Dr Warwick Ruscoe - SSWAHS = SWSLHN + SLHN

It seems that not only was Dr Ruscoe involved as a Managing Director of HCC and subsequently a consultant to the HCC (and as a major shareholder - to James Hardie Industries) about the development of the Taj Mahal-type private hospitals on the North Shore, but it does seem that he spent some time administering the Greenoaks Private Hospital (Greenacre, NSW) as the following legal matter seems to suggest.

"MEDICAL TRIBUNAL OF NEW SOUTH WALES
DEPUTY CHAIRMAN: HIS HONOUR JUDGE WALL, Q.C.
MEMBERS: DR. B. AMOS DR. B. POLLARD and MS. L. ADAMSON
FRIDAY 20TH MAY, 1988
RE: COMPLAINT AGAINST DR. PETER JAMES DAWSON DECISION

"A complaint was lodged by the Secretary of the Health Department of NSW on 13th October, 1987, alleging that Dr. Dawson has been guilty of professional misconduct in respect of the treatment of Mrs. Carole Lesley Tatham at Greenoaks Private Hospital, Greenacre on 18th August, 1985, the particulars of which were:

"The Tribunal received submissions in the form Dr. Dawson, A/Prof. Torda, Dr. O.F. James, Dr R.L. Millard, Dr. Dr. M.S. Jun and Dr. W.J. Ruscoe which had all been prepared for submission to the Investigation Committee which had considered the matter on 10^th August, 1987.

"The transcript of these proceedings before the Investigating Committee was also admitted before the Tribunal. The relevant hospital records, including operation and anaesthetic records and post-mortem examinations reports were also admitted into evidence before the Tribunal."

The nature of this hearing was that Dr Dawson employed as an anaesthetist in Dr Ruscoe's hospital failed to identify a respiratory problem during the surgery of the patient who subsequently died. The reports flowing from the investigation do suggest that there was a great deal of confusion and misinformation which seemed to be present in the discussions between Dr Dawson and the surgeon.

Some of the discussion related to whether or not a crucial piece of equipment used by the anaesthetist during the procedure was actually operating as it should. It does seem that Dr Dawson may have been correct about the failure of the equipment which would have alerted the surgeon and Dr Dawson that things had gone awry. In fact His Honour did make the point that there may very well have been an equipment failure. Nevertheless His Honour did find that Dr Dawson did fail in his duty and subsequently ordered that he be deregistered.

This does lead to a peripheral question. Should Dr Dawson have been appointed to the position of anaesthetist at The Greenoaks Private Hospital? Certainly, during the Tribunal Hearing even Dr Dawson admitted that his use-by-date had pretty much expired. So should the buck stop on the Chief Executive's desk given that Dr Ruscoe most likely had the say as to who was appointed.

Secondly, given that even His Honour noted that the critical piece of equipment had failed to alert Dr Dawson and the surgeon to the fact that the patient was in respiratory arrest during the surgery. So who should be responsible for the maintenance of the surgical equipment. Does the buck also stop with the Chief Executive of the Hospital? In my view, and hopefully in the view of others, Dr Ruscoe should have been held more accountable for the patient's death than appears to have been the case.

What do you, the reader of this blog, think? Is this the man we really want to organise the health care needs of the community in the Southern Highlands?

"Wenkart's built an elephant and made the residents look at its arse." - Peter Barley

This posting, which is primarily a re-posting of an article, accessible in the public domain, was first printed in the Sydney Morning Herald on 16 October 1992. As such, the article is retained for the valuable lesson it gives about how medical entreprenuers can over-reach themselves when trying to explore the "bigger is better" model of health care.

As we are now entering a new phase where the Federal Government is encouraging Divisions of General Practice and a new breed of medical entrepreneurs to develop Medicare Locals and Super Clinics it is perhaps timely to remind those tempted by the new money to consider the perils of those past experiences.

A personal commentary made here by Socrates about the local situation in the Southern Highlands was deemed "offensive and defamatory" by one person named in this 1992 SMH article. Given that the informant insists on sending their letters to a third party it has taken some time for this message to get through to Socrates. However, now I know!

As a consequence, any personal comment previously made by me, on the content of this article and including the persons named in it, has been deleted.

On 16 October 1992, Valerie Lawson (Sydney Morning Herald) wrote:

"WHO CAN ever forget the medical superstar of 1985 - Dr Geoffrey Edelsten? He was the very model of a modern medico-entrepreneur with his blow-wave, his Porsche with the SEXY number plates, his pink helicopter and his trophy wife, Leanne.

