Grand Rounds v5(30) is up

Pharmamotion is hosting Grand Rounds this week. Head over there to check it out - even this blog gets a mention this week!

Next week, it will be the turn of Diabetes Mine. Get your entries in early!

What Waiting List? A followup.

I received an insightful comment from Anonymous in response to my post on Waiting Lists. My reply follows.

Anonymous said...
I disagree with the assumption that waiting list manipulation doesn't change how long patients wait for operations.

If we use a lie (using stats) to say there is no waiting list problem then additional resources will not be allocated and ignore attempts at increasing real efficiency. This means that real waiting times may increase along with losses in quality of life, patient productivity, increased complications and increased cost of care. It’s not just the usual cost of the operation but all the related costs before and after that don’t show up in the hospital stats.

Differences in the delay of processing of forms will change the order when patients are seen.

Dear Anonymous (why are there so many people called Anonymous???),

I would agree wholeheartedly with you if the statistics were actually used for resource planning - unfortunately as far as I can tell they are only used as a political football. I am not saying that sitting on waiting list forms is a great thing to do, just that we live and work in a pragmatic world and have to get on with things.

I remember clearly in a chat with a friend who was a government lackey a few years ago why we don't look at more useful KPIs - the response was that there was no interest in measuring a KPI unless it was a number that could be improved upon and promoted in a media release.

Efficiency is squeezed to its limit already - there is no efficiency gain to be realised. Our driver at the coalface is the desire to treat patients as best we can, not to meet arbitrary targets or make the Minister look good. The only thing that can be improved upon is more capacity by capital investment - and this will never happen because placing a chokehold on capacity is the only way to limit ongoing costs! Just like the logic that if we have fewer doctors the health budget will be smaller. Bugger the patients.

As for differences in delay of processing forms... all the forms for our specialty went through me. It didn't matter how long I sat on them, or when I put them on the list, or when I received them. I filled out the forms, I submitted the forms, I reviewed the waiting list, and I booked and scheduled patients into theatre where I then operated on them.

Patients were prioritised by me on the basis of firstly clinical need, secondly resource availability, and waiting time came a very distant third. The patients were more frustrated by delays and cancellations on the day of operation than an extra week after 2 years of waiting. This is what happens every day in every hospital I have worked at. How about yours?

Meeting Fatigue

 
Where hospital administrators meet... and where doctors meet.

One of the discussion boards I attend recently commented on the usefulness of multidisciplinary meetings. These are typically where one unit has a combined meeting with another unit (often to review cases, radiological imaging, or histopathology) in order to reach consensus views on how to manage a particular case. These are quite valuable tools as they allow cross-fertilisation of ideas, multiple perspectives on a single problem, and a chance to air sometimes unusual options or nut out some difficult, challenging cases.

Sometimes, however, you can go overboard with these meetings - in the past I have often experienced "meeting fatigue" where i typically tune out and either stare blankly into the air or fall asleep (especially in radiology meetings held in a darkened room... it is harder to fall asleep while staring into a microscope but not impossible).

I recall as a neurosurgery registrar I used to walk into the end of the neurology-vascular radiology meeting so that we could start the neurology-neurosurgery radiology meeting which then led into the neurosurgery-oncology radiology meeting then followed on by our orthopaedic-neurosurgery-spinal radiology meeting.

When I switched to Thoracics I realised that the oncologists then split off after this meeting to their oncology-respiratory-thoracic surgery meeting, followed by our thoracic surgery pathology meeting upstairs.

The vascular surgeons, on the other hand, did their own vascular radiology meeting before the neuro-vascular radiology meeting, then went on a diabetic and high-risk foot round and clinic with the endocrinologists and orthopods, followed by a dialysis access round with the nephrologists, before doing their own ward round.

Of course, the oncologists followed neuro-oncology and thoracics-oncology meetings with an upper GI-oncology meeting that afternoon, a colorectal-oncology meeting the next day, a breast-oncology meeting and a urology-oncology meeting, before having a big drug company lunch and flying off to Noosa for the weekend gratis to meet up with the cardiologists.

