KERRY O'BRIEN: Welcome to the program. While few would dispute that Australia's public hospitals are bogged down by political arm wrestles between the states and Commonwealth, the raft of problems that have combined to create the crisis over years are far more complex than a simple black-and-white political tug-of-war. How to actually break the gridlock is a challenge which has brought many would-be reformers to tears. Rebel health professionals, who in desperation have formed a ginger group seeking radical reform, say the road to that reform doesn't always lead to Canberra. Tonight, in the second part of our look at the future of public hospitals, we scrutinise a scheme that puts the wood on members of the public to directly decide how the health dollars available to their communities should be spent. Jonathan Harley reports.
JONATHAN HARLEY: Dr Darryl Mackender is on his daily rounds through the halls of Gosford Hospital, north of Sydney. He's not visiting patients but hospital administrators. His mission - to find a casual doctor or locum to fill the endless gaps in his staff roster.
DR DARRYL MACKENDER, GASTROENTEROLOGIST, GOSFORD HOSPITAL: Dave will just have to find a registrar and ED from somewhere else. A resident and ED from somewhere else. Talk one of his day residents into doing nights.
OTHER ADMINISTRATOR: Have you talked to [inaudible] about it?
DR DARRYL MACKENDER: He'll love it. I'll walk around there now.
OTHER ADMINISTRATOR: Sounds like a good plan.
DR DARRYL MACKENDER: Alright.
JONATHAN HARLEY: In Sydney, accident and emergency resident Clare Skinner is confronting the realities of embarking on a career in public hospitals.
DR CLARE SKINNER, EMERGENCY SPECIALIST: It's a mess and unfortunately, it's real people that fall between those gaps and we need to start sorting it out.
JONATHAN HARLEY: In Canberra, they're joining veteran medico Kerry Goulston to tread the halls of power. They call themselves the Hospital Reform Group and they'll tell any politician who will listen that working in public hospitals has become a labour of love.
PROFESSOR KERRY GOULSTON, FACULTY OF MEDICINE, UNI OF SYDNEY: It's a feeling of battling with a huge system and the system has become bureaucratised - there's no question about it - so it's a much tougher system to work in.
JONATHAN HARLEY: Across the country on the south-west coast of Western Australia, dairy farmer Ross Woodhouse has more on his mind than his new calves. He's helping decide how to best spend health dollars in Margaret River.
ROSS WOODHOUSE, DAIRY FARMER: My whole concern about the health service is sustainability - whether our health service is, in the long term, sustainable.
JONATHAN HARLEY: Ross Woodhouse was drafted to an unusual experiment in health care reform, one which the hospital reform group believes is key to taking pressure off public hospitals. The initiative is called Citizens Juries.
ROSS WOODHOUSE: I was a little bit sceptical, I guess. I thought maybe it was just a whitewash. The whole thing was designed to be a PR exercise, really not to get to the bottom of what a health service requires.
JONATHAN HARLEY: The idea sits somewhere between a town hall meeting and a focus group - randomly select 14 voters, sit them down with the hard facts about the health of the local population and the money available to look after them. Then, make them choose how best to spend the budget.
ROSS WOODHOUSE: And we had examples thrown up to us that it cost $1.5 million to have three or four patients basically in a hospital and costs $1.5 million to run a hospital for the year, so the question then arises, is that efficient use of capital?
PROFESSOR GAVIN MOONEY, HEALTH ECONOMIST, CURTIN UNIVERSITY: It was put to them - OK, if you are going to have these, what are you going to give up? Fascinatingly, what they were prepared to give up was some of their small, as they saw it, inefficient hospitals and some of their small emergency departments.
JONATHAN HARLEY: The jury had to identify six main priorities for their hospital system. The program was run by the state Health Department and chaired by health economist Gavin Mooney.
PROFESSOR GAVIN MOONEY: What they came up with was a strong view of what they wanted more of was greater equity and greater fairness in the way resources are used, particularly for disadvantaged people and especially for Aboriginal people. They also wanted more resources for mental health, for people suffering from mental illness. They wanted more resources for prevention and public health.
JONATHAN HARLEY: The results closely echo the reform group's prescriptions. Spend more money on keeping people out of hospitals so as to ease the burden on a straining system.
PROFESSOR KERRY GOULSTON: You have to be bloody sick to get into hospital. We're the end of the line as far as health care goes. The vast bulk of health care is delivered outside hospitals and therefore, if we can prevent illness, we can keep people well. If we can prevent them coming into hospital unnecessarily, if we can support them better once they are leaving hospital, this will be beneficial across the community.
JONATHAN HARLEY: These priorities are now being implemented. Progress will be reviewed next year but whatever the merits of the jury's verdict, not everyone shares the reform group's faith in the actual process.
