Health decision-makers blasted: It’s time to make some noise says Macaskill-Smith


Health decision-makers blasted: It’s time to make some noise says Macaskill-Smith

John Macaskill-Smith
Pinnacle Ventures’ John Macaskill- Smith says the alternative to politically driven models of care is an “organic” approach, like health care homes
Primary care leader John Ma­caskill-Smith says there has been a shocking deterioration in health sector leadership, and he’s calling for a grass-roots


The problem starts at the top. The top saying the bottom is the problem and needs to do more to effect change is disingenuous and certainly lacks insight.

It’s what I’ve been screaming about for years and like Bryan all it ever seems to get you is audits. My huge concern at the moment is the deliberate passive stance being taken by our College, who like it or not, does play a major political role in representing us. The ASMS has been spectacularly successful in NOT being passive. 

Yes yes yes.  Have to say there has been a very passive stance from nursing too. No one seems to have worked out how to save this health sinking ship of which you speak. Nursing and medicine need to be working more closely together for anything to succeed but that requires genuine goodwill from both sides and both groups are struggling to be understood  and truly accepted by the powers that be at the top. Therefore we all cling on to what we are comfortably used to, terrified to make real change and simply remaining at the starting blocks unable to run. Maybe we don t need any bureaucracy at all. 

Let me assure you Barbara, some of us are definitely NOT “comfortable with it”!

Skin in the game. We know the health bureaucrats are a mixed bag / hella awesome w their eye on max bang for buck and placekeepers who just biding time before next plum appt. That this has happened to health - a kind of fossilisation of leadership - when we face the "tsunami of need" is clearly not ideal and its salt in the wound to think of tax dollars going to severance packages like the CEO debacle at Waikato when folk in Midlands GOING WITHOUT. John is not wrong. We need healthcare 3.0 and we need it yesterday but its likely some lancing of pus going to go down first. 

I worked in the Royal Hobart. It was hard then. This is from the registrars saying "it" public hospital bed block / cannot stand. Read.

ALARM bells ringing about dire problems in emergency departments are not new, but have reached crisis level when registrar doctors — the engine of healthcare — are speaking out, risking careers and their mental health.

Having practised in ED for 40 years, I have seen this problem grow.

Level 4 escalation should be rare.


The emergency department is the pinch point in a seriously stressed system, as beds become blocked by patients awaiting a ward bed to be vacated. This overflows to the ambulance bay, where unloading is blocked by patients awaiting a bed in the emergency reception area.

When all ambulances are on the ramp, as has happened, they cannot respond to community calls, a serious life-threatening problem

Further down the line, walk-in patients cannot be attended to, because no suitable accommodation is available.

Then we enter the theatre of the absurd, with nurses and doctors sitting ready to receive patients, but not being able to access them, so the waiting room becomes the clinic, already dangerously overcrowded with ill patients sleeping on the floor, as seen in third world countries.

Now comes the crunch, for, as the registrars have pointed out, those in the long queue suffer and die at a greater rate than those with a clear path to a bed. This has been known for 15 years, from pioneering work by eminent Tasmanian emergency physician Professor Drew Richardson, at ANU and Canberra hospital. Nationally it is about 1000 patients annually, and 40 in Tasmania. Same as the road toll.

Waiting room deaths have devastating effects on staff and should never happen in a functional system. They cannot prevent it.

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Ambulances line up at RHH emergency entrance. Picture: NIKKI DAVIS-JONES





Patients are also delayed getting to intensive care, because vital interventions are available in the ED, or to the operating theatre, where infections are drained, appendixes removed, bowels unblocked, fractures reduced and pinned, all time-dependant for successful recovery. Thus the whole hospital suffers.

Forty deaths from an infectious disease would call for drastic action, like a flu epidemic, but it is brushed aside — as surge demand, winter flu and tourist ships.

But it’s all of these, and more all the time. So what are the causes? Identifying them will lead to solutions.

None of the solutions lies in the ED, and building bigger EDs is counterproductive. Just more trolleys to occupy, waiting for a bed.

WHO is occupying hospital beds unnecessarily? Those not receiving acute care, who could safely be discharged, if a place were available. Nursing home beds are tightly controlled by federal government and supported accommodation is in short supply, and rationed for those not able to afford it, being on the pension. This can be up to 10 per cent of available beds, about 100 beds statewide, and needs a commonwealth-state fix. Now.