The liquid flowing through the Edelsten medical empire was not blood, but money. It was fuelled by the profits from pathology and property, but while the empire grew the Taxation Office watched. Edelsten's practice of tax minimisation helped service his debt for a while, but finally the tax man pounced and Edelsten was bankrupt.

If Edelsten had not gone belly-up in 1988, he might well have swung into the next big phase of entrepreneurial medicine, the development of the high-tech private hospital and medical centre alongside Sydney's over-burdened and financially troubled public hospitals.

As it was, his former partner, Dr Tom Wenkart, and two other medical entrepreneurs, Dr Warwick Ruscoe and Dr Carl Bryant, seized the moment in 1988. Just as Professor John Dwyer of Prince of Wales Hospital has recently revived his plan to create a hospital-resort at Prince Henry Hospital, Doctors Wenkart, Ruscoe and Bryant contemplated planeloads of overseas tourists on a health pilgrimage to their luxury hospital resorts. The vision was state-of-the-art Taj Mahals offering high-tech medicine, all funded by private health insurance."

"What went wrong for the locals (Wenkart, Ruscoe and Bryant)? For one thing, timing. The Sydney hospital palaces - like so many of the city's new hotels - were conceived in the bicentennial year of optimism. That year, an overheated private hospital market saw bed licences trading at "astronomical sums", according to Dr Campbell. Then came the property slump, the recession, the rise in interest rates and a fall in private health insurance.

One investment banker sniffs: "These private hospitals were designed as Taj Mahals. The men behind them are salesmen with a vision. These things are designed as monuments to them. They are over-engineered and over-capitalised. You can buy private hospital beds now for under $100,000, but these new ones were costing $200,000 to $300,000 a bed to build."

The company which wants to build Northern Private alongside Royal North Shore was also given a financial infusion last year when James Hardie lent HCC$34 million. James Hardie is the biggest shareholder in HCC with 50 per cent; other major shareholders are Medibank Private and Leighton Holdings. HCC won the Northern Area tender for the hospital with a payment of $5 million.

Since then, the original plan for a 210-bed hospital has been scaled back to a 150-bed hospital costing $60 million. "Shareholders are looking at financing it themselves," said Dr Warwick Ruscoe, a consultant to HCC and its former managing director. However, James Hardie's group planning manager, Mr David Luke, said the company was also "talking to potential investors outside the company. It's difficult at the moment. A lot of investors seem uncertain".

The market is suspicious about James Hardie's commitment to HCC, believing it may offload its stake completely, as foreshadowed by company executives last year.

HCC also has the right to develop a private hospital on land it has owned for four years adjacent to Westmead Hospital, but this project has been put on hold indefinitely, Dr Ruscoe says.

In April this year, the council received an application from Macquarie for a 300-bed private hospital with a 150-room hotel attached, a medical centre and 80 medical suites, plus associated retail stores including a fast-food style of restaurant and parking for 1,266 cars. (The number of beds in the private hospital has since blossomed to 500.)

On July 2, the council called a public meeting at which residents objected to the look of the building, its height and overshadowing effect and the traffic impact of the complex, in operation 24 hours a day.

Members of the Camperdown Residents Action Group who attended included Jenny Thompson and her law student husband, Peter Barley, who live directly opposite the planned service entrance of the private hospital in Church Street. Peter Barley remarked: "Wenkart's built an elephant and made the residents look at its arse."

Another objector at the meeting was Dr Harry Haber, a local GP and past president of the Central Sydney General Practitioners Association. Said Dr Haber: "The GPs think Macquarie should stick to its pathology. They want to open a large general practice business in the new hospital. If they do that, why should we not boycott Macquarie Pathology Services? They would also hope to capture all the private pathology work at the private hospital."

Dr Wenkart replied: "The local GPs feel endangered, but the days of the solo GP are numbered anyway."

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 7

It would seem that the long arm of the Southern Highlands Division of General Practice has reached up to the Bankstown GP Division's Twitter page. Ah well! I guess it had to be expected that the self-protectionist executive and Board of the Southern Highland Division would seek to, like King Lear, hold back the tide of growing criticism from its members and others in the community.

What is there of which to be critical, one might ask? Well let's examine what the role and function is of any Medicare Local as defined by the Federal Government and reported by Grant McArthur in last weekend's Herald-Sun:

"Medicare Locals are intended to be primary care networks in charge of planning and delivering health services in their area, with GPs, allied health, nurses and pharmacists possibly sitting on their boards.

"The Federal Government is yet to outline whether it will manage day-to-day services and doctor rosters, or if it will take a more administrative or advisory role."