As far as I can tell, the only specialties that did not have multi-disciplinary team meetings were the ED physicians and anaesthetists. Actually, that is not true - the anaesthetists sometimes went to a surgical-anaesthetics morbidity and mortality meeting, so that leaves the ED physicians on their own.

The bigger the hospital, the more time you seem to spend in meetings and not actually treating patients. Sometimes I think that an "MDT" meeting really means "monotonous, dull time-waster".

Grand Rounds v5(29) is up

Grand Rounds Vol 5 Issue 29 is up at Getting Closer to Myself. Make sure you go and check it up for a roundup of the medical blogosphere!

Waiting Lists? What Waiting Lists?

Waiting in Line at the Eiffel Tower - gadl @ Flickr

It is hard to ignore the news in Victoria about waiting list manipulation. Ho hum. This is old news. If you want to know how to manipulate a waiting list, refer to my previous blog entry. Every few months a politician rants on about how waiting lists are down and everything is just dandy. Shortly after the opposition carries on about how waiting lists are going up and the sky is falling down. Then an election happens, and sometimes they swap sides... and guess what, the newly-elected government politician says waiting lists are down and the newly-ousted opposition says waiting lists are up and the cycle goes on.

At the bottom of all of this political to-ing and fro-ing is an army of doctors, nurses, and paramedical staff who try their level best to treat as many patients as possible with the money that they have been allocated. It's not a lot of money, and there are an unending stream of patients, but we do what we can.

And then in between this sandwich is a layer of bureaucrats who fiddle the numbers. The Department of Healthiness, or Human Servicing, or Ageing Gracefully, or whatever (let's call them The Department) look after the politics, and dole out the money. The Hospital Administrators hold out their hands and grab as much cash as they can. The line between The Department and The Hospital Administrators can be very grey and muddy. Some people work both sides of the fence.

It is an area of pragmatism and compromise. The Department asks for good media release material - reduced waiting lists, greater throughput, briefer ED waits. The Hospitals deliver. No-one asks how they deliver... they just do. If you ask for Key Performance Indicators (KPIs) then you will get KPIs. If this means fiddling the books, then you fiddle the books. What does it matter as long as patients are still treated exactly the same as they were before? The media release is just meaningless drivel. At the end of the day youse goes to the hospital and youse gets your operation (after a variable waiting period which is dependent on so many factors that understanding it all would take a PhD or a Masters Degree).

I admit that I have worked in Victorian Hospitals. At the request of Booking Office Managers I have signed off on forms making patients "Not Ready For Care". I have kept waiting list forms in my bag for two or three weeks before handing them in to the data-entry clerks. I have seen waiting list forms sit in a pile for several weeks waiting to be entered. Never has this process made any difference to how long a patient has physically waited for their operation - only the accounting. This is not isolated to a single hospital in Victoria - this happens in every hospital in Australia, and most likely around the world. The same thing happens in every large organisation or company world-wide. Don't be a hypocrite - if you are a manager you are probably doing exactly the same thing to your KPIs.

I once worked in a hospital where my manager would deliberately lose my overtime claim sheet for several pay periods in a row. After a few months she would find them all and pay my overtime, along with all of my colleagues in the same department. We thought she was incompetent until we realised that she got a monthly bonus if the salaries came in under budget. Once a quarter she would pay us out and forgo her bonus - but the other three months made up for it.

Where patients wait a long time for their operation there are generally only a limited number of reasons:

1. Rate-Limiting Steps. There are only so many resources to do a particular operation, and everyone has to wait. This may mean waiting for investigation results, theatre allocations, specialty staff availability for complex operations, ICU beds, or special equipment for a particular operation. Basically all operations need critical planning and preparation steps to be performed first. If one of these steps cannot proceed, then it becomes a rate-limiting step.


