And as a result the patients are starving.
It would appear, from reading this and other coverage of the sorry state of affairs at Royal North Shore Hospitals, that the hospital’s problems are related to the fact that decision-making in the hospital has been effectively concentrated in the hands of administrators whose principal concerns are the financial bottom line (and with a narrow, unstrategic, intellectually lazy conception of what this entails) and adherence to bureaucratic protocol regardless of the effect this has on the delivery of clinical services, with minimal or no input from health professionals such as clinicians or nutritionists.
This way of running things comes straight from the New Right toolkit of public choice theory, one of whose obsessions is the fear of “provider capture” by professionals (and their unions) in government services such as education and health. Such professionals, so the story goes, are motivated principally by self-interest of one sort or another, and thus if empowered to make decisions or influence policies in such services, will use such influence to enrich or aggrandise themselves at the expense of their employers and the wider public interest which they are supposed to serve. The solution is to exclude the professionals from influence over policy and management as far as possible, and vest power in generic managers free of links to vested provider interests.
Thus Australian hospitals should (and to a large extent do) divest themselves of in-house catering operations by self-interested professional chefs and outsource to commercial caterers, and exclude the self-interested professional nutritionists from any input into hospital menus, decisions on which are made by generic administrators. As a result, patients starve.
I had an early warning of this type of thing in 1989 from a hospital worker who was then a member of the same political party as myself. At that time the hospital where he worked on the Gold Coast had decided to shut down its in-house cooking and catering capacity in favour of outsourcing. My comrade predicted that this would lead to a deterioration in the quality of patients’ diets as the contracted provider would most likely be unable or unwilling to cater for individual dietary needs, to provide additional portions where needed, or to provide food outside of set meal times. Much of this has come to pass at Royal North Shore Hospital.
The theory of “provider capture” can be reformulated thus: on the basis of ideological rather than scientific assumptions about human psychology and human motivation, “economically rational” governments must not allow decisions on the delivery of educational or medical services to be influenced by people who understand education or medicine, as such people will inevitably seek self-enrichment and/or self-aggrandisement rather than the public interest in the quantity and quality of education and medicine. Such decisions must be made by people who are free of the taint of vested professional interest, even if this freedom from contamination comes from knowing nothing about education, medicine, or any professional speciality other than maximising the bottom line.
You’d have to be puffin’ muffins to believe it.
It would be too ironic if this turned out to be the same political party as Morris Iemma.
I’ve always thought that it made no sense whatsoever to employ managers who are so far removed from the profession managing a professional organisation. Programming teams need project managers who understand software development so that realistic goals are set and a realistic time frame outlined. Surgical teams need a Head of Surgery who has been a surgeon in order to provide a surgery that is run well as a surgery rather than as a business.
This obsession with the financial bottom line in hospitals (and education) completely ignores the fact that the real bottom line for a hospital should be saving lives and helping people get well (for schools, turning out well educated students). Yes, it’s important to minimise waste but in a public service there will always be a certain amount of waste and inefficiency. Scrapping services in order to meet ridiculous targets means the institution is less able to get on with what it was founded to do.
To say the same thing another way, Sam, whilst efficient delivery of services should always be the ideal, inefficient delivery of services should be the preferred second-best option over efficient non-delivery of services.
Sam Clifford says…
Yep. Good analogy. Needed, but too rarely granted. (See Dilbert’s Pointy-Haired Boss, although unfortunately, the managers described in this article are more effective at serving themselves.)
Paul’s in The Greens, I believe.
Content free bureaucrats.
The bane of any professional in any industry.
Which should be obvious given the high cost of non-delivery vs potential gains from efficiency. Of course focused performance measures tends to create a tunnel vision within management causing them to ignore the big picture in favour of their little lot.
I have seen far too many hospital meals, from both sides of the tray. They are, without a doubt, one of the most vile forms of slop ever devised.
But.
That article was fast and loose. I am sure that half the hospital population had inadequate caloric intake for their calculated needs. I challenge you to find a hospital without this. Sick people stop eating. It is a predictable metabolic response, especially when combined with the ubiquitous drowsiness severe illness provokes in the elderly. The disgusting nature of the food is unlikely to help and a failure to involve dietitians is foolish but that basic rate of malnutrition is unsurprising.
Secondly, the increased length of stay brought up by the opposition member is association not causation. Sicker people eat less. Sure, eating less makes you sicker but the idea that a round of steak and kidney pie with added sustagen will magically halve your bed stay is statistic as propaganda.
The numbers you want are; what proportion of patients were served a meal inadequate to their needs and what proportion begged their family for takeaway. The only helpful statement in that article was that the patients hated the food.
From the link: “A survey of 777 patients across the Northern Sydney Central Coast Area Health Service last year found 51 per cent were malnourished - and many had not entered hospital in that state.”
Can we see the survey? Who conducted it? Against what criteria? What were the situational circumstances? What was the sample size? How was “malnourished” defined?
In the absence of any evidence other than a Herald beat-up, I’m utterly unconvinced that people are routinely starving in NSW hospitals and the reference in the link to nutritionists being put out because they don’t think they’re central enough to menu composition is a dead giveaway. It feels remarkably like another health interest group pushing self-interest in the guise of patient safety.
