Tuesday, January 18, 2011

Is Bellingen hospital safe?

I received an email during the week from a colleague concerned that the campaign to save/redevelop Bellingen Hospital was losing traction in the face of national changes to health services, apparent promises from the authorities and, I suspect, sheer tiredness.  In this context, the Bellingen Hospital Action Group (BHAG) apparently put out a statement at the end of last year saying they had a commitment from the North Coast Area Health Service to keep the acute beds in the hospital and that the job was done. You will find some of my past posts on this campaign here.

I am not close enough to on-ground issues to make a response on the specifics in the email. However, noting that the BHAG web site is now down, I thought that I should make some general comments based on my own experience. In particular, I feel that now is just the time when those served by the Hospital need to be most focused. This post explains why.

Impact of National Changes  

Back in April last year in Implications for New England from health reforms I took Bellingen Hospital as a case study. There I said in part:

One of the problems for New England from the changes is just what the changes might mean at local level. This is quite complicated, but I think that locals need to watch this like a hawk 

Since that post, I have tried to monitor the on-ground effects of the changes across New England, but it is quite difficult without detailed investigative reporting of a type beyond the resources of a part time blogger. However, my view remains the same. We just don't know how things will work in practice.

Mid North Coast Local Health Network & the formation of Government Policy

The new Mid North Coast Local Health Network came into operation on 1 January 2011. Very little information is yet available on its web site. Members of the Governing Council are listed, but no information is provided that I could find as to their background.

In two Armidale Express columns last year,  Belshaw's World - true wisdom rarely the sum of bland numbers and then Belshaw's World - round holes, square pegs and a region cruelled, I looked at the way Government policy is formed. 

While the new Network is smaller and has its own Council, while there is meant to be greater local input, the reality is that it is still operating in a highly centralised system, all the statistical data and planning reports on which past policies were based are still there, as are the people who made the planning decisions.

All the national agreements governing the new system with their myriad of performance statements were negotiated and will be implemented by just the same officials involved with previous policies. You can think of all this as an inverted pyramid whose point rests on the hospital. It would be unrealistic to expect much to change.

Continuity of Official Memory

Officials have quite long memories. If they fail to get things up one way, they will do so another. Let me illustrate by example.

Some years ago, the Commonwealth Government formed the view that Australia needed fewer but larger tertiary institutions. As so often happens in health, this was applied as a one size fits all approach.

As part of the process, the Government announced that the Armidale College of Advanced Education and the University of New England should merge. There was no justification for any small centre to have two tertiary institutions. Further, merger would save money by reducing the overhead associated with two institutions, the economies of scale argument.

I was opposed to the decision because the culture and missions of the two institutions were different, while I doubted the validity of the policy arguments. A friend and I organised a protest that culminated in a public meeting attended by several thousand people. The proposal was shelved. However, the official view had not gone away.

The proposal was resurrected a little later by the subsequent Hawke Government on advice from the same officials. This time it went through. Since it was intended in part to achieve economies of scale, the combined funding of the two institutions was reduced by an amount equal to the expected savings. No allowance was made for the costs of merger. The end result of all the changes was something of a disaster that almost destroyed the University of New England.

The Importance of Persistence

If what I say is true, why bother? Surely locals are powerless? Not so.

If you want to do something new, if you want to achieve change, then you have to be persistent. It may be that you will fail in the longer term, in which case you only get some short term gains as happened in the Armidale case. Still, in writing the history of the broader New England as I am at the present time, a remarkably large number of things were achieved by local or regional action undertaken in the face of entrenched opposition.

The Problem of Capture

Anybody dealing with Government faces a problem of what we call capture.

Ministers and officials have positions, refined arguments and lots of supporting information. Faced with entrenched opposition on a matter, they try to find find a path through. This includes giving concessions. 

On the other side, those dealing with Government generally cannot help being influenced by discussion and argument. Depending on persistence and relative power positions, the outcome moves towards some form of compromise. One side-effect of this is that the opposition actually ends up being captured by official thinking.

This is not necessarily wrong. However, it carries the risk that people will give up at just the time they should be persistent.

I am not suggesting opposition for the sake of opposition, nor that compromises should not be reached. Indeed, from my experience, one major problem with local activism can be the unwillingness to accept any middle path. Sometimes this works. More often, it can lead to total failure. It's a matter for judgement as to the best path.

The key thing is to be aware of the strategic issues involved. Some issues, a dam for example, may be yes/no. Others like a hospital are much longer term. These issues inevitably involve both compromise and persistence.

Burn-out and the Long Term Activist

Unlike governments, lobby groups or political parties with their full time staff, community activism depends upon volunteers. This makes it very difficult to keep long term pressure up. People, and I am speaking from my own experience, just burn out.

There is no easy answer to this. Sometimes it just happens. At other times, changes in direction are required to give people a break. Bellingen may well be in this position now.

Looking Forward

I think that BHAG has actually done a pretty good job through its own efforts and in providing a centre around which others could coalesce through, among other things, the Facebook page. There is no doubt in my mind that Bellingen Hospital would have lost more services without this effort. However, the story does not end here.

The fight over Bellingen Hospital was never about a single service. Rather, it was an attempt to maintain the best range of possible services. The fact that the old North Coast Area Health Service has given an undertaking re emergency beds is a first step that needs to be monitored. The focus should now shift to other services and the maintenance of community  support for the hospital.

I have written this post just from a Bellingen perspective. However, there is a broader issue.

Australia is short of doctors. The desire of the NSW Government to save money, to gain greater economies, has actually led to a sharp decline in certain types of medical training. The positions have gone.

Here we have a conflict between two objectives, immediate economy and efficiency on one side, longer term doctor supply on the other. Today, there is a fair bit of discussion about the best way of re-building medical training to increase supply. This requires new approaches.

Training cannot be done just at major base hospitals. We need a hierarchy of hospitals linked to different types of training. This is where a hospital like Bellingen could come in.


nellibell49 said...

Thank you once more for your ongoing support and insight. Yrs Lynne.

Jim Belshaw said...

Thanks, Lynne. I wanted to be as helpful as I could. It's not easy to keep going!