2. Administrative foot-dragging. This is where clinical or financial approval for a particular procedure takes a long time, or is difficult to organise. There is no excuse for this except lazy, procrastinating administrators who don't think anything needs to be done any earlier than the next committee meeting in 3 months time.


3. Patient indecision. Some patients just cannot make up their mind. They want to go on the waiting list but they don't want their operation when you ring them up. "It's not convenient." "I'd rather wait until school holidays." "Let me do it when I come back from New Zealand." "I can't get time off work." These patients inevitably get upset that they have been waiting 5 years despite ringing them 20 times and they complain interminably, often to their local MP.


4. Genuine stuff up. Sometimes forms get lost. Sometimes some poor data entry clerk spells a name wrong, or accidentally presses delete. Sometimes the doctor's handwriting is illegible. We don't like it when this happens, but it happens.

Waiting lists are a fact of life. Political maneuvering is a fact of life. Management data fiddling is a fact of life. Media beat-ups are a fact of life. Like Dr Simon Leslie of Shellharbour Hospital, I'd rather just get on with the job of fixing people.

We have an unhealthy obsession with statistics and numbers. Collecting data on every scrap of activity is the reason why hospitals have half the numbers of beds they had 20 years ago - they have all been converted to offices for data-collectors, administrators and managers. The administrators need administrators, and then they need auditors to oversee the administrators, and directors to supervise the auditors.

Why can't doctors and nurses just be given the money and the trust that they can go about their job treating as many patients as possible. So what if the waiting list is a bit longer this year, or a bit shorter? No amount of number juggling can hide a 5 or 10-year trend. Stop focusing on short term goals, stop using health statistics for political gain, and you will get accurate figures and more importantly the trust of your staff.

• Hospital data fiddling raises national concerns - ABC Radio PM (Click to See)
  
  

  Hospital data fiddling raises national concerns
  PM - Tuesday, 31 March , 2009 18:50:00
  Reporter: Simon Lauder
  
  LISA MILLAR: The revelation that a Victorian hospital has been faking waiting-list data for more than a decade has raised alarm bells about how Australia's hospitals are assessed and rewarded.
  
  The Victorian Government has responded by scrapping bonus payments for hospitals and ordering random audits.
  
  Simon Lauder reports.
  
  SIMON LAUDER: After months of allegations and headlines about the manipulation of figures at the Royal Women's Hospital, a Government-ordered audit confirmed it has been going on since 1998. The independent auditor found patient records were falsified to improve reported waiting times by as much as three months.
  
  Although the hospital says it's been years since it received any bonus payments for the falsified data, the Government's responded by shutting down a $40-million bonus fund, used to reward hospitals for meeting performance criteria. It's also ordered random audits of hospitals.
  
  The revelation's prompted others to suggest the Royal Women's Hospital is not the only place where performance data is fiddled with. This surgeon phoned in to ABC local radio:
  
  SURGEON: A number of my patients are regularly made not ready for care once they're placed on the waiting list and they look like they get their operation inside the month but their actual wait from the time the waiting list form is filled out is significantly longer than that.
  
  SIMON LAUDER: Allegations of similar behaviour have also been levelled at Mercy Hospital and Bendigo Hospital; both of which deny they fudge their figures.
  
  The Premier John Brumby says the Royal Women's Hospital case highlights the pitfalls of performance-based pay, which is being increasingly embraced in Australia.
  
  JOHN BRUMBY: More and more of the funding mechanisms that we are seeing across Government now are performance based. If you look at the agreements that come out of COAG, if you look at the hospital and reform commission report, they're all about performance-based funding.
  
  And I think what's occurred here means that we need to make sure that the reliability of the data, all of the measured outputs out of the system are as accurate as possible.
  
  SIMON LAUDER: Associate Professor of medicine at the University of Queensland, Dr Ian Scott, says if hospital data is to be relied on, the Federal Government needs to set the standard.
  