Pressure can be put on families to remove them when care finishes. Tough, but reality, they are keeping the sick out. In the US they become liable for daily fees, over $1000 a day, until discharge. Although this is low-hanging fruit, the stalks are tough. Nobody likes this one.

DEMAND AND SUPPLY Nationwide, acute public hospital beds have not kept pace with population, yet such beds are expensive, almost $1 million per bed per year, so governments are not keen to open more, but expect efficiency dividends year after year. We have reached the end of efficiency savings, many more beds are needed.

EXPECTATIONS increasing for medical/hospital care with an ageing population, and many more folks living with chronic disease, punctuated with episodic catastrophes, needing hospitalisation. Diabetes, heart disease, strokes, cancer, chest disease, serious trauma (once lethal) are all now compatible with longer life spans, at a cost. The pharmaceutical revolution has assisted chronic illness, and the very high standards of joint replacement has led to unprecedented orthopaedic demand.

Elective surgery, once cancelled often, is now fairly given some priority over emergency patients. There is a dividend in keeping these people out of hospital, and denying them access when they have had a fair go already, and can be offered a much cheaper, comfortable death at home. This needs closer liaison between GPs, specialists, and hospitals, and could be better funded with liaison nurses and doctors.

PRIVATE HOSPITALS, where much of the surgery, obstetrics and routine medicine is done, don’t like complex elderly patients because they stay longer and often need a team approach better provided in the public sector, so these people are turned away from private hospital EDs, despite having health insurance. They often have lengthy stays, block beds and sometimes die. Revision to Medicare items and fees in private may go some way to address this problem.

QUESTION whether the ED is the best place to deal with a problem. Mental health patients, already in the system, rarely need the ED, just access to the phone, answered by a professional, who can discuss and sort the problem. They only need ED if they are also sick, or maybe in police custody for assessment as to hospital or remand or prison.


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Psychiatric services need their own reception centre now. Mental health are poorly and very expensively served at ED. Many of their problems can wait until daylight hours.

Many call ambulances out of desperation, not knowing where to turn — “beam me up Scotty” to ED where it will all be resolved. Back pain, headache, diarrhoea, fever, cough, minor trauma all can be dealt with outside hospital, maybe 5 per cent have red flags, pointing to more serious illness needing hospital. Studies worldwide show 35 per cent of ambulance rides may be unnecessary. Put an emergency physician in the ambulance control centre to review dispatch, now.

A community emergency, plane crash, big fire, terrorist bombing, infectious disease outbreak would have a devastating outcome in such a blocked system. Even a worse than usual imminent flu season would sorely test the current capacity.

It’s time to stop the talk and excuses, listen to those vital, hard-working registrars, and get on with some short-term and longer-term solutions. Anything else wold be criminal neglect.

Emergency physician Dr Bryan Walpole has been director of Emergency at RHH, co-director Department of Medicine, Senior Lecturer Emergency Medicine UTAS, state president AMA and vice-president of the Australian College for Emergency Medicine

Fundamentally the problem is PHO's: they represent neither the public nor providers. Nor do they represent DHB's. Simply put they are incapable of actually addressing the issues within the community or communicating the community's needs to the DHB. They are very good, however, at negotiating barely comprehensible contracts that pass increasing costs and liabilities without any compensation to providers. I know this because I have to try and make sense of these contracts for local providers. A High Court Judge has described the contract in very unflattering terms and I have to agree with him - not just because he is a Judge but because he is right! This is a consequence of these so-called leaders.

It is not about models of care, it is about a sustainable service. You cannot have a sustainable service without adequate funding. If the service is forced to be self-funding by applying a co-payment then access becomes an issue because of affordability. Restricting the ability to apply a service fee that makes the service sustainable simply to give the illusion that it is making access affordable and demanding a "different business model" demonstrates that the leaders have little or no comprehension of the issues. In case you missed it, I am looking at you Minister. You have effectively alienated the providers. You have made everybody's job that much harder.

Exactly right, Bryan.  In my position of being largely dependent on patient fees, sustainability is impossible with artificially low fees.  However my days of funding those earning more than I do are over!  This, and previous Governments care more for control than quality primary care and have NO concern for General Practitioners, particularly those with Vocational registration.