TONY ABBOTT, FEDERAL HEALTH MINISTER: They're no substitute for political decision-making. In the end, politicians and policy makers can't subcontract out the decision-making process.
PROFESSOR GAVIN MOONEY: This is actually taking the health service back into the hands of people but it does put a lot of pressure on health service administrators. It takes a lot of guts to do this sort of thing. It takes a lot of leadership. The biggest problem that we have in a health service in Australia at the present time is lack of good leadership, both political and bureaucratic.
JONATHAN HARLEY: Dr Darryl Mackender is at a crossroads in his career. This gastroenterologist and the Australian taxpayer have invested a great deal in his professional development.
DR DARRYL MACKENDER: I trained for 10 years, worked for 10 years. So, yeah, I'm 40 and I guess the next 10 or 15 years is probably the most productive 10 or 15 years the system will get out of me.
JONATHAN HARLEY: But the public hospital system might not get much more out of Dr Mackender. The lucrative path to private practice looks increasingly attractive, away from the pressures of patching together staffing rosters.
DR DARRYL MACKENDER: It's not about incomes, it's not about - you know, you try so hard to fix something and eventually you say, "Well, there's not much I can fix - let's move on".
JONATHAN HARLEY: As everywhere, Gosford Hospital depends on casual doctors or locums to fill big gaps among the doctors and nursing staff. It's another symptom of Australia's and the world's doctors' shortage. The problem is, casual fills are an unknown quantity.
DR DARRYL MACKENDER: There's very little regulation in terms of the locum system, in knowing who you are getting, what sort of training they've had, even to the point whether they are adequately registered or credentialed to do the job you've asked them to do.
JONATHAN HARLEY: And they are expensive. Casual rates means a locum earns around three times the normal rate. The casual doctors are usually better than none at all but how can hospitals know what they are getting? The reform group is pushing for a national accreditation scheme but who'd run it? Well, it's back to that old state-Commonwealth tennis match.
TONY ABBOTT: That's really a matter for the states that have total responsibility for the running of the public hospital system. I know that there are many concerns in local communities, there are many concerns in the various professions about it but in the end, that is a matter for the states.
JOHN HATZISTERGOS, NSW HEALTH MINISTER: It's very easy, when running a department of some 20,000 bureaucrats in Canberra spending $1.1 billion but not treating a single patient, to be divorced from the interface that we as state health ministers daily deal with.
JONATHAN HARLEY: Dr Clare Skinner does deal with these problems every day.
DR CLARE SKINNER: I think that a bad day in emergency medicine is the worst day of your life but a good day in emergency medicine is far-and-away the best.
JONATHAN HARLEY: Her generation will inherit the job of staffing Australia's public hospitals, a job all the more daunting in the face of an ageing population. By 2020, a third of Australian hospital beds, a third, are expected to be taken up by senior women with broken bones.
DR CLARE SKINNER: I've watched the system sort of start to crumble at the edges and I don't think it is anything particularly new. It just seems to be encroaching and encroaching but I think it is also heartbreaking to see inefficiencies in the system and lack of good equipment and lack of staff that cause patients to have bad outcomes. That's heartbreaking and I think that's going to increase as we see more staff pressures and less rational decision-making, things crumbling away. We need to actually get in there now and start thinking about what we want.
DR DARRYL MACKENDER: One of the things I'm worried about is spending the rest of my life looking after baby boomers with not enough doctors to do it. Being dishonest about the level of service you can provide to the community is a good way to put sick people in the wrong place at the wrong time with the wrong people looking after them and inevitably, someone's going to get hurt. The patients get hurt but also the poor staff get hurt. They don't like being involved or being asked to do stuff they're not capable of doing, being asked to look after people without the right resources to do and then having an adverse outcome - and being paraded in front of the local paper as being the person at fault when really it was the fact they shouldn't have been there in the first place with that patient, without more help.
JONATHAN HARLEY: For the long-waiting patient we met last night, Danny Rappard, he appears to be moving up the list, no thanks to an overnight improvement in the Queensland hospital system but public pressure. The state Health Minister's office has told us that Danny Rappard is now booked to see an orthopaedic specialist by the end of the month. That's a year after being told he needed specialist treatment immediately. Hopes for speedy surgery now are tempered by years of experience.
DANNY RAPPARD: You know, you lose heart. I have. I've given up. I gave up end of last year sort of thing. I just gave up and said, "This is my life". My parents have sort of got me down here and lifted me up a little bit, hopes up a little bit. They've sort of been dashed a little bit again. You just give up. What can you do? There's nothing you can do, absolutely nothing.
KERRY O'BRIEN: Scratching the surface of one of Australia's big public policy problems. Jonathan Harley with that report.