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From: The Question of Collocation
Australian Doctors Fund Collocation Meeting
Sydney - 20 May 1998
Address by Dr Bruce Shepherd, Chairman, Australian Doctor's Fund
Being a Depression child, unfortunately not a baby-boomer, it was my privilege to be selected as a Junior Resident Medical Officer at Royal Prince Alfred Hospital in 1958. Attached to Prince Alfred Hospital, on its eastern side adjacent to St Andrew's College, was Gloucester House, the "private wing" of Prince Alfred Hospital.
Each night a Junior Resident Medical Officer was rostered on for Gloucester House. In charge of Gloucester House at night was a redoubtable lady of indeterminate years who terrorised most of the Resident Medical Officers. Provided you did a round with her and listened to her over a long cup of tea it was unusual to be called during the night.
If, on the other hand, the round was not done and the tea partaken the brash Junior Resident Medical Officer could expect phone calls and perhaps the odd visit throughout the night. The Honorary Medical Officers of Prince Alfred Hospital who had privileges at Gloucester House, which connected by a bridge to the Anderson Stuart Theatres, could generally rely upon the patients at Gloucester House to be cared for by the Residents of Prince Alfred Hospital.
Most of the Honoraries at the hospital put in a good deal of unpaid work, both teaching and treating patients at the hospital. It was probably not unreasonable that they were extended some privileges.
My overall feeling as a very young doctor was that the arrangement attenuated the relationship between patient and treating doctor. I am not sure what happened to Gloucester House but I suspect it hasn't survived.
At that time there were appendages to other teaching hospitals. There was Wade House connected to The Children's Hospital in Camperdown. St Vincent's Private which subsequently was rebuilt with some temerity on the part of the Sisters of Mercy who built it so it could be converted to a motel should their financial enterprise fail. Fortunately for them it did not, due not a little to the fact that private health insurance was almost compulsory at that time.
The very reason why private hospitals are built on the campus of public hospitals are the same reasons why they could constitute a threat both to the private and to the public sector. In the '80s I spent a lot of my time importuning my colleagues to treat their private patients in private hospitals. There was, and there still is, a tendency for some of our busier surgeons to admit their private patients to be treated on their public operating list. In the early days of Medicare when there was a very strong ideological influence on the admitting officers, privately insured patients were discouraged from declaring their insured status, being told they would get the same doctor whether or not they went privately. With the economics of the public hospital system becoming tougher and tougher this has all changed. From on highest coming instruction that wherever possible the private patient was to be admitted as a private patient. These days most patients from doctors' rooms who are private patients are rather encouraged to the public sector and indeed are even allowed to be promoted on the queue.
In a somewhat desperate attempt to help the private hospitals and in the issues of fairness, I was, against AMA policy, advocating a facilities fee to the doctors who treated their private patients in the public hospital. This seemed only fair when all the ancillary services, especially Registrar and Resident availability, gave a very comfortable life to the treating doctor - no longer performing honorary work.
PERSONNEL:
Consciously or sub-consciously the builders of the collocated private hospitals are catering for the weaknesses of human nature. Cost shifting, which has become an art form in the State health systems, whereby all sorts of ruses are used to attract Commonwealth money into the State system cannot help but occur in the collocation situation. Part of that cost shifting will be "personnel shifting", perhaps starting with the surgeon who has a little more difficult case than usual on his private list, asking his Registrar to drop whatever unimportant thing he is doing in the public system and come over to give him a hand, to "can you keep an eye on this patient over the weekend if you are on, (or even if you are not on)".
Already in some collocated hospitals the full time employed intensivists have contracted to look after the private sector. As there is no clocking on in the public hospital system for staff specialists, who is to supervise how much time is put into their public hospital services and how much time is spent in the private sector next door? Even if only a small percentage of staff specialists abuse this system all will eventually wear the extra controls which must eventually follow. Undoubtedly there will be some blood split on the floor in the intervening period.
What happens when the doctor who has chosen the path of private practice who has the expenses of secretarial help, nursing, etc to gather, to say nothing of rental, sees as his direct competitor a staff specialist who has all of those for free, who has signed an agreement to charge only the medical benefit schedule and can turn a good profit doing so. We will see an increasing number of specialists relinquishing private practice to seek the easier life.
