Abstract
DEAR SIR,
I read with interest Peter Shea's paper[1]and the Comment by Tom Callaly.[2]While agreeing with their assessment, I view the problem as a system failure rather than a fault of the medical administrator or for that matter that of the manager. It is important to recognize the difference between personnel failure and system failure because the latter requires more drastic changes.
When the large mental hospitals closed with opening of general hospital units and the establishment of community services, the old system of service delivery with medical superintendent as head came to an end. The governments at this stage looked for an alternate model. Corporate structures successful in business and financial activity attracted their attention.
The new system was that managers were expected to provide certain outcomes for which government provided the funds. The managers employed doctors to achieve the target set by the government. A system of internal monitoring was expected to assess the results and any failure rectified by internal strategies or by infusion of funds. The system on paper appeared to be satisfactory. However, there were obvious difficulties: (i) health benefits are not easily assessable in the short-term;(ii) managers are not adequately informed about health issues; (iii) doctors are not experienced in financial management; and (iv) advances in medicine and the increasing expectation by patients brought in new pressures.
Corporate structures such as the banks and insurance companies attracted the talented professional manager. The ‘managers’ in the health sector had a narrow focus of ensuring the expenditure was within allocated funds. This is understandable, but the manager also failed to give an accurate feedback to the government of the state of the services.
A symbiotic existence developed between the manager and the medical administrator. A medical administrator is needed under the Mental Health Act of Victoria to function as authorized psychiatrist. He is also needed to give a medical stamp to decisions made by administrators and get colleagues to ‘toe the line’. Last, he is expected to do some propaganda work to show that targets are achieved. He cannot avoid this, because these targets are contractual obligations that he has signed. Questionable publications, deceptive name boards and luncheon meetings supported by drug firms are some of the gimmicks employed to impress the non-medical manager. In turn, he is given a higher salary from the ‘savings’ and ‘goodies’ from the network. It is not necessary to have a good clinician for the job; in fact, appointment of such a candidate would put the system in jeopardy. The system does not get good applicants. If it does, it is already programmed to reject them.
The fault in the system lies in internal monitoring of progress. It is incompatible with the human instinct of selfpreservation. If the system is to work, this critical function must be external.
This monitoring of services must be done by an authority staffed with professionals experienced in clinical and health service research. Hospital statistics are a poor substitute for properly conducted epidemiological studies. For example, of what use is the figure of service-related suicides published annually without any knowledge of the number of suicides due to major depression not seen by the service. After all, the hospital is to serve people in the catchment area. There are other advantages in setting up this authority consisting of researchers, clinicians and managers, because it could serve as a pool of individuals that could provide future managers and medical administrators.
In the meantime, can any change be brought about? It has been suggested that more serious clinicians should accept administrative positions and try to bring about change. This approach has failed. Such clinicians have quit in disgust. My view is that no clinician worthy of his name should accept such servile positions. Clinicians are in a position to break this symbiotic exis-tence. They should do only what they are best trained to do. There is no need for them to share the responsibility for failure. Ultimately, this might precipitate a need for change.