  IAN SCOTT: We're increasingly in an era where there's going to be constraint on health budgets, where expectations are going to have to be reconciled with the fact that we have a limited amount of money to spend on health care and I think that if we get distracted and use money in producing dodgy data, simply not to embarrass the health minister, then I think that's not an appropriate use of resources.
  
  SIMON LAUDER: So is there a warning in the Victorian example for other states and indeed the Commonwealth?
  
  IAN SCOTT: I think there is. I think quite definitely we need to ensure that if data is to be collected, it has to be standardised, it has to have agreed definitions around the data elements that are being collected.
  
  SIMON LAUDER: So if the Commonwealth is to judge the performance of the states and their hospitals on this data, does the Commonwealth need to take more of a leadership role in overseeing the collection of data?
  
  IAN SCOTT: I think that's probably true. I mean at the end of the day I think we do need to move more towards a national data set. I think we need to have some standardisation around the data that we're collecting across the country and to that extent the Australian Government then should play a greater role in helping to define that dataset and to help design and fund the processes by which that data is collected, it's collated centrally, analysed and reported.
  
  LISA MILLAR: Dr Ian Scott speaking with Simon Lauder.

  
  
  
• Nothing but the truth - AMA Vic President Doug Travis (Click to See)
  
  

  Nothing but the truth
  Doug Travis
  April 1, 2009
  
  
  Illustration: Spooner
  
  Patient treatment is being compromised as hospitals try to work the system.
  
  THE Victorian community has been dismayed to learn that a trusted institution, the Royal Women's Hospital, has been falsifying and manipulating reporting data. Yet, as the Victorian Government acts to stamp out the perverse incentives that have led to data manipulation, the Commonwealth is ready to impose reporting requirements across the health system that may reinvent those incentives.
  
  Federal Health Minister Nicola Roxon should therefore be watching this story unfold and considering the lessons learned.
  
  Good information is the lifeblood of good health care. For an individual patient, the more a doctor knows of his or her history and diagnostic profile, the more likely a good outcome. To protect the health of the community as a whole, we need accurate and complete reporting. Manipulated and falsified data means that Government cannot adequately plan for the future health needs of Victorians.
  
  Presenting a rosy picture hides the problems in our health system. For example, because of overstated successes, governments have held back on tackling bed shortages in Victorian hospitals. These shortages have become critical in recent years, meaning that bad data is compromising safe and effective patient care.
  
  Other hospitals may be found to have manipulated data. AMA members suggest that several hospitals have set up systems that appear designed to meet key performance indicators (KPIs) rather than good patient care, such as creating short-stay units attached to emergency departments. The definitions of "time to care" are tweaked in some hospitals to produce a more favourable KPI outcome.
  
  The community expects hospital boards and management to instil a culture that values integrity, long-term vision and whole of community service, not a culture that concentrates on the short term.
  
  A hospital under pressure puts staff under pressure. Nurses and doctors are working hard to ensure that the patients in the hospital are looked after to the best of their ability, despite a shortage of beds and a shortage of staff.
  
  Until Monday, Victorian public hospitals had perverse incentives that paid extra funds to hospitals that reported they met their KPIs. More funding went to hospitals that did well, and less money to hospitals that were struggling with extra demand.
  
  Imagine you are in a highly pressured environment with too many patients and not enough resources. A manager comes in and tells the staff that if they don't meet the KPIs, the hospital loses funding. Staff get a clear message. Meet the KPIs or patient care will suffer.
  
  The suggestion that hospital boards and management are not aware of data manipulation is puzzling — hospital officers must be accountable for the culture in their organisations. Yet as state Health Minister Daniel Andrews professes fury, he elects to hold no one accountable.
  
  If the minister's actions are part of a plan to draw a line under the past and move forward, then his failure to punish can be understood. If the minister is serious about changing the culture and replacing the trust in our hospital system, he needs to back up his words with action.
  
  First, the minister should be congratulated for removing the bonus payments system that has contributed to the problems of data manipulation. This is an important and valuable first step.
  
