Back to Basics
Industrial Relations in the Hospital and Medical Services Industry (II)
Dr B D Shepherd
The hospital and medical services industry has some
features which are probably unique. The hospital Industry
has a private component which is private, although
the income of the surgeons who work therein is partly
derived from government. The public component takes
care of patients who are entirely funded by government,
as well as those who are private but whose accommodation
is heavily subsidised by government. In New South Wales,
65 per cent of the surgery performed on private patients
is undertaken in the public hospital system. This is
partly due to the fact that there are only 5 category
one (first class) hospitals in the State and only 17
per cent of the State's hospital beds are in the private
sector, many of these private beds being little more
than nursing home standard without surgical backup.
(This contrasts with other States, where 30-40 per
cent of beds are in the private sector.)
Practice Outside the Hospitals
Due to an over-production of medical graduates, most
of whom are in general practice, there is a marked
over-supply of general practitioners in the city. Despite
this, there are many quite large country towns with
an under supply of doctors. This situation will worsen
due to the unsatisfactory resolution of the Country
Doctors' Dispute. It may be reasonably said that each
State has at least one medical school too many.
Another anomaly is that, despite the overproduction
of medical graduates, there is a shortage of resident
medical officers in the public hospital system, especially
in New South Wales. This is due to the poor conditions
of service and poor remuneration of RMOs in this State.
This has resulted in the State government importing
sub-standard medical graduates to fill the vacancies
left by the premature departure of RMOs from the public
In this paper I wish to look at the inter-relationship
between two professional groups---the medical profession
and the nursing profession---in the public and to a
lesser extent the private hospital system; to say something
about the position of the Health and Research Workers'
Union; to touch upon techniques of misinformation used
by a government department in order to disguise poor
performance; to examine the approach and position of
the medical profession, especially in New South Wales;
and to relate the effect on the community of the industrial
position in the medical and hospitals industry and
to speculate upon some remedies.
Not so many years ago some nurses paid to be trained,
bought their uniforms and paid their board at the hospitals.
Probably a majority worked for a few years after they
graduated, then married and became lost to the profession.
Today nurses are no longer trained in hospitals. They
are trained in a classroom. There are many of us who
are concerned about the preparation they receive for
assuming clinical responsibility and for carrying out
many of the arduous tasks required of the nursing profession.
Be that as it may, the nursing profession is a gentle
one and as such has not been well cared for by its
employer, the government. In many ways, their professional
level of responsibility was used against nurses. This
is an instance where proper care and attention on the
employer's side may have averted a major disaster and,
what is more, have prevented a great deal of power
falling into union hands.
As the years went by, nurses became aware of a strong,
well-led union, the Health and Research Workers, which
was gaining increasing advantages for its members---
the cleaners, the domestics, etc. who work around the
hospitals. It was not easy for a Sister to accept the
fact that the cleaner, who appeared to do a great deal
less work and work a great deal fewer hours and accept
a great deal less responsibility, was receiving more
income. Inevitably stronger elements took over the
nursing unions. These elements sought (and eventually
obtained, after a great deal of industrial turmoil,
especially in Victoria) markedly increased rates of
pay---rates which, as you can see from the paper of
our earlier speaker, may not be sustainable in the
industry. These victories by the leaders of the nursing
profession have led to a new-found militancy which
has flowed over into nurses' relationships with hospital
authorities and the medical profession. This is not
always to the advantage of the patient.
In addition, a new power-base has been established
in the Colleges of Advanced Education. At one time
the Matron of a hospital was at the apex of the whole
career structure, but an alternate career structure
has developed outside the hospitals in the colleges.
This is an area for concern as nurse educators in the
colleges become increasingly separated, both in time
and distance, from the workface and professional reality.
In the past the medical student was taught almost
exclusively, in his clinical subjects, by privately
practising clinical doctors. These doctors gave their
services without remuneration and indeed considered
it a privilege to do so, this being very much in the
Hippocratic tradition. In those days the students'
heroes were almost always privately practising doctors.
Today much more teaching comes from fully employed
clinicians. Many more medical students and young graduates
perceive their career structure as being in continuous
employment---a relatively rare thing not so many years
ago. Working against this, of course, are the poor
conditions experienced by RMOs at the present time.
On the other hand, there are many visiting medical
officers who are regarded as privately practising doctors,
who regard the takeover by government and nationalisation
of the profession as inevitable and, for a variety
of reasons, do not wish to put any energy into resisting
this onslaught, preferring to jockey for the best possible
position when the takeover occurs.
Visiting Medical Doctors
In his report following his Inquiry into Private Medical
Practice in the Public Hospital System, Professor David
Penington stated that the present difficulties between
the medical profession and the government occurred
with the advent of sessional payment, for what had
been, up until then, honorary service to the public
hospital system. Previously, Professor Penington said,
the medical profession had enjoyed independence and
been regarded with respect by hospital authorities;
once payment was received, they began to be viewed
by the hospitals as employees, less notice was taken
of their advice and the rot set in. Sadly, in certain
public hospitals, this loss of respect has resulted
in an altered relationship with the nursing profession,
some of whom feel they should be able to run a separate
race; once again it is the patient who suffers. Fortunately,
this relationship does not occur in all hospitals and
is perhaps seen least in the private hospital system.