And this was the reported comment of the Victorian Government's Health Minister in the same article:

"We think it is unfortunate that the Commonwealth has not been very precise about the role of Medicare Locals," state Health Minister David Davis said. "They have said they want to do more after-hours GP work, but exactly how they implement that has not been laid out.

Even blind Freddy can see that this does require community and health provider consultations at best and, at least, to be involved in informing the community as to what the "semi-autonomous" Southern Highlands/Wollondilly Medicare Local will look like, and what services, if any, it will provide.

Again, a search of the local press, the Division's own website, and that of the Macarthur Division reveals nothing forthcoming from the CEO and Board of the Southern Highlands Division of General Practice. If information has been merely trickled from top down to the local GPs who are members of the Division then that process hardly constitutes being a "primary care network(s) in charge of planning and delivering health services in their area".

This then begs the question: "When will Dr Ruscoe and the Board of the Southern Highlands Division of General Practice become open and transparent about their plans for the delivery of health services in the Southern Highlands and the Wollondilly communities?"

I'm told that at one meeting, late last year, of Mental Health Professionals in the Southern Highlands a suggestion was made that Dr Ruscoe be invited, to a subsequent meeting, to discuss the evolution of the Medicare Locals in the Southern Highlands. The response from the GPs present at the meeting was that there are other people of more interest than Dr Ruscoe who could be invited to speak at subsequent meetings. One could consider from this comment that even members of the Division believe that Dr Ruscoe is more of a legend in his own mind than in the minds of others.

Certainly the absence, already, of any public comment about the local version of the proposed Medicare Local could mean that Dr Ruscoe may have been a speechless invited speaker! So, who is this man who seems to wield such power and influence? Perhaps Socrates's next posting should bring some clarity to this question.

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 6

On the Bankstown GP Division Twitter a question was raised about the scope and scale of the Southern Discomfort felt in Bowral about the state of health services and, I guess, about the comments I made about the Southern Highlands Division of General Practice.

My purpose was to draw attention to the extreme variance between the actions taken by the Bankstown Division and the lack of action taken by their counterparts in the Southern Highlands, in respect of the advocacy for a more appropriate Medicare Local. In the case of Bankstown the Division there took an active role in developing a coalition of organisations and other health providers to agitate and advocate for the maintenance of a family focused medical practice. Their community was being supported by the Division and was being invited to participate in the process.

In the Southern Highlands the Division of General Practice has not made any public comment, has not issued any press releases, and has not even published any information about the proposed changes on their website. The whole process of change appears to have become the Southern Highlands Division of General Practice "secret business".

To my knowledge no NGO or community group with a stake in the way in which health services are meant to be delivered has been advised about, or invited to, anything to do with the development of a Medicare Local as a "Branch" or "semi-autonomous rural network". One of my informants has recently advised me that the nearest that any such explanation has been forthcoming is a promise from the CEO of the Division to address some of the local psychologists about what impact the changes may have on their private practices. It also seems that the meeting has only come about because the CEO is a neighbour of the psychologist arranging the meeting.

The question needs to be asked: "Why has there not been the same level of discussion, activity and collaboration with consumers, health care providers and NGOs in the Southern Highlands as there has been in the Bankstown and similar areas?"

Possibly, the Southern Highlands Division of General Practice CEO and Board may feel that they are on top of the issues related to the implementation of the "semi-autonomous rural network" but it seems that the GPs, who the Division purportedly represents, have been left in the dark as much as has been the local community. To my knowledge there has been no dialogue with the GPs, and there certainly has been nothing in the local press. Nor has there been a public meeting for community members, health care providers and health care organisations who will obviously be affected by any implementation of a local Medicare Local.

To the Bankstown GP who asked the question about the scope and scale of the Southern Discomfort I ask "How would you feel if you had no input or feedback as to what was about to (perhaps) radically change the way in which health services would be delivered to you, as a consumer, or by you as a medical practitioner?" My belief is that most people would want to know about the change or, hopefully, want to take an active role in any proposed change. Unfortunately, in the Southern Highlands, no one other than the Division of General Practice CEO and the Board knows of the change, nor has any organisation appeared to have an active collaboration within the process.

Yes, the Southern Discomfort is extensive in scope and scale - and just wont go away.

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 5

Socrates is putting in a bid to see if the Southern Highlands community can attract Dr Susan Harnett to become the CEO of the moribund Southern Highlands Division of General Practice. What a dynamic individual she is! Articulate, expressive, and someone who has the committment and desire to bring about the best possible outcome for the patients in her area of the South West Sydney Medicare Local.