  The next step the minister must take is to direct all hospital chief executives to report truthfully from now on, or face dismissal. As a representative of the Victorian people, the minister cannot be seen to condone actions that betray the community's trust. The minister must also make public all the data that shows the demand pressures on the health system, including previously secret information on outpatient waiting lists. We need all the data to have a sensible debate about resources for our health system.
  
  However, as the Victorian Government removes some of the barriers to accurate reporting, the Commonwealth Government is considering a host of incentives across the health system that could create more problems than they solve.
  
  Again, hospitals (and states) will have incentives to report success against benchmarks, rather than concentrating on quality care. Roxon has also floated new benchmarks for general practice to improve a range of health indicators for their patients, such as weight, insulin dependence and smoking.
  
  Under these proposals, GPs who help some of the most disadvantaged in our community may be penalised. The incentives mooted appear to encourage doctors not to see sick people.
  
  I hope Roxon is watching the Victorian health system closely to see what perverse incentives can do to resources, planning and quality care. We must report accurately and truthfully to be accountable to the community.
  
  The bottom line problem is that the truth can be embarrassing. Let's address the problem, not by spinning the statistics to avoid embarrassment, but by treating enough patients, so that the truth does not embarrass us.
  
  Doug Travis is president of AMA Victoria.

  
  
  
• Minister orders hospital audits after dud figures - The Age (Click to See)
  
  

  Minister orders hospital audits after dud figures
  April 1, 2009 - 2:40PM
  
  Elective surgery waiting lists will be audited at every Victorian public hospital in response to a widening scandal over manipulated figures.
  
  Victorian Health Minister Daniel Andrews announced on Wednesday a director of data integrity would be appointed to oversee system-wide audits of hospital waiting lists.
  
  The announcement follows revelations the Royal Women's Hospital in Melbourne manipulated figures to make waiting lists appear shorter.
  
  A damning report by the auditor-general has exposed fundamental flaws in hospital data keeping, saying the problem is widespread and figures cannot be relied on for accuracy.
  
  It has also identified figure fudging in the emergency department at the Latrobe Regional Hospital in Gippsland.
  
  Mr Andrews said independent auditors would immediately start checking the books at Latrobe.
  
  Former Victorian public advocate Julian Gardner has been appointed to the Royal Women's and Latrobe Hospital boards to stamp out improper practices, he said.
  
  "I take responsibility for these matters, I am determined to fix these issues, I am determined to stamp these practices out, and I think the measures that I have announced today, along with the reforms I announced on Monday, are a big step forward in terms of fixing these issues," Mr Andrews said.
  
  AAP

  
  
  
• Audit slams phantom wards scam - The Age (Click to See)
  
  

  Audit slams phantom wards scam
  Julia Medew and David Rood
  April 2, 2009
  
  
  Audit slams phantom wards scam
  Julia Medew and David Rood
  April 2, 2009
  
  The Royal Melbourne Hospital. Photo: Marcus Ferraro
  A SCATHING audit of four Victorian hospitals has confirmed staff are creating "ghost wards" and manipulating surgery waiting lists to secure bonus funding and avoid critical scrutiny.
  
  Auditor-General Des Pearson's report on hospital data, tabled in Parliament yesterday, cast serious doubt on the accuracy of Government health system performance reports.
  
  It also shifted the spotlight back on beleaguered Health Minister Daniel Andrews and the Department of Human Services for not providing "effective quality control regimes" and validating data reported to them for funding.
  
  "These conditions have opened the way for inappropriate practices such as data manipulation, which undermine the integrity of hospital performance monitoring," the report said.
  
  Mr Pearson's audit found three hospitals had been inappropriately listing elective surgery patients as "not ready for care" and that one hospital had recorded "admitting" patients to wards when they were still languishing in emergency departments. These practices could be more widespread, the report said.
  
