Category Archives: Minister Hill

SA Health Budget Waste – Jack Snelling take note!

There has been a change in SA Health his year as outgoing Health Minister John Hill retires and Jack Snelling steps into place. I don’t envy whoever has this portfolio – the cost of health continues to rise, as does demand – and yet available health budgets are shrinking.

This week the ABC reported $1 billion health cuts over the next 4 years in SA health. The Minister was reported as saying “I think we can reduce the number of clinical staff and still maintain a reasonable level of services.” Personally I disagree – hospitals are already at capacity and despite ‘efficiency saving reports’ from the likes of KPMG, ministers need to realise that you cannot run health like a widget-factory; there needs to be surge capacity and slack in the system. However, I am all for saving money when appropriate. Which is why recent spending on unnecessary equipment by Country Health SA puzzles me.

In late 2012 a new anaesthetic monitor was delivered to us on Kangaroo Island. We were told it was part of an across Country Health SA strategy “to meet requirements” in Operating Theatres. Sure enough, the new monitor is a ‘you beaut’ device, with touchscreen technology and allowing us to do fancy things like spirometry and bispectral index sensing – which we never had before.

The problem is, the old monitor worked perfectly well and didn’t need replacing. I’ve checked and double-checked the ANZCA guidelines – and can’t find a requirement to have these extra functions which we’ve been told are ‘mandatory’. I’m not even convinced of the need for BIS, other than in paralysed patients being transported where risk of sedation failure may be present (read more on BIS here).

The disappointing thing is that we really need an EXTRA monitor in our location.

Currently post-op patients are monitored in ‘Recovery’ which is also our small ‘Emergency Room’. We use the MRX defib as a post-op patient monitor. Which is fine, so long as there is no emergency patient who also needs monitoring. As well as the need for two monitors, there have also been occasions when the anaesthetic monitor has malfunctioned – so having a backup immediately available makes good sense (particularly when you are on an Island!)

Using MRX defib as sole monitor in ED/Recovery - no backup!

Using MRX defib as sole monitor in ED/Recovery – no backup!

So my efforts in the past have been directed to getting an additional monitor for our ED/Recovery…as well as to purchase equipment to meet ANZCA standards (equipment to manage a difficult airway being one particular bugbear). We’ve had some success – we’ve sourced and fitted out a difficult airway trolley and some signage. Sadly there has been no committment by CHSA to supply a fibreoptic device or videolaryngoscope (I ended up purchasing my own) to manage a difficult airway…and have been told there are ‘no funds’ to purchase an additional monitor.

The Health Minister Mr Jack Snelling wants to save money. I get that. But this new monitor allegedly cost $17K. There are fifteen sites across CountryHealth SA which provide anaesthesia – so that’s $255K spent on monitors which may not be needed.

There you go Mr Snelling – a $255K saving for you.

I’ve emailed the CHSA lead for anaesthesia, Dr Sara Norton to ask about this. She tells me she was unaware of the decision to purchase these new monitors and did not consider either BIS or spirometry as mandatory requirements for monitoring. Which makes the purchase of these $17K per piece monitors even more puzzling. To date, Sara has not been able to get an explanation from Peter Chapman (Acting CEO of CHSA) re: this decision.

Seriously – that money could have been better spent in rural hospitals on essential additional equipment. We are repeatedly told there is ‘no money’ and purchase of much equipment falls upon efforts by local charities like CWA and Rotary. I think rural Australians deserve the same access to essential equipment as their metro cousins…and wish that decisions on equipment purchase were made in consultation with local clinicians.

Perhaps Jack Snelling should be asking Dr Peter Chapman – who is making these decisions and where is the governance?

Zen & the Art of ED Management



There has been a lot of discussion this week regarding pressure on the Emergency Department at Flinders Medical Centre in South Australia.

Rack ‘em and stack ‘em!

I have a ‘soft spot’ for Flinders. I worked there as a junior resident and then registrar in the late 90s/early naughties and like to think that I learned a bit. The Consultant staff were excellent and engaged in training. The nursing staff were fantastic. And the work was great fun – I certainly enjoyed the immediacy of emergency/critical care but was seduced away to rural medicine by the lifestyle advantages and variety that this work offered. More importantly, the one thing that affected my decision not to complete training in ED/ICU was the lack of control over factors in my work (some might say that dealing with Country Health SA is similar, and you would be right, but more of that in another post).

The big issue for the ED is ‘access block’ – the inability to efficiently deal with emergency patients because there are insufficient beds in the ED..because there are patients waiting for beds ‘upstairs’ ie: in medical and surgical wards. And why are there no beds? Because the medical and surgical wards are either run at 100% capacity leaving no room for ‘surge capacity’…and/or that medical beds may be clogged with patients awaiting discharge to home, nursing home or country hospital.