Her coalition of general practitioners and health care workers had a breakfast meeting at Bankstown this morning. Not only is she effectively knitting together a strong coalition of health services she and her committee are effective in informing the community and health care providers about what the future direction is for their local health services.

In fact, if Socrates wants to know what is happening in the Southern Highlands he only has to go to the Bankstown GP Division's website or Twitter to get the good oil! In contrast, the silence from the Southern Highlands Division of General Practice is deafening! Not one word about their plans for the Medicare Local in the local press. Not one public meeting of health care providers reported as being planned by the Division. Obviously the autocratic machine in the Division is working on something but the community and other health providers will be left like mushrooms - in the dark!

Here, in part, is what Dr Susan Harnett was able to say to their large roll-up of interested people.

“This business breakfast was part of our response to recent federal government changes to how family medicine works across Australia,” said Dr. Harnett.

“On February 22 2010, the Prime Minister announced the federal government will form new family health organisations, Medicare Locals, across Australia,” said Dr. Harnett. “Over coming months, these Medicare Locals will make sure community and health organisations work ever more closely with local hospitals and family doctors.”

“When the PM launched Medicare Locals, she described them as an invisible engine, joining up health services. The PM said that our patients may never see or hear the Medicare Local engine working behind the scenes. But if the engine works well, then patients will simply get the best care.”

“Here, in south west Sydney, the Medicare Local will cover a huge area. The Medicare Local will centre on Bankstown, Fairfield and Liverpool, and take in the urban edge of the Macarthur region. Meanwhile, a separate, semi-autonomous rural health network will extend south of Camden, through Wollondilly, to Bowral in the Southern Highlands,” she said.

“Across this huge Medicare Local, the real challenge for each health and community organisation will be to think through what this means for them locally. While the federal government has described the many benefits of joined up health services, the reality is that our many family doctors, non-government organisations and other health providers need to have a good reason to take time out of their day to meet, and to actively collaborate on improving patient care in their local area,” said Dr. Harnett.

“Even though the Medicare Local hasn’t yet been finalised, we’ve already found that a really broad range of organisations across south west Sydney really want to work more closely with local family doctors, and to work collaboratively towards improving the health of our many diverse communities,” she said.

“Today, through the SWSHC, we’ve brought together many health organisations that have never even spoken with each other before. And in so doing, we’ve also opened up new ways for these organisations to do business locally,” Said Dr. Harnett.

”Joining up local health services just makes business sense. This is the missing ingredient that will really make the South West Sydney Medicare Local work. By building new bridges, we’ll make sure everyone has a real stake in improving the way health works across this part of Sydney,” she said.

“Through this SWSHC breakfast, we’ve taken the first steps to family doctors working in new ways with disability and community organisations, with local pharmacists, physios, with mental health, ageing and other health providers,” said Dr. Susan Harnett.“

“This is our once in a lifetime chance to improve how local health works. This business breakfast was just the the first step to a healthy future for families across south west Sydney.”

Note the words she uses when Dr Harnett describes the scope of their Medicare Local. This is the first confirmation that the Southern Highlands Division of General Practice may be extending its grip into the Wollondilly Shire.

"Meanwhile, a separate, semi-autonomous rural health network will extend south of Camden, through Wollondilly, to Bowral in the Southern Highlands,” she said.

The use of the word "semi-autonomous" opens up some hope that someone else other than the current CEO and Board of the Southern Highlands Division of General Practice will ever be able to demonstrate that it is capable of meeting the requisite strategic objectives as set out by the Australian Government for Medicare Locals.

In the meantime, Bankstown GP Division and its Health Coalition, can we borrow Dr Susan Harnett!? Please!

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 4

What is expected of the Medicare Locals? In summary the following principles are the key points required of any organisation that holds itself up as an appropriate organisation to receive the Federal funding to manage a Medicare Local.

"The overarching objective of MLs is to ‘coordinate primary health care delivery to address local needs and service gaps’. The guidelines set out the functions of MLs, including the expectations of the Government, according to the following ‘strategic objectives’:

• Improve the patient journey through developing integrated and coordinated services
• Provide support to clinicians and service providers to improve patient care
• Identification of the health needs of local areas and development of locally focused and responsive services
• Facilitation on the implementation and successful performance of primary health care initiatives and programs
• Be efficient and accountable with strong governance and effective management"

