After a week in which one Sydney hospital’s problems triggered national health debate, a prominent specialist gives an insider’s perspective based on his 30-plus years working in NSW public hospitals. Dr Rob Loblay, 60, a senior lecturer in immunology at the University of Sydney*, tells Melissa Sweet that he is frustrated and angry how successive governments have squeezed hospital budgets.

Q: What have been some of the major changes in public hospitals over the past 30 years?

The demise of general medicine and the emergence of sub-specialisation has been a two-edged sword. On the one hand, patients are getting better treatment. The downside is that people who have complex problems or who have more than one problem often don’t get them addressed by the one physician. They have to see several different specialists to deal with their problem and often there is no one who can take a global perspective. Thirty years ago there were three layers of management in hospitals. Now there’s about 15 layers. There’s been a need for better financial accountability but in the process we’ve got an army of accountants and every application for expenditure has to go through three or four layers of people and they’re all there to obstruct you. We’ve had staff freezes which last months.

Q: How does this affect your work?

Everybody is working harder and longer. Governments have been trying to restrain expenditure, and costs have been increasing, and so those two things together mean that hospitals have been tightening the belt for 25 years. It’s been heading in the direction of death by a thousand cuts. Each year we have had to do more with less because the demand was increasing at the same time as resources were decreasing. It’s been a huge challenge. It’s a source of friction and dissatisfaction. When resources are restricted, people tend to fight among themselves for the diminishing slice of the cake, instead of fighting with the bureaucrats and administrators. That leads to a loss of harmony within the institutions of public hospitals. It leads to infighting. Many departments have just become dysfunctional. It’s a crumbling of the institutional community that has happened over a long time. I sometimes talk about it as Balkanisation.

Q: Have federal policies promoting the private sector eased the pressure on public hospitals as they were intended?

When I graduated, my senior colleagues believed that the public health system was there to look after the indigent and the hopeless people, and that the private system was where their priorities lay. That completely switched to a much more equitable system in the early 70s but Medicare has been allowed to gradually wither, which I find incredibly frustrating. All that money that went into subsidising private health insurance should have gone into the public hospital system. The health system has gone backwards in the last decade. It’s been really frustrating. I don’t know many colleagues who think the withering of the Medicare system and the contraction of hospital funding is a good thing. The only reason we haven’t had more catastrophes and disasters and politically high profile things like the Royal North Shore Hospital is just luck.

Q. What do you think of the Federal Government’s proposal for local boards to manage hospitals?

It’s such a lot of garbage. We’ve been there, done that. It’s not about whether you have a local board or a CEO or an area health service – what it boils down to is, it’s the budget, stupid.

*The hospital where Dr Loblay works is not named as public hospitals discourage staff from speaking to media. Often staff can only do this while wearing another professional hat.