Because there is no slack in the system, the clogging of ward beds filters back to the ED causing access block. And when the ED is full, the unhappy situation arises when ambulances cannot handover their patients because the ED is full and ambulances are ‘ramped’(literally wait on the ramp outside the ED). And tying up ambulances waiting outside EDs means there are not enough ambulances to deal with emergencies in the community.

Ramping has been a common phenomenon at Flinders Medical Centre in the past few weeks. Last Friday I was at an EMST course at Flinders and heard that the Director of ED, Dr Di King had resigned after being called into the CEOs office and asked to guarantee that ramping would not occur.  Of course this is impossible – Dr King has no more control over this than anyone else – the solution lies with the CEO and Minister of Health, not the ED Director. And so Di resigned, putting more pressure on a beleaguered Health Minister.

Yesterday Dr Dave Teubner came out and said it was safer for people to remain in an ambulance than to be seen in the ED. Dave is a passionate ED doc…he is not some hopeless academic, but a chap who really gives a damn. He is of course correct – it is better for people to be at least in an ambulance with oxygen, suction and a paramedic than lost in a corridor in the ED, unobserved and awaiting assessment or treatment with access to neither.

In essence, the whole idea of a well run health service should be to ensure that care is escalated with every referral. It is frankly dangerous to have care take a step downwards from ambulance to ED, as is the case at FMC when under bed pressure.

This is a concept that is a particular hobby horse of mine – the idea of ensuring there is never a ‘therapeutic vacuum’ or ‘inertia of care’. Every single thing we do should improve patient care, not stall it or even detract from it.



Certainly people admitted to an ED should see an increase in the level of care delivered to them. And so on…every single doctor, nurse, paramedic is doing his or her utmost to make this happen.

But the system seems to conspire against us.


And of course this is not just about ramping in the ED. It also applies to rural medicine, to the operating theatre, to in-patient care and to discharge.

Like many people working in health, I get hot-under-the-collar bemoaning failures in ‘the system’ where things could (and should) be better. Particular bugbears include 
  • lack of equipment to manage a difficult airway in rural EDs and theatres
  • lack of ownership of equipment and emergency training for rural staff
  • cost-shifting between State and Commonwealth coffers for ED patients
  • lack of discharge summaries from people who have been admitted and discharged from metro hospitals
…and so on.


What can we do to improve things?


Well, political pressure is one – I would imagine that Dr Di King’s resignation has served to highlight the issue locally and perhaps prod the Health Minister into action. 


More so, we can engage and try to make things better. I’ve been revitalised in the past few months by some of the information coming through the blog-o-sphere, with concepts of relevance to my practice that one is not going to get from a textbook or clinical placement. So I’ve done a survey on difficult airway equipment for rural GP-anaesthetists. I’ve offered to run some small group scenario-based sessions for nursing staff at the end of each of my anaesthetic lists and whenever I am on call for A&E. And I’ve been developing a web-based repository of emergency training for local use…how to set up the oxylog, where to find and use the rapid rhino kit for dealing with an epistaxis, a dump mat for RSI etc.


Another new idea is borrowed from the UK – a ‘one minute wonder’ fortnightly update on topics of relevance for our multiskilled rural nursing staff – basically a single A4 poster explaining how to find/set up/use a piece of ED equipment – displayed on the wall above the iStat machine to give people something to read whilst waiting for the iStat or Troponin reader to do it’s stuff.


Small things, but they might make emergency management in the bush easier.


Of course, the astute reader would wonder why these initiatives are not flowing ‘top down’. It would seem intuitive to have a minimum standard of airway equipment in rural hospitals, to have standardised ED kit and protocols, to train staff in equipment use beyond the token annual ALS refresher.


But this doesn’t happen. Change takes time, there needs to be initiative and drive, and solutions need to be appropriate to the local situation.



Anyone else got any pointers to drive change and improve emergency management in rural areas?

Country Emergency Department Fees

Well I’ve just received a letter from the Federal Health Minister which seems to broadly confirm my suspicions that the charging of fees for country patients attending a public hospital ED is incorrect.


You may need to click and open separately to view



Of course there is a grey area in what is a ‘GP after hours’ type attendance and what is an emergency attendance – and with that comes the potential for massive cost-shifting from the State (charged with providing free public emergency treatment) and the Commonwealth (providing Medicare compensable services).


Country patients are caught up in this, as in South Australia they have been charged fees for attending the ED in rural hospitals. Now historically there was an arrangement (not defined in a contract, but in an agreed schedule of fees for paying doctors called SARMFA) that allowed a rural doctor to charge a private fee in circumstances where a patient requested private treatment by a particular doctor, or where care was provided in the country hospital as part of ongoing care or prior arrangement.


