Dr Patel II

This week’s column is on the shenanigans over the inquiry into Jayant Patel, the rogue doctor of Bundaberg.

Since Troppo is kind of becoming a site of record for my column and I appreciate people’s comments, I’m postiing it. Anyone who likes reading my columns might like it. But its a commentary on unfolding events more than anything of great originality.

The Interim report to nowhere?

Sometimes short-term pressures undermine our longer-term effectiveness. The urgent drives out the important. The short term pressures on politicians are all about the management that is media management of issues. Voters can’t complain. We’re in favour of politicians showing more ‘vision’. But that’s in theory. The last politician who tried to get us to embrace a comprehensive long-term policy vision was Dr John Hewson last seen plummeting Earthward. We prefer our politicians to treat promises like a skydiver treats his main parachute after it fails to open.

Whether we end up with anything to show for all the suffering Jayant Patel has visited upon us remains very much up for grabs, but it depends on how effectively some important figures can transcend the urgent to ensure that they deliver on the important.

The Premier is, yet again, in “something must be done” mode dispatching senior bureaucrats to give press conferences in Oregon and firing letters to all and sundry in US bureaucracies (though they’re already well aware of the situation). Tony Morris’s Royal Commission has been no less frenetic, though perhaps more industrious producing a substantial interim report an astonishing 6 weeks after being appointed.

Such a well written report is a remarkable achievement in the time it took. But subsequent discussion suggests that the public call for a murder prosecution might have been ill judged, both because it intensifies Patel’s motives in going to ground, and because it prejudged evidence from a medical audit now suggesting that Patel’s error rate was not clearly outside acceptable limits.

And to my economist’s eye there’s another danger of too legalistic a focus. As my former colleagues at the Productivity Commission often observed, lawyers with whom we worked often took their own frame of reference from existing legislation when the point of our inquiries was invariably to consider how the policy, including the legislation, could be improved.

In addition to recommending criminal action against Patel which was appropriately an essentially legal discussion the Interim Report’s other main focus is the “area of need” policy under which Patel was appointed. Under this system, if a medical need cannot be met locally, it is then met from elsewhere in the state or from interstate. Failing that it can be filled from overseas. That’s where Dr Patel came in rather literally I’m afraid.

Morris found Queensland Health administered the policy with “scandalous . . . lassitude”:

 Queensland Health still works under a five page policy document that is nine years old and thus based on legislation which was repealed four years ago!

 Though it claims to have been working on a new policy for two years, it could not provide even a draft to the Commission.

 It took no steps to ensure that “area of need” appointments are temporary as required in the legislation.

Damning of Queensland Health as it is, these findings are also a bit of a red herring if one’s focus is on how any future system should work. There’s something about the “area of need” legislation that smacks of parochialism, if not protectionism. Doctors should be assessed on the merit of their training in the first instance and their performance after that. You may prefer locals, but if I need to get my insides messed with I want the best surgeons available and I want to know that proper checks have been made, wherever they’re from.

We should be aiming for a system that’s rich in information about health outcomes. Its overwhelmingly greatest benefit would be in encouraging everyone in the system to do their best. But as a useful byproduct it would detect the worst from wherever they hailed. And not just at the outset, but whenever their performance fell below acceptable standards.

Perhaps the other inquiry into Queensland Health Systems by consultant Peter Forster will ultimately attend to the important. It has been almost invisible compared with the sound and fury with which Messers Morris and Beattie have attended to the urgent.

Perhaps the Morris inquiry will go on to develop its policy thoughts for the future more coherently. And well before the hi-jinks set off by the Interim Report, Premier Beattie’s own initial sketch of his ideas on improving Queensland’s health system was wide-ranging, thoughtful and constructive. There’s no logical reason why Mr Beattie’s current Vaudeville on the trail of Dr Patel need necessarily compromise the important. Let’s hope it doesn’t.

But whether we’re aiming to make Queensland’s Health system once again the best in the world, or just detect the next Dr Patel, his status as a foreigner is, at best a minor detail and at worst a dangerous distraction. If we miss that basic truth, the next Dr Death we’ll be talking about might not be a Jayant Patel. Instead he’ll be a Bill Smith, or a Dick Jones.

Let’s hope we don’t leave it till then to build the system back to good health.

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2022 years ago

And to think a Howard Govt would ever want to take back Health from the States. It must be comforting for them to know, that when you’ve got a few teething problems with Immigration, you can always rely on Health in the States to relegate your own administrative cock-ups to page3.