“Such decisions must be made by people who are free of the taint of vested professional interest, even if this freedom from contamination comes from knowing nothing about education, medicine, or any professional speciality other than maximising the bottom line.
You’d have to be puffin’ muffins to believe it.”
Really? Ever been a hospital administrator trying to get an utterly incompetent and dangerous doctor, peer reviewed by his college? You’ll hear all sorts of reasons why this can’t happen from, “we were together at medical school” to, “it’s too undignified, he deserves better” to, “he’s been a bit down lately but his heart’s in the right place” (which was more than could be said for his patients).
Ever sat in a room with a dedicated and professional intensive care nurse arbitrarily rejected for a senior appointment for which she was the successful candidate because the docs wanted a much less qualified unsuccessful candidate personally known to one of them? It took three weeks of the CEO wrangling with senior specialists for basic equity and fairness to prevail. But….bloody bureaucrats, etc.
The NSW hospital system has significant challenges and “bureaucrats” are the traditional fallback position whipping boy, but IMO they’re a pretty
minor part of the problematic scheme of things. Try entrenched and competing intramural health cultures - hospitals are often reminiscent of walled Italian villages in the Renaissance - internecine warfare etc. Try Nursing’s endless search for professional validation in any scenario other than the the sort of traditional hands-on patient care perception that the public expects and the consequent invention of endless layers of sub-nursing beings to compensate.
Try shaking the Specialist Colleges grip on medical training and placement. Not only do they appear like medieval guilds they actually retain the culture, mores and practice of medieval guilds and they have incalculably more power in moral and PR sway than these allegedly rabid neo-liberal “managers” who are supposedly “the problem.”
Ever heard hospital managers demanding through the media that NSW Health sort this out? It may be that Managers are an eminently disposable commodity and Senior Staff Specialists are not.
Geoff, quite often, as a part of care for elderly patients, who make up a very high proportion of hospital bed occupancy, their GPs arrange a time in hospital for them so that that they can be cared for. One of the indicators for that admission is malnutrition because as people reach great age they can forget how to swallow and are generally less able to care for themselves. Their presence in the hospital malnutrition statistics would be a sign of a problem being addressed by the hospital and not of a problem with the hospital’s care for them.
The other thing is that many people can enter hospital with conditions which will cause them to be unable to keep down food and therefore dramatic weight loss, and hence malnutrition, is caused by their condition, not hospital dietary practice.
I would ask the same questions as you have and until I had the answers I’d take this report with a large grain of salt.
The meals provided in the Armidale hospital, of which I’ve had far too many, and am sure to have far too many in the future are exactly the same as those provided by Meals on Wheels (which a well-meaning friend got me on for a few months until I realised they were too expensive). I can assure you Armidale hospital does provide good nutritious meals, which incidentally are of the same standard university college meals were in the 1980s. And the people who provided meals to the UNE colleges were, rumour has it, the same people who provided meals to the State’s prisons.
I’ll bet if the same criteria were used to assess blog writers and commentors that at least 51% would be “malnourished”.
How on earth do you survey people to assess malnourishment?
Are you malnourished? please tick.
1 Yes very
2 Yes a bit
3 Dunno,
4 No not really
5 No course not.
Given the hospital stays are somewhere between 4 hours for day surgery to 3 or 4 days for most people it’s a bit hard to see how someone is caused to become “malnourished” by the content of the food.
In most places it is exactly the same food from the same provider as meals on wheels and despite complaints is better a large percentage of people would eat at home.
Most people don’t eat all that much in hospital, it’s always been a problem. People don’t eat much because they are sick and because they are in bed, and because they are not at home in familiar surroundings. A lot of people come into hospital “malnourished”
I’m always curious when the media criticise health services (or any other service) for meeting allocated budgets (focus on the bottom line). What is the alternative proposed to meeting budget? Spending whatever you bloody well like on whatever you like and bugger the income? Going 2% over? or 10% over or 20%?
The challenge in most health services is to get clinicians actively involved in decision making - not to exclude them. Lots of clinicians want to have an involvment that involves sounding off to someone for 10 minutes once a week then bitching when their favourite issue isn’t funded or given a free ride. Like say increased staff and influence of a dietetics department.
I don’t know of the problems with this particular hospital and it may be that indeed the meals are ratshit and non nourishing and everyone there, incuding the adminstration, needs a good kick up the arse or worse.
And there are lots of problems with hospitals but headlines like “patients are starving” just aren’t useful.
The Herald has run story after story on various shortcomings of RNS over the last few years, possibly because a good proportion of its readership live in that area. Or possibly because some senior Herald person had a bad experience there. While I’ve never been a patient there, trips to other public hospitals and chats to nurses suggest another common thread. Simply put, the vast majority of staff are people of goodwill and dedication. The information systems around them, however, are dreadful. Whether it’s patient records or just ward inventory, staff are struggling with limited access to records, lack of basic failsafes in records admin, and equipment shortages that should be unthinkable (eg, a ward running out of swabs and having to “borrow” them from another ward). There is a lot of serious groundwork in the area of hospital records that has simply NEVER been tackled in NSW, so ALL the information systems are prone to failure.