This seems a sensible compromise to allow rural doctors to attend patients at the hospital both in and after hours for GP-type consultations or private care. Example might be an agreement between doctor and patient to meet at the hospital after routine consulting for a review of an eye injury, utilising the hospital’s slit-lamp. or arranging to be seen for a skin excision or to administer intravenous therapy.


All well and good.


Then in 2010 a new contract (in fact the first time a written arrangement about rights & responsibilities) between CHSA and rural doctors came into being. This is a good thing and it was hoped that would create a level-playing field with rural doctors getting equivalent deals, rather than the hotch-potch of ‘local deals’ that saw some doctors getting lucrative locum rates for being oncall, others struggling to balance the impact of providing oncall work for the hospital with their private practice.


The negotiating teams of both AMA and RDASA invested a lot of time and effort into getting the ‘best deal’, but as time wore on the AMA walked away from the offer whilst the RDASA recommended to their members on a temporary basis, expecting a new and better deal to be negotiated by the end of November 2011.


My concern has been that, for the first time, there is a contract that is explicit about the charging of fees. Whilst the SA Health Minister acknowledges that CHSA are responsible for the provision of public emergency services in the country, there is a catch. The contract specifies that only ADMITTED patients are entitled to free treatment – non-admitted patients are to be charged by the attending doctor.


This seems to fudge the previous arrangement designed for private services or ongoing care between patient and treating doctor. Instead, people who present to a rural ED in South Australia are charged fees unless they are admitted….and yet patients with similar problems who go to a metro ED are provided the service for free.


The Health Minister says this is because rural hospitals do not have a salaried medical officer on site. Fair enough. I’d just argue that if the Hospital feels they need to call in a doctor, that that doctor is paid for their services – and the patient does not.


Of course, if the patient presentation is trivial (a GP-type attendance) then it would be appropriate to divert them to a GP-after hours service or to GP clinic the next day – and Medicare or private fees would apply.


It’s all down to definition. What is an admitted patient? The bean-counters take the view that a patient has to be present for > 4 hours, although occasionally this requirement can be relaxed for certain things (type C attendances, a definition derived from mostly day surgery units).


So we have a position now enshrined in a contract, where rural patients may be charged for things like reduction of a fracture, IV fluids, X-rays, assessment after a car crash, mental health emergency in a country ED…on the basis that these are ‘GP services’. These are things that a GP in the city may well refer patients to an ED for.


Medicare advisors tell me this is illegal and that doctors should not charge for such non-admitted ED services where patients attend a public ED. The Dept of Health & Ageing letter suggests the same.


The only explanation from CHSA is that this is allowed because of a ‘longstanding arrangement for treatment of private patients as part of ongoing care or prior arrangement by a specific doctor’. 


I am all for this – when such care is agreed and is genuinely private. I have no qualms charging a private fee for my private GP services. 


Seems hard to explain that all this to the carload of NSW tourists who have crashed and seek assistance at the local hospital only to be saddled with a bill. Or the patient with a fracture-dislocation that requires X-ray/reduction/plastering…and many more examples.  Understandably some patients refuse to pay on the basis that they are attending an ED. CHSA insists that the doctor charges Medicare..who say that this practice is illegal…and CHSA doesn’t answer this query.


So, where are we at now?


There have been two extensions to the rural doctors contract (which was to expire 30/11/11) so far…the current extension ends in just under four weeks and still no contract offer available for perusal.


In an effort to address this anomaly, RDASA had proposed that triage 1-2-3 patients are to receive free treatment. Seems fair, although it does ignore the issue that triage is just about treatment priority, not complexity and is ill-suited to decisions about whether ED attendance is appropriate or not. There is a myth that triage 4/5 patients are ‘GP-type’ presentations, when in fact these patients are often elderly, complex and require admission or the services of an ED not a GP (minor fractures, plastering, X-ray etc). ACEM have issued a media release on this which is informative.


Despite that, I’m still struggling to get paid for attending a triage 1 call in…with CHSA insisting the patient be billed under Medicare.


So, there you have it. 


- A contract that seems to be in breach of the National Healthcare Agreement.
- Cost-shifting fees onto patients who are already rurally disadvantaged. 
- And only a few weeks to go until the most recent contract negotiation expires.


Really, is this any way to do business? It seems that Country Health SA hold both rural patients and the medical workforce with a lack of respect. I despair, because this sort of thing does little to encourage recruitment and retention of rural doctors to South Australia.


I guess there’s no votes in the bush.