Rural Hospitals: Doctors Must Stand their Ground on Safety

THE recent Four Corners exposé of the failings of rural and regional hospitals was confronting. Just like many recent stories about the drought, the program jolted urban people about the desperate state of affairs in rural towns, while for rural residents it created hope that those with power and influence may see fit to take action.

We do not seek to review the cases presented by Four Corners but rather distill what we see to be the signs of regional and rural hospitals under great strain. The program provided a reminder of the adverse outcomes resulting from this strain; it is consistent with our long experience in rural hospitals and the public health system at large.

Bed blocks cause pressure in the entire hospital system, not only the emergency departments. The blocks also affect movements to and from the operating theatres, to and from the wards and from community to hospital. In rural settings, bed blocks not only result in sick patients on corridor trolleys and chairs, they also cause patients to pile up in smaller hospitals, unequipped and unstaffed to handle very sick patients, as they wait for transfer to larger hospitals.

Stress from juggling excessive demand translates into clinician burnout, inability to maintain professional excellence, apathy and, eventually, indifference. 

When morbidity and mortality audits indicate the system is failing, a culture of suppressing evidence instead of constructively addressing challenges using clinical governance only compounds patient and staff risk.

When the system is struggling to properly care for patients, it might be reasonable to ask whether that same system has the resources to train and supervise its students. While we see the benefits of an immersional approach to clinical placements for students, we strongly object to them being used as cheap labour solutions in understaffed departments.

The need for accurate, contemporaneous documentation is not disputed. However, the paperwork burden can sometimes become so overwhelming that it defeats its purpose, getting put aside or filled in mindlessly.

The old adage that a proper history is vital for an accurate diagnosis remains as true as ever, but that takes time. So too do physical examination and vital signs.

We could not help but observe some ironies in the Four Corners program.

The reporter lamented in Latrobe that there was “a lack of GP clinics in the area who are willing to bulk bill”. Setting aside that clinics are not persons, Four Corners did not offer any analysis as to why this might be. Perhaps it has to do with the rebate freeze? Perhaps it has to do with the demoralisation

 of general practice? Much has been written before about what is wrong with general practice presently (here, here, and here).

The Four Corners cases provided some analysis of doctor errors, and in fairness, there were some very frank opinions from doctors on how the mistakes happened and should not have happened. But we were also struck by who was NOT interviewed.

This goes to the heart of the cultural and systemic problems facing rural hospitals; senior bureaucrats and media officers run the narrative. Clinicians live in fear of their jobs and disruption to careers. The Four Corners program is only the latest chapter about the lack of trust in the system.

If we had been interviewed, our time in rural hospitals may have yielded the following responses:

  • understaffing is the number one problem and seed of most of the other problems;
  • the above causes pressure on rosters and over-reliance on locums and agency staff;
  • there are not enough beds and this causes bed block;
  • there is an inability to divert or turn away ambulances when the beds are blocked;
  • administration staff are too detached from clinical care and don’t help enough or at all during busy times;
  • administration staff are overly concerned about ticking boxes for their performance indicators rather than genuinely providing adequately resourced and safe patient care;
  • complaints and suggestions don’t receive replies let alone actions – the performance indicators need to include timely reply to correspondence; and
  • investigations that are meant to analyse systems too often end up blaming clinicians, leaving administrators untouched.

So how do we move forward?

We should stop pretending as a nation, as actual or potential patients, or as health care practitioners that we can deliver on increasing demands without being allowed the time to safely diagnose and treat. This means time to focus on the needs of the patient, take an accurate history, perform an adequate examination, consider and investigate the differential diagnosis, and properly inform the patient about the management plan.

Time is a resource that is critical for good patient outcomes and reducing error. And yet all too often it is assumed by politicians and bureaucrats that good clinical practice can be made more efficient by curtailing or omitting critical steps in diagnosis and treatment. As the ABC has shown, omissions can come at a very high price.

It is time for the health professionals, on behalf of patients, to stand their ground on what it takes to properly assess and safely treat patients. If governments want to cut taxes so that individuals have more discretionary income, meaning less for publicly funded health care, then it may be time to charge to improve safety in public hospitals, just as airline passengers accept the need to pay for their safety in the air.

Our public hospital system is under increasing pressure to provide health care, not matched by adequate resourcing, contributing to distressing accounts of avoidable and unacceptable patient harm, as in the Four Corners program. Continuing the status quo will ensure that an under-resourced and overwhelmed system will provide more reports of failure to protect patients, families and staff.

Dr Aniello Iannuzzi is a Visiting Medical Officer at Coonabarabran District Hospital a Clinical Associate Professor at the University of Sydney and University of New England

Dr Chris Davis FAMA is a physician and former Queensland assistant health minister.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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