The distribution of power within the health system has a profound impact upon how the funding cake is divided and to what effect.
In the article below, health economist Professor Gavin Mooney suggests that hospital clinicians – and particularly some types of hospital clinicians – wield too much power.
He asks: how can we get a better balance between the interests of individual patients and the wider public good?
Challenging the power of hospital clinicians, for the sake of the greater good
Gavin Mooney writes:
Working with hospital clinicians on various occasions, I have been forcibly struck by the gap that exists between clinical medicine and population health.
Trying to get agreement, not only about how to prioritise between different specialties, activities, treatments, etc, but why this is needed, it is clear that hospital clinicians are driven by an individualistic ethics which results in their being interested only in their patients.
The idea of the social ethics that lies behind, for example, the betterment of population health is alien to them.
In a sense that is fair enough and as a patient I would not want anything else.
But as things stand, it is a mistake to think that what individual clinicians, left to their own devices, do with their own patients might result in what society might want from the system as a whole – some overall public good as seen by the community at large.
In so far as it is recognised as an issue at all, the idea of maximising population health is not seen by hospital clinicians as their problem. It is someone else’s.
“Then whose?” I ask. “Who has the responsibility to try to ensure that health care resources are used as well as possible (in economic terms efficiently, with some allowance for equity)?”
Interestingly, trying to answer this fundamentally important question is difficult. I recall one surgical procedure being identified by a group of senior clinicians as being such that there was evidence that it did no good. Yet it was still being carried out in that health authority.
Why? Because those doing it thought it did do good – and no one was able to stop them!
This sort of problem means that more people are suffering and dying than need be the case. Again, seemingly, not the hospital clinicians’ problem.
The idea that some clinicians might give up some of ‘their’ resources because another can do more good with them is anathema.
(I note in passing that those whose resources these really are – the citizens – and those whose health in combination is at stake – again the citizens – are nowhere to be seen or heard in priority setting debates.)
This, while disturbing, is no surprise to me. Working in one health authority, I was asked by the CEO to see what I could advise to reorganise theatre use to help to reduce waiting times overall. This study floundered as only 44% of the surgeons were prepared to allow me to have access to their data. (These were public patients.)
I tried to work with the 44% but, when I suggested that one surgeon move to another theatre at another time, I was informed by the CEO that thiswas not on, as that surgeon had been operating in that theatre at that time for the last 30 years.
A priority setting exercise in a set of hospitals went very well until an attempt was made to implement it.
It was decided by the executive to start in one specialty where it was thought there were inefficiencies. The head clinician in that specialty then point blank refused to take part. No one could make him. The exercise died and with it almost certainly some patients unnecessarily.
A chief medical officer wanted to close a unit of a particular surgical specialty as, he said, there were too many. He asked if I could work with a group of surgeons to determine which unit to close. I did, and came up with a clear answer showing which unit was least efficient.
Discussing the findings with the Chief Medical Officer just before I was due to present them to a meeting with the surgeons, he told me he was not going to close any unit. I wonder why?! I pointed out that he had just lost about $1 million that might have been used, for example, on Aboriginal health.
If power were distributed equally across hospital clinicians, then within hospitals the issues raised here would still matter but matter less.
But it is not. By and large surgeons have more power for example than geriatricians or psychiatrists.
The teaching hospitals in Perth overspent by $100 million. They were bailed out. At the same time, the Aboriginal Medical Service in Perth, Derbarl Yerrigan, overspent by the same percentage, but a much smaller absolute amount. They were not bailed out. They were forced to close some of their services.
Hospital clinicians wield much more power than those running other health services such as Aboriginal Medical Services.
There are two important issues here. First, there is no recognition of a concept of the common good and second, there is a vacuum in health service power to seek to implement policies which would promote the common good.
I am a health economist, not a medical economist. A definition of health economics is something like: using the tools of economic analysis to try to ensure that society’s resources which can affect health are used efficiently and equitably.
I want to see medicine continue as a noble discipline. I want to see hospital clinicians continue both to care for and care about their patients.
But I want them to do this in the real world of scarcity of resources and to stick to what they are good at, which is treating patients. The sort of power that hospital clinicians exercise and the sort of ethics they subscribe to are fine at the bedside. Indeed I would defend that vigorously.
But when that power leads to inefficiencies and inequities that result in people dying and suffering unnecessarily, it is time to think again.
The question: “who is responsible for the overall efficiency and equity of the system?” needs to have someone named in the answer, and that someone needs to have the power to foster population health as a whole.
All of this is about power but it is power hidden behind the veil of ethics: the individualistic ethics of the medical profession – especially hospital clinicians – and the lack of recognition of the social ethics needed in the health care system.
But who will agree to take on the power of the hospital clinicians?
This is a fight worth fighting. Otherwise, as now, people will continue to suffer and die unnecessarily.
• Gavin Mooney, Health Economist, University Associate, University of Tasmania
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