While some of the hardest working doctors I know are staff specialists, I would have to say that overall staff specialists and academics tend towards the ordered life. It is often very difficult to offer an all encompassing service expected by private patients and at the same time maintain a well ordered, circumscribed lifestyle.
There is also the issue of the delegation of work to more junior medical staff by a staff specialist who has pinched off into the private hospital much facilitated by collocation. If this occurs, as I believe it inevitably will, it cannot be good for the patients nor for the junior doctor who will miss out on teaching. That junior doctor will be over stressed and given a very bad example.
We may be seeing with Collocation the end of private practice as we know it and a great threat to what we all hold dear, and that is the sacredness of the doctor/patient relationship - certainly this could be the case if we don't have transparent and tight rules governing personnel.
FINANCIAL:
I have already alluded to the unfairness of the competition which can occur in a collocated private hospital where the employed medical practitioner has an inordinate advantage over the visiting doctor. When we see how difficult it is to keep, or rather to delineate, financial responsibilities of the States and the Commonwealth in regard to patient care, how will it be possible to apportion costs to the public sector, owned by government, and the private hospital next door. Just recently I was jokingly told that one hospital, one collocated private hospital, in Sydney has a patron saint for fluorescent tubes which prevents them from failing so that there has never been a need to order fluorescent tubes for that private hospital. I am sure other speakers will speak of this in more detail.
PATIENTS:
Obviously I should have put this first, because that is what we are in the world for. How confusing will it be for patients to arrive at North Shore Hospital, who have been told by governments since 1984 that they are entitled to free treatment, only to have pressure put upon them to transfer to the private hospital. At least now they receive a number of bills which have a doctor's name on them. If the system which is apparently partly imposed in Melbourne Private is imposed here, patients will pass through the private hospital without any knowledge of who was responsible for their care or at least not without taking a good deal of trouble to find out. Whether we like it or not the present system of Medicare guarantees to all the population that they can have free treatment in the public hospital system. How easy will it be to say to them "we have no beds in the public, you will have to go private if you want to be admitted".
Already at North Shore Hospital there is a displayed list of doctors who are prepared to charge private patients coming through the public hospital system the medical benefit schedule only.
Forever the Federal Minister for Health has been claiming that the biggest disincentive to people taking out private insurance is the multiplicity of bills they receive and the gap. Our statistics, and I am sure Roger Kilham will allude to this, indicate that it is less than 10% of patients who find this a disincentive and this is only 10% of those who have had some experience in a hospital situation. Of the populace at large it would be much less. Perhaps the real reason why the Minister wishes to introduce no gaps and single billing is to facilitate this process of flick-passing the privately insured patient from the public sector.
EFFECT ON PRIVATE HOSPITAL SYSTEM IN GENERAL:
Some of our best free standing private hospitals are finding themselves in difficulty. HCoA itself has said that in the St George District it has been necessary to close down several private hospitals. They cannot cope with the competition from the collocated hospital. I am not sure what has happened to those doctors who have been used to using those private hospitals, who do not have an appointment at St George Public Hospital. I have certainly seen hospital spokesmen quoted as saying that it is necessary for a doctor to have an appointment at both the public and private. A recent advertisement which was stopped at the last moment was for an orthopaedic surgeon at St George Hospital, required to have privileges at both hospitals.
I must express my deep concern that a wonderful hospital like The Mater will have difficulty surviving no matter how high the standard they have achieved. Worse still would be if a collocated hospital on the Royal North Shore Hospital campus should fail as well.
When we see how hard many of us have fought in the Blewett years to ensure that a private system survived it would indeed be ironical if it were destroyed by a Coalition Government. This I perceive is a very real risk. A risk exacerbated by the dreadful damage that has been done to the public hospital system over the last decade or so.
Today the fall in privately insured patients was announced as 0.5%. What we lack is an overall plan. These bandaid measures fail to recognise that a private paying system cannot continue to compete with a free system. We seem prepared to risk a take-over of our private and indeed our public sector by overseas interests rather than fix the problem.
Bruce D Shepherd AM, MBBS(Syd), BDS(Syd), FRCS(Eng), FRACS(Edin), FRACS, FA(Orth)A, FAMA
Chairman, The Australian Doctors' Fund
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