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Deaths and Politics in Victorian hospitals

Growth is choking our city, our public transport, our parking lots, and streets and causing more and more "shortages", and rising costs - particularly in hospitals. Does it take a death of someone waiting to get some funding? More democracy in the system would solve a lot of the problems. When workers are too scared to complain vigorously, the patients aren't heard either. Does anyone have a choice in this system? Who is responsible?

Never enough money for hospitals with this rate of population growth

(Article adapted from a comment on deaths in hospitals on 10 October 2011.)

A May 2010 proposal for the Austin Hospital in Melbourne described the emergency department as treating about 16,500 more patients a year than it was built to manage, blowing out waiting times for care. The nearby Ivanhoe district had been declared an "activity centre" for more population growth. This means 17,000 NEW residents are planned for this small catchment area of the hospital in the next decades. The Austin Emergency Department (Casualty) now sees over 20,000 more patients/year than it was built for, or 40% more than a safe capacity.

Add all the other "activity centres" and the demands on this and all Melbourne's other hospitals will be compounded and escalate. Obviously this will further detract from medical care in rural areas. We are in a bottleneck gridlock of growth, and funding simply can't keep up. The two industries our State government largely rely upon- housing construction and foreign students - are both on shaky grounds, and both inherently require ongoing population growth. Most of this growth is fed by high immigration but its impact on hospitals is erroneously blamed on a small rise in the number of elderly patients, who are progressively being sidelined out of the main hospital system.

Does it take a death of someone waiting to get some funding?

There are already plenty of deaths, and other adverse events, but that doesn't stop it. And the deaths don't just occur to people on waiting lists. They happen to people who have already made it into hospital beds. Deaths in hospitals are 'managed' on paper until it becomes more or less impossible to attribute them to anything except isolated circumstances, or some scapegoated individual, sacrificed to the institution's survival. Inquiries almost never affect management; only hands-on staff, although management dictate how the hands-on work and often, to satisfy their own projects, interfere with common-sense priorities. It is very hard to sue a hospital. Their every step is managed by their insurers who have created a paper virtual system like wall-paper over what really happens. Hospital accreditation seems to be largely a protection racket, adding to costs and boosting the legalistic virtual system.

Unbalanced management layers crush basic services

Hospital management is top-heavy. Highly paid CEOs take their orders from a State Government keen to have a lovely virtual hospital for political reasons. Human resources teams interpret events according to the letter of very unfair workplace laws, to save money and to preserve power away from hands-on practitioners. There is a wad of middle managers dominated by narrow efficiency and treatment ideologies whose jobs and mortgages depend on them enforcing unworkable rules. Some are completely cynical, some are ignorant, some are so narrowly focused that they cannot see the wood for the trees. Others are fighting to make money to feed and house their own families and take no prisoners.

Unworkable rules suffocate resistance on the ground

The unworkable rules function to suppress on-the-ground criticism of conditions for patients and staff. The way this works is that, whenever a nurse or doctor stands up to management, some inevitable failure to document a detail will be raised as if it is a major issue of safety and professional competence. If the nurse or doctor tries to defend him/her self, the matter will be formalised into a first written warning. This is only two steps away from the sack. A professional can lose their ability to practice just by irritating management enough to have them find cronies to express unjustified alarm about that person's practice. Or they can be in the wrong place at the wrong time, when someone more powerful or popular or enmeshed needs a scapegoat. The workers are judged by boards which accept hearsay. Victorian law does not recognise defamation in Victorian workplaces, so management can say anything about a worker without proving it. They only way defamation can be pursued is after a person loses their jobs if the can show that it led to unfair dismissal, and we know how little power is left in that option.

How it works

Medication errors are a good example of vulnerability in practitioners. Medication mistakes are inevitable in practice. People under pressure make mistakes frequently. This is however not taken into account, although everyone knows that the pressures are becoming intolerable. Mistakes may be frequent, and every member of staff will make them, but management can still arbitrarily designate one of two identical incidents as an unusual and serious mistake and the other as inconsequential. They can ignore mistakes, as they often do, or they can decide to punish them. But if they choose to punish someone, the person accused has no access to the comparative statistics and information about other mistakes made that week, month, year by others, which would place their own mistake in perspective. In the 'merit system' different staff get different treatment according to how much management can rely on them to toe the line.

Toeing the line means that you don't protest against too many admissions, poor treatment of patients, lousy decisions.