As a result of the Macken Determination in New South
Wales, relatively generous sums of money were allocated
for some work in certain specialities, to visiting
medical officers in the public hospital system. In
particular instances, the reward for giving the same
service in the public system is much greater than that
imparted by the fee commonly charged to buy such a
service in the private system. As a consequence, there
is a reduced disposition toward private practice in
this area. From a community point of view this is not
good, as almost invariably a service given in the public
hospital system costs the community twice as much as
it does when given in the private system.
Resident Medical Officers
As stated earlier, RMOs' conditions of service are
untenable: many are expected to work more than 48 hours
at a stretch; they are poorly paid; they have an uncertain
tenure of employment; many are asked to take responsibility
beyond their training; they are unhappy about postgraduate
instruction; and they are frightened to claim the overtime
they work for fear of adversely affecting their career
opportunities (there are many anecdotes of threats
made by hospital executives in this regard). All in
all, the resident's lot is not a happy one and many
are voting with their feet, leaving vacancies in the
public hospital system. Many indeed are abandoning
the profession altogether---something which would have
been almost unheard of a few years ago.
Health and Research Workers' Union
This is a strong, well-led union which has obtained
good conditions for its members by successful negotiation
with a minimal creation of industrial turmoil. Unfortunately,
the productivity of this element in the public hospital
system is not high. In general it can be calculated
that the same services in the public hospital system
done by contract labour would cost about half as much.
As has been said earlier, this union's success has
been partly responsible for the unrest in the nursing
In the public hospital system the employers are represented
by an over-burgeoning bureaucracy: at last count, for
every doctor, nurse and therapist, there were 3.5 clerks,
administrators, domestics, cleaners, etc. As is usually
the case, the administrators have an ill-defined work
description and have much time, should it be their
wont, to impose increasing controls. They are responsible
for ever mounting red-tape, paperwork, etc.
The result is an over-bureaucratised, inefficient,
poorly motivated public hospital system, with the previously
main driving forces---the medical profession and the
nursing profession---somewhat dispirited and frustrated.
Public Image of Public Hospital System
Possibly the truth will out, but in many instances
it takes time. Gradually the NSW public is realising
the faults of the public hospital system. There has
been a major cover-up by the Health Department and
the Minister. We have only to look at a few instances
of this. Consider a set of graphs from the Hornsby
and Kuring-Gai Area Health Board. A normal, intelligent,
educated person glancing at these graphs would gain
the impression that the productivity of the operating
theatres, delivery rooms, etc. was on a steady rise.
It is only if we look carefully at the time-scale beneath
that we see that the years start from 1987 and go back
to 1983. In fact, productivity, etc. is well down.
I have not found one person yet, amongst scientists,
clinicians, etc., who has seen graphs drawn this way
before. It is only in the last two years that graphs
have been presented in such a fashion in this report.
We go to another page of the report where the figure
of roughly 400,000 occasions of service is cited: this
is frequently used by the Minister as a yardstick of
the productivity of the public hospital system. Time
and again he has said that the services given by the
public hospital system have risen remarkably since
the Dispute and even prior to it. It is only when we
identify what he regards as services that we realise
the mendacity of this. We see that under the heading
of 'lifestyles', there has been a rise from approximately
7,000 to around 24,000. On inquiry it transpires that
'lifestyles' is when a group of healthy people meet
together with a nurse and do a few exercises or whatever.
For you and for me a service from the hospital implies
something concrete like a casualty treatment, an operation,
a delivery. It would be just as honest---indeed more
so---to take as an occasion of service every time a
nurse washed a patient's back, cleaned up a bed, etc.
If we look at the true indices of hospital service,
we note that there has been a very real reduction in
productivity---for instance, operations have been reduced
by almost 40 per cent. What I am saying is that you
just cannot trust the propaganda put out by this government
department (and in all probability by most government
departments) of State.
What of the Future?
The NSW Branch of the AMA has a strongly committed
high quality team, many of whom are fairly battle-hardened
and who are motivated by a desire to help the profession
rather than to accept the accoutrements of office.
Much has been initiated to protect the profession,
to make it more efficient and better able to serve
its patients. Much more has to be done. It is the intention
of the Hawke Government to introduce in the Budget
Session of Parliament legislation to establish a participating
doctors' scheme. In brief, this means that if you,
as a patient, attend a doctor who does not adhere to
the government fee structure, you will not be eligible
for the Medicare rebate. In other words, the doctor's
fee will have to come out of your pocket. Many people
will be unable to afford taxation, the Medicare levy
and fees as well. The intention is to achieve control
of the profession. Canada has this system, as also
has Albania; they are the only two countries in the
world where such control of the medical profession
If, as is likely, there will be a strong influence
on the Federal body of the AMA by the middle of the
year, that body will undertake to prevent this legislation
I believe that a great deal can be done by the community
at large, and especially by members of The H R Nicholls
Society, to help other members. There is no doubt that
a public statement made by somebody of some standing
outside the profession has much greater influence than
if I sound off. Indeed what happens to the profession
very strongly affects the community.
At the present time the case for truly Liberal Government,
for a less interventionist government, is being very
poorly put. We need to examine what can be done by
way of communication to remedy this. We need to show
more courage than we have to date in pursuing what
is right and just. If we do not, we will have imposed
upon us a society we deserve.
Why HR Nicholls?