  The report did not name the hospitals involved, but Mr Andrews confirmed Latrobe Regional Hospital had been manipulating its emergency department data and that the three remaining hospitals were the Royal Children's, the Royal Melbourne and Dandenong hospitals. It is unclear which were inappropriately altering surgery waiting lists.
  
  Until this week, public hospitals received bonuses for reaching Government benchmarks, including some that related to emergency department performance and elective surgery waiting lists. But after the discovery of fraudulent data reporting at the Royal Women's Hospital, Mr Andrews has decided to abolish the system.
  
  Mr Pearson's report said in some cases, nurses were retrospectively altering patient data records so the hospital met Government benchmarks. It also found hospitals were inconsistently measuring waiting times for care.
  
  While no hospitals had received funding that would need to be withdrawn, the report recommended sweeping changes to the system, including the implementation of new checks and balances.
  
  The finding comes after The Age revealed allegations in May that hospitals were creating "virtual wards" and fudging waiting times to attract funding. At the time, Mr Andrews said he would investigate the issue but since August, he has repeatedly denied there was any evidence of data manipulation to investigate.
  
  Yesterday, Mr Andrews said although responsibility for the health system rested with him, he did not think he had mishandled the scandal. He said that when allegations of data manipulation were raised with him last year, there was no hard evidence to prove it, and the Department of Human Services had "processes in place".
  
  He is resisting growing calls from the Opposition to resign and said his priority was to fix the problem. "I'm sorry if any patient has been adversely affected by these inappropriate practices; there is clearly a need to improve," he said.
  
  As the crisis gathered pace yesterday, Mr Andrews announced a system-wide audit of elective surgery waiting lists to match an audit already assessing emergency department data. He also announced the creation of a "Director of Data Integrity" role within DHS and appointed former public advocate Julian Gardner as a delegate to the boards of the Latrobe Regional Hospital and the Royal Women's Hospital to ensure their problems would be fixed.
  
  In response to comments from Federal Health Minister Nicola Roxon yesterday that deliberate data manipulation would have serious implications on future funding, Mr Andrews said: "I don't expect that there will be any impact on commonwealth health funding."
  
  In a fiery question time that saw shadow treasurer Kim Wells ejected from Parliament, the Opposition repeatedly called on Premier John Brumby to sack Mr Andrews.
  
  But Mr Brumby defended his Minister, saying he had taken decisive action to ensure tight standards across the hospital system.

  
  
  
• Bullying, bottlenecks and death by a thousand paper cuts - SMH (Click to See)
  
  
  
  

  Bullying, bottlenecks and death by a thousand paper cuts
  March 28, 2009
  
  'At heart, I'm a doctor who likes to look after patients' . . . Simon Leslie's case forms part of the Garling review into the culture of NSW hospitals. Photo: Jacky Ghossein
  
  The story of Shellharbour Hospital's Dr Simon Leslie is a microcosm of the malaise Peter Garling observed on a statewide tour of 61 public hospitals, writes Julie Robotham.
  
  ON APRIL 28, 2006, Shellharbour Hospital boss, Michael Brodnik, distributed an email. A decision had been made, he wrote, to set up a new unit within the emergency department.
  
  "The unit will be … four beds, conceptually down the right hand wall of ED but using the concept of 'virtual beds'," he told colleagues. Patients who arrived at emergency and needed admission would be assigned a virtual bed if no official in-patient bed was available, remaining physically in emergency. Brodnik said he had no control over the change, reassuring staff: "It really is a paper exercise."
  
  The rationale was to get patients off the emergency department's books within eight hours of arrival - a watershed imposed by government as a so-called "key performance indicator" or KPI, amid political pressure over backed-up hospitals and ambulances unable to offload patients.
  
  At Shellharbour Hospital, an outpost serving the cookie-cutter sprawl that straggles down the coast from Wollongong, that target was hard to achieve, because some patients had to be transferred for diagnostic tests.
  