Documenting death to death

Deaths are managed by insurers and lawyers. If you have something to say about a death, you had better have had the clairvoyance to document your concern in writing at the time, otherwise it 'did not happen'. "If it's not documented, it did not happen" is a common phrase. Everyone can know, but no-one dares to say. In fact most of what doctors and nurses do is done using speech or action; they cannot document everything in writing, but if they don't they cannot admit to it.

Australian nurses and doctors now spend enormous amounts of time documenting that they have done certain things required by law. It does not actually matter in a court of law whether or not they actually did these things; only that they wrote that they did. Very hard to prove a person didn't do something days or months later when they wrote down that they did. The system is full of cumbersome checkboxes indicating that you observed a patient, monitored them, and checked equipment and medications. For the last decade there have been several computers on every ward and nurses and doctors spend most of their time entering in notes about what they are supposed to have done. How much time does that leave to actually do what they are checking off? Not much.

The Faulty-Towers world of virtual hospitals

This is the age of construction, under duress, of virtual hospitals with virtual wards and virtual patients by real nurses and doctors who are, incidentally, trying to care for real patients. To survive psychologically it is necessary for nurses and doctors to cultivate cynicism. This way of working is exhausting because nurses and doctors spend most of their time and energy 'documenting' their virtual practice, and then squeezing in the real work in wards where there are continual admissions on top of the people already there who need care. No wonder people die. No wonder it is hard to staff hospitals.

Bosses who can't say no to politicians

And the doctors in charge of various departments seem to be chosen for having a style where they never say, "No." They never say, "Enough." They never say, "We have x beds and they are full, so we cannot take any more patients." So the wards and the country are in overshoot. And the nurses and doctors in the ranks have to wear this.

Keeping workers disorganised

One way that management wallpapers over the huge cracks in the system and to avoid revolts is to import workers from overseas. These nurses and doctors depend utterly on their jobs. They don't have access to free health care or unemployment benefits, so they are simply not going to blow the whistle. This is why having immigrant workers whose right to stay in the country depends on their retaining their job undermines nursing and medical care in Australian hospitals and working conditions. It also disorganises solidarity. Long-term staff cannot plan together to feedback sensibly to management in a workplace dominated by insecure new workers who won't back them up.

Accident Compensation Edifice without substance or compassion

Workers who suffer undue stress because of unfair accusations will often seek protection under the Accident Compensation System, only to find that their claims fail because disciplinary action was involved at some stage of the claim and the Accident Compensation laws have clauses that make it almost impossible to claim for treatment or illness if a disciplinary action was involved. Hospitals are quick to find coincidental reasons to formally discipline any worker who brings in a union. The Accident Compensation laws also allow huge lee-way for management decisions, which effectively means that if management give some reason, any reason for their action, however unreasonable, it will be deemed okay in Accident Compensation. It also doesn't have to be substantial; it can be a mere opinion.

It is also very hard for a worker to maintain any kind of resistance to unreasonable demands when they are defending their reputation and their ability to earn a living in an unfair system that does not really allow for reasonable human error. A system which talks about human rights for patients, but does not apply these to their staff, makes human rights impossible to uphold.

Bullying laws

Bullying laws also don't work because they are administered not to work. Unions describe individual cases with excellent documentation, but management and the law administrators simply avoid compliance with bullying law.

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Victoria's public hospitals are struggling to meet demand, according to the latest report card from the Australian Medical Association (AMA). Only 70 per cent of urgent patients seen within the recommended time.

While bed numbers have increased, Victoria still has fewer beds per thousand people than the national average. The shortage of beds and high waiting times is indicative of our population boom, and it has no signs of easing. The growth areas of Melbourne will take in our city fringe and plans for 350,000 new homes, 400,000 jobs and new rail stations and roads are part of the overall strategy. Growth always outstrips funding, and ability to accommodate and care for all the influx of new people. Health care is seen begrudgingly as a low priority, and cost rather than a benefit. Corporate Victoria, with a government being run for the benefit of big businesses, doesn't have funding for hospitals and public health is down on the priority list. Victoria needs another 800 hospital beds.

By Sunday afternoon 700 beds had been closed, with 315 of them in metropolitan Melbourne and 385 in regional Victoria. The nurses' union is demanding an 18.5 per cent pay rise over three years and eight months and the preservation of nurse-patient ratios. The stress of trying to cope and provide quality patient care is being compromised by lack of funds, and population pressure.