Has the Southern Highlands Division of General Practice ever been able to offer "integrated and coordinated services"? What support has it ever offered clinicians and service providers to improve patient care? How has the Division's CEO and Board gone about identifying local health needs and the development of locally focused and responsive health services? Has the CEO or the Board ever participated in any public community forum or meeting to gain any impression of the local needs? Apart from the government funded programs and initiatives what primary health care has the Division ever promoted outside the organisational structure of the Division? Where is the proof that the Southern Highlands Division of General Practice has been efficient and accountable of the Federal and State funding with which it has been provided in past years? If it is an honorable and honest Board and CEO perhaps they can explain why the government funded mental health programs have been limited because the money provided has been diverted towards the Division employing its own staff. Does this suggest good governance and financial management? The only answer for any of these questions and for any response attributable to the "strategic directions" enumerated by the Federal government for Medicare Locals is a universal "No!"

and

"MLs are expected to ‘provide more integrated care’ and ‘ensure more responsive local GP and primary health care services’. These examples point to the importance of the interface between MLs and the Commonwealth and MLs and the States if they are to achieve their objectives. Integration at the local level is also likely to be critical. The goodwill of external organisations and individuals, over which the ML has little or no control, and the availability of incentives to encourage organisations to participate in the MLs will be important.

Although the first group of MLs are likely to be drawn from ‘high functioning’ Divisions of General Practice, many of which have had experience in negotiating some of these issues, as MLs their role is much broader.

To fulfil the Government’s long term objective for MLs to provide a ‘coordinated package of care’ and act as fund holders for primary care, an agreed definition of what constitutes primary health care and sufficient empowerment of MLs would seem to be necessary pre-requisites."

One has to ask whether the historical record of the Southern Highlands Division of General Practice meets even the basic requirements for these "strategic directions" and "expectations" enumerated in these foregoing quotes from Canberra.

Has the Southern Highlands Division of General Practice been a "high functioning" Division? Has it been able to work with other health and welfare based organisations in the Southern Highlands? Has it ever been able to "provide a coordinated package of care" to meet the whole of life health needs of the local community? Has the Southern Highlands Division of General Practice ever held consultations with any NGO or representative community group about the health need requirements of the local community? How integrated have they been with their local community and the other health service providers? The truth is that the the CEO and the Board of the Southern Highlands Division of General Practice would have a resounding "No" or "None" marked against each of these questions on the Division's report card.

Yet, by default and for no other reason, the Federal and State governments could be sending about $2 million dollars per year of taxpayers money to the Southern Highlands Division of General Practice to spend in providing boutique services and programs through the Division's organisational structure in an attempt to enhance its own status, while local GP practices attempt to maintain the health and well-being of the Southern Highlands community.

God help us all if the Southern Highlands Division of General Practice remains controlled by that failure of a medical administrator. This area will either get no funding, or will not be able to retain any funding provided by the Federal and/or State governments.

SSWAHS = SWSLHN + SLHN and the Medicare Locals - 3

Ouch! While I have to say that the Bankstown GP Coalition Network have achieved their best outcome in that they have a smaller urban Medicare Local which enables them to provide the type of family practice health services it has come at a cost to the people of the Southern Highlands. The Bankstown GP Coalition Network is now connected with the Liverpool-Fairfield and Macarthur Divisions of General Practice. This limits the whole northern Medicare Local to the urban areas within the southern boundary of the Macarthur area.

This change to the Northern Coalition of GP Divisions then changes the configuration of any possible Medicare Local which takes in the Wollondilly and Southern Highlands Shires. So what might happen? Well, as has been reported previously in this blog the, Southern Highlands Division of General Practice has gone remarkably mute on the subject. Their website is devoid of any information available to the community. In fact they have not had an updated newsletter to their member GPs since July 2010. Quite a difference to the Bankstown and Macarthur Divisions websites.

Now here is the dilemma facing us in the Southern Highlands! It may be that our local entrepreneurial CEO of the Southern Highlands Division of General Practice is looking northwards to draw in the Wollondilly general practices to the current Southern Highlands Division. While that might increase the size of the population of their catchment it gives no promise of anything changing to benefit the people's health needs. To date, there has been no communication from the local Division about their plans for the community. How unlike the work done by the Bankstown Division who engaged their community in the fight for their health services.

What will be alarming is if the current CEO and Board of the Southern Highlands Division of General Practice will become the controlling organisation of an enlarged area. One could hope that the GPs of the Wollondilly Shire will insist that there is a spill of the current Board and that the position of CEO is made vacant. I would be confident in saying that most of the GPs in the Southern Highlands would like to have the opportunity to have a purge of the current operators of their Division.

It would be refreshing (but notably unlikely) if Dr Warwick Ruscoe stepped aside. His history of being a medical administrator has not been without question and conflict. Perhaps in the saga of the Medicare Locals history is beginning to repeat itself.