Talking Point: Culture card is a right Royal flush

JOHN BURGESS: The huge problems at the RHH are too easily dismissed with glib reference to organisational culture

BEWARE: It does seem petty and inexcusable for senior figures in our health system to allow the “culture card” to be played unanswered against their health system.

RARELY does a day go by without reports identifying “culture” as the culprit for one or another failing within the world of sport, business, politics or our society at large. Neither is Tasmania’s public hospital system immune (Mercury, November 2 and 6), with regular and now predictable claims and counterclaims about the inability of our state’s public health system to keep up with the community’s need for accessible emergency department care, elective surgical treatments and outpatient clinic services.

Sadly, the “culture card” is an easy one to play, particularly when political stakes are high and dollar costs substantial. But, when a government tacitly allows this card to stay in the deck, it risks playing a lousy hand itself, with cultural blame being a cheap solution to a health crisis as opposed to getting the diagnosis of what is wrong in the hospital system correct.

This can make all the difference between the hospital access crisis remaining unresolved versus delivering a well-functioning health system to the community.

So, do we have a cultural problem in the Tasmanian Health Service, and if so, who is responsible and how much is it contributing to the crisis for patients trying to access Tasmania’s public hospitals?

Culture is a vague term. We all have a sense of what it means, such as when seeing a positive or negative one in a business or sporting team. Culture can have a range of technical definitions. Still, the one I favour when thinking about organisations and teams is the practical concept of, “culture is the way things are done around here” (Deal and Kennedy). For our public hospital system, culture is about the shared values, aspirations, motivations and ways of working for the people and the teams who make up our hospitals, our Health Department bureaucracy and the Health Minister’s office.

Given the acrimony and dysfunction that have plagued the Tasmanian health debate in recent years, the long-suffering public would be forgiven for cynically wondering if this bunch of people and teams had much at all in common, let alone a shared culture. And to some extent, the sentiment is not without a reasonable basis.

It is recognised in the academic literature that hospitals and complex public sector bureaucracies have multilayered subcultures, many of which are necessary for optimal patient care, but all by necessity must be aligned with the common purpose of delivering patient care; the right care, at the right place at the right time and for the right price. Sustainable patient care must have patients as the central focus and purpose of what all the people and teams involved in healthcare are working towards.

As noted recently in the highly respected British medical journal, the BMJ, “a growing body of evidence links cultures and quality, but we need a more nuanced and sophisticated understanding of cultural dynamics”.

Unfortunately, the public has probably seen little of the required nuance and sophistication coming through in the repetitious and increasingly tedious health care blame game that could be considered the “culture war” of health politics in Tasmania.

The Australian Medical Association has previously called for the key players in health in Tasmania to come together and show some courageous leadership, putting partisan politics aside, and developing a shared vision for an excellent, and yes, affordable health system for all Tasmanians. A shared vision that can form the basis for a strategic plan that gets the best use out of the resources already available in our public, private and community health sectors. This vision needs leadership, and good leadership must necessarily model the type of collaborative and supportive culture the health system needs, one that we can all be proud of and sign up to.

Back to the question of whether it’s a cultural failure in our hospital or political and bureaucratic failure in the health service leadership?

I’m minded to agree with the sentiments in the Mercury’s Letters pages of November 6. Blaming hard working, overstretched hospital staff could be considered a cheap stunt. The staff, as eloquently and movingly noted in a letter by Dr Luke Rayner, seek to improve their culture when they are getting it wrong. But, the overarching and dominant culture of the staff in all disciplines and groups within our health system is to care for patients, to show compassion and to try to do their best despite the adversities of the surrounding political and funding environment.

It would be fair to say that healthcare workers worldwide show remarkable ingenuity and perseverance when delivering care, despite the obstacles that may be in their path. In Tasmania, we are blessed by opportunities, talented staff and a remarkable, democratic political system served by people at all levels who inarguably express a wish to make a positive difference.

With such attributes, it does seem petty and inexcusable for senior figures in our health system to allow the “culture card” to be played unanswered against their health system, against their subordinate hospitals, and against their front-line staff who work 24/7 to keep our public hospitals alive. To make little or no public response, no defence of staff, and to not advance a clear and overt affirmative plan to support staff and culture in THS public hospital is hard to understand.

As the old saying goes regarding failing organisations and cultures, “a fish rots from the head”. So before the culture of hard working frontline staff in our state’s public hospitals is conveniently used as an excuse for access block and ambulance ramping, those in ultimate charge of the public health system in Tasmania should stand up, step forward and show both leadership and support for those at the front line, those who invariably are always there, doing their best to help patients whether the politicians and bureaucracy lead well; indifferently or poorly.

Professor John Burgess is president of the Australian Medical Association Tasmania.