  By May, Shellharbour was still processing emergency patients too slowly, and emails were flying. The head of the hospital's emergency department, Dr Simon Leslie, sent a measured one to Sue Browbank, Brodnik's boss: "We are being asked to run our health service on the basis of the need to treat one statistic," he wrote. "Doctors have not been ignorant or uncaring of the need to manage our resources appropriately … but are driven firstly by patient care and community needs."
  
  For a while, Leslie continued a vocal opposition to the imaginary beds. The directive to reclassify patients "according to any objective look at it was fraudulent", he told the Herald last week. "It required staff in my emergency department to write down records that were incorrect."
  
  Later he tired of battling the fait accompli and settled back to running front-line health care in the hard-to-staff hospital.
  
  That could have been the end of it, but then Peter Garling, SC, came to town. On April 14 last year, at one of the inquiry's 34 public hearings, "Dr Leslie told me the 'virtual ward' was a fiction to compensate for the fact that Shellharbour Hospital does not have a short stay unit," Garling recounted in his report. Leslie's evidence resulted - finally - in the ward's abrupt termination, though this, as he had previously observed to Browbank, was, "easy because it doesn't actually exist".
  
  Three weeks later, Browbank informed Leslie of the appointment of a Southern Hospitals Network Director of Emergency Medicine - which, according to Garling's later deconstruction, "both technically and in reality … effected the abolition of Dr Leslie's position".
  
  Leslie was ordered to stop calling himself director of the emergency department and told he could instead apply for a part-time position. "How is it possible," he asked a human resources manager, "to remove me from the role for which I have a contract and in which I have been acknowledged and satisfactorily functioning for over two years?"
  
  The vaporisation of his job and claim it had never really existed were normal practice during "amalgamations and clinical reviews," the manager soothingly responded. "In many cases roles and responsibilities have changed, staff displaced and new position descriptions written."
  
  Leslie's was a story Garling could not resist. A microcosm of the poisonous malaise he had observed on a statewide road-trip to 61 public hospitals, it comprised four elements the senior counsel had noticed repeatedly: a bottleneck between emergency and in-patient beds; inflexible performance criteria imposed from on high, then middle-management sleights-of-hand to meet those demands; and a yawning gulf of alienation between clinicians and administrators.
  
  So when Leslie updated the inquiry on the personal fallout from his testimony, Garling in late September 2008 ordered five people as well as Leslie to four gruelling days of extra hearings, devoted to the doctor's treatment. They included Debora Picone - in 2006, chief executive of the South Eastern Sydney Illawarra Area Health Service, but elevated in 2007 to director general of NSW Health.
  
  That won Leslie no respite. On the contrary, shortly after Garling's summonses landed on managers' desks, Leslie was cut out of meetings and told to hand back his pager and vacate his office - though ultimately he did not do so, successfully arguing both were essential to his work.
  
  In her sworn evidence, Browbank acknowledged Leslie's job description was signed by a doctor expressly delegated to work out his role and title. Yet she maintained the position could not exist, because the doctor had no authority to create it.
  
  Garling rejected the semantic contortion. Browbank's stance "flies in the face of the obvious facts revealed by the evidence and is wholly untenable," he concluded.
  
  Because Leslie's treatment was "unreasonable, repeated, unwelcome, unsolicited, offensive, intimidating, humiliating and threatening," Garling wrote, "I find it amounted to bullying and harassment in accordance with NSW Health's own guidelines."
  
  Leslie is an unlikely poster boy for victimhood. Affable and easygoing, it is hard to imagine him having the sleep disruptions and obsessive thoughts he says beset him at the time. He simply carried on going in to work. "At heart," said the 52-year-old, "I'm a doctor who likes to look after patients."
  
  Doctors who like to look after patients are the backbone of the health system, but are massively disenfranchised.
  
  Re-engaging them would be the most critical step in reforming NSW Health, Garling said, proposing a Clinical Innovation and Enhancement Agency - under which clinicians would determine protocols for patient care. As well, