excessive working hours for doctors [1, 2, 3];
• inadequate capabilities at John Tonge centre [1];
• long waiting times for surgery [1, 2, 3, 4, 5, 6, 7];
• decline in bulk billing under Medicare which shifted poorer patients from GPs to overload emergency facilities [1, 2]. However it was also suggested that it is not correct to blame overcrowding on end of bulk billing, as this simply overloads emergency rooms, while overcrowding is due to more seriously unwell [1]
• over-extended emergency departments [1, 2];
• lack of intensive care facilities [1];
• funding cuts, staff shortages and bed closures [1];
• lack of staff and beds [1, 2, 3, 4, 5];
• excessive investment in buildings without also employing staff to provide treatment [1];
• poor staff morale, staff shortages and ward closures at Royal Children's Hospital [1]
• fewest medical practitioners and lowest health spending per capita of all Australian states [1]. On the other hand the Productivity Commission has produced data showing Queensland's relative efficiency   [1] - so perhaps relative low spending is not the main source of the problem;
• lack of care for mentally ill [1, 2, 3];
• disability services that are below national standards [1];

Medical deficiencies

• closed shop for training of medical practitioners [1];
• not training enough doctors [1] / specialists [1];
• unfilled training positions for specialists [1];
• medical errors [1, 2, 3] and negligence [1];
• mental health system was described as unaccountable, incompetent and life-threatening [1];
• employing a struck-off psychiatrist as a top mental health professional in Queensland health [1]

Challenges to Queensland's health system due to changes in, and features of, its environment have also been identified, including:

• strain on health system due to aging population [1];
• high costs of medical technology [1];
• poor average health position of indigenous Australians [1, 2];
• attacks on staff by drunk / disgruntled patients [1, 2];
• poorly educated community suffering a higher rate of health problems [1]
• emerging health challenges facing the community including: widespread obesity [1]; chronic diseases which are now affecting the young and middle aged; and 'super bugs' which resist antibiotics [1];
• more effective use of market mechanisms within the health system - this being one of the proposals by the Productivity Commission for the next stage of competition policy reforms

Attachment C: Putting the Problem in Context

The systemic defects in Queensland's public administration (including the health system) outlined in this (intended) submission are arguably the result of an unbalanced approach to economic strategy to deal with the imperative of economic change over the past 10-20 years.

How this strategy gave rise to problems in public administration generally is suggested in Decay of Australian Public Administration. The latter refers to consequences of the adoption of 'new public management' models which have included (a) politicisation (b) emasculation of Public Services; (c) and ineffectual governance with consequent symptoms including: poor economic performance; social stresses; and chronic weaknesses in infrastructure, service delivery and regulatory roles. These arose from:

• financial constraints on, and distortion of, public functions supposedly to boost economic productivity; and
• politically driven erosion of the professional / technical competence of the public sector in order to ensure there could be no 'bureaucratic resistance' to the latter 'reforms'.

That the economic strategy which drove such changes has been severely unbalanced is argued in Review of Competition Reforms: A Commentary - which refers to:

• the focus given to ensuring competition without a corresponding attention to competitiveness (ie to the ability to compete successfully, which competition alone does not ensure and which is now emerging as a critical challenge for Australia's economy); and
• the failure to realistically take account of the effect which theoretically constructive changes would have on practical aspects of public administration.

Coercive Centralism

Another source of dysfunctions in Queensland's health system is likely to have originated with the fiscal imbalances within Australia's federal system, and to have then escalated in a vicious circle.

This is a subject which is starting to gain attention in other quarters, and so will not be addressed here in detail, except to note:

• the distortion of public sector activities which financial imbalances can give rise to (eg in terms of fragmentation; duplication; and buck-passing);
• the escalation of problems in the effective performance of state functions associated with the rapid growth of special purpose funding in the 1970s - which (a) inhibited longer term financial commitments and (b) forced state agencies to become more skilled in lobbying than in actually doing their job (in the same way that tariff protection affected manufacturers);
• the current federal government's adoption of an increasingly coercive approach in its relationship with the states - because it reached the (not unreasonable) conclusion that the states (quite predictably) are not performing effectively;
• the coercive approach is likely to increase, rather than reduce problems, because it involves (in effect) the application to the states by the federal government of the same sort of overly simplistic prescriptions which state administrations have coercively applied to their agencies for a decade which compounded the systemic difficulties they suffered.

These points are explored further in Australia's Governance Crisis.