Francis Xavier Holden
2022 years ago

Nic – that is a good column. I have only skimmed through the report and some of the transcripts, so if I am relying on memory and if II make any errors of fact I’m happy to be corrected. A few quick and dirty points if I may.

1 There is a danger with these sorts of public inquiries that they become a forum for the disaffected and those with other agendas utilise the inquiry to “hit and run” and make points that feed into agendas personal, political and professional. For example some nurses may run a meta agenda that “nurses are the backbone of the health system and doctors are highly paid prima donnas who don’t get their hands dirty” (or in the case of Patel get their hands dirty but don’t wash them). Doctors may run the line “If only the bean counters and nurses would revert to the good old days when doctors ran everything without question then all will be well” and so on a so forth.

2 We have already seen examples of the above. One of the country’s most militant unions, the AMA, has already publicly called for a return to doctors running the system. No one seems to mention that it was “doctors running the system” at Bundaberg that contributed significantly to the problem. The recruiting agency that found Patel was run by a medical doctor, Patel was a medical doctor, the Queensland Gov representative who decided on areas of needs and accreditation was a medical doctor, Patel reported to Miach who was a doctor, Miach reported to Keating who was a doctor. What we have here is a surfeit of doctors in charge not a deficit. None of the other VMO’s or Senior Surgeons and Consultants at Bundaberg called Patel on his activities.
3 The Infection Control Nurse has been portrayed as a brave whistleblower by the press and implicitly by the inquiry. We are told her story of following Patel around begging him to wash his hands and wear gloves. This is a weird misunderstanding of the role of Infection Control role. The role is not to baby sit and check on naughty professionals but to set up systematic procedures for monitoring and reporting and, most importantly FIXING systematic or individual lapses of good practice. There should have been written incident reports daily or hourly if needed on the failure of a surgeon to basic follow hand washing and other procedures. These should have been coming from all staff including other doctors. This inturn should have triggered reports to a Patient Safety or Clinical Risk committee and subsequent censure or re-training or restriction of activities of the offending staff member (Patel in this case). It is not the job (and in fact it is counter productive) of the Infection Control person to run around like a kindergarten teacher ineffectually asking people to wash their hands or wear gloves.
4 The effectiveness of quality and safety systems is directly related to the multi disciplinary nature of the task. Clinical Risk systems and committees work when they are transparent, non punitive, decisive, forward and prevention focussed and comprise wide range of professionals as well as lay persons and independent outsiders.
5 I share you concern about the culture of the legal profession effecting these inquiries. Health and Medicine is about multiple professional roles interweaving and overlapping and co-operating. No one profession has a natural monopoly on any activities. The legal profession is, in general, comfortable with a monopoly on many professional legal activities and has resisted (rightly or wrongly), industrial change and unbundling of activities. This world view is bought into the questioning and conduct and outcomes of these inquiries. This results in appeals for clearer demarcation between roles and monopoly roles are supported rather than questioned. This is against all the trends in health care delivery and quality.
6 The Area of Need criteria is and will always be political. It is after all a subsidy of sorts to rural areas. In and of itself it shouldn’t to lower standards, unless you believe all foreigners are under skilled. There is of course another issue. In medicine there is an increasing specialisation and clustering around best performing centres for certain procedures. These centres set best practice, and eventually commodifying once unusual procedures which are then, taken up by local and general services. (an example is cataract surgery, not so long ago it was performed only in specialist centres and involved a 3 day inpatient stay . Now it is a routine procedure performed locally and safely with the person in and out in a few hours). The implication of this is that rural and regional areas, like urban areas cannot expect to have ALL complicated procedures performed locally. Wishing things were different doesn’t make them safer. Some areas will never have the minimum throughput to carry out certain procedures safely. Doctors are required to know more and more about less and less to operate safely. The exception is GPs who are required to know more and more about more and more. But you will note most GPs don’t put themselves out as experts, or attempt to do all, or any, surgery, but see themselves as vital coordinators and integrationists of patient health. There is a danger, fostered by stories of miracles in the media that “heroic” medicine is the best. Not true. It is the worst. See also below.
7 The chattering classes dinner party boast of the folk wisdom of obtaining or having “the best surgeon around” is by and large nonsense. In the outcome skills of surgeons and others they cluster tightly around a very normal curve. That is there are very few outliers and in fact the aim is to increase the middle cluster and boost the middle cluster up the safety scale. The big deficit here is most punters don’t have access to these figures. I’m in favour of limited publication of hospitals and surgeons defect rates.

Nicholas Gruen
2022 years ago

Thanks for that Francis. I can’t see anything on which I’d want to correct or disagree with you on.

I would add a couple of comments. I think that the economist’s way of seeing professions – effectively as combines – is often useful, but its not terribly sociologically insightful. People like monopolies on power, for all sorts of mundane and non-economic reasons. I think the economic reasons for Doctors wanting to be boss – or lawyers for that matter – are just icing on the cake. People like power.

Secondly, I don’t fancy publishing doctors and hospitals error rates without good correction for risk rating. I invite you to check out a system I invented (someone else may have invented it before me, but they still haven’t come forward if they hav!) for allowing the self rating of risk – which I think has all sorts of nice qualities – one could use it to grade doctors at the same time as direct patients to the best clinical treatment.

It’s outlined under ‘prognostic information’ in this article – http://www.lateraleconomics.com/outputs/AJPA%20Article.pdf. given your obvious background in the area, I’d be interested in your views.

Francis Xavier Holden
2022 years ago

Nic – I agree people like power. There aren’t a lot of economic reasons for doctors wanting power.

Risk ratings are important if we are to publish error rates. There also needs to be rates over a reasonable period of time, say 3 years, in order to smooth out extraordinary events. The self rating component of risk is important and so is benchmarking to worlds best practice. Worlds Best is an often overused term but in these days of instant communication and cheap available computing power there is no reason not to have international benchmarks, as well as national and sector benchmarks. It’s pretty bloody cheap to send a surgeon and nurses or a bunch overseas to say, UK to spend a week or two in an international best practice institution to observe (and even operate) procedures and systems and bring this knowledge back

If I read your paper right you are suggesting that the market failure in, say, health is an information failure that can be corrected by a light touch government intervention involving government monitoring, collating and publishing error rates. You are suggesting, correctly I believe, that this information offers economies of scope and that information is not diminished by being widely available. I ‘d suggest that in common with Open Source Software this information can attract free added value by being transparent.

I’d suggest that the error rates should be available by institution and procedure, not by individual. The success or outcomes of surgery, in particular are tightly bound to systems and multi disciplinary teams and approaches rather than individuals. In addition focussing on institutions helps place the emphasis on peer and team pressure within institutions to improve practice and avoids the old “only bad apples” furphy. This is not to deny that there will be some bad apples and outlier individuals. (it’s not yet clear to me but it may well be that the Patel Case consists of a bad system allowing a bad apple to flourish, a good system would have flushed him out very early).

Proceeding slowly with haste and caution is important. The media has a very limited ability to deal with complex issues and any rating system will use proxies and be shot through with grey, complicated and nuanced information.

The case of Australian of the year Fiona Woods is noteworthy here. As far as I am aware Dr Woods has not published her “spray on” burns treatment in any peer reviewed journal anywhere in the world. Again as far as I am aware no other burns unit in Australia utilises her method. She invented the method and also owns the production of the spray on stuff. There are no current controlled trials being conducted by any other independent unit in this country.

Despite the above she is lauded by the media as “heroic” and has received Australian of the Year for her work. This is an example of how sloppy rushed publication in the media can work to distort rather than inform.

There is a reasonable degree of literature about benchmarking and transparency in error rates. The most quoted and highest profile is the New York (city system only I think) publication of mortality rates (It may have also published morbidity rates I’m not sure) for their hospitals.

New York Data: http://www.healthgrades.com/directory_search/Hospital/State_City/New_York/index.cfm
(looks to be wider than city only, also looks like it has morbidity, but unfortunatly seems pay per view. Another issue – user pays won’t work.)

The Victorian system has made a good start with the publication of waiting times for procedures. This enables customers / consumers/ patients / GPs to perhaps choose where they might be better off booking in to get quicker access to a certain procedure. (It is complicated by the fact that many people will be on multiple waiting lists even after the need for the procedure is gone). This waiting list publication also creates pressure on institutions to improve performance and benchmark waiting times.

Victorian System Elective surgery performance data: http://svc023.wic022p.server-web.com/yourhospitals/performance.asp

The National Elective Surgery Waiting Times Data Service: http://www.aihw.gov.au/hospitals/waitingtime_data.cfm

[In the abscence of information I reckon the best rule of thumb is volume of throughput.]

Francis Xavier Holden
2022 years ago

oops – the above legislation is only the New York Hospital Infection Disclosure Act

2022 years ago

Does anybody have downloads of the Morris Emquiry transcripts or know of a website where they can be accessed? These f**kers ahve already taken them off the website and replaced it with the usual corrupt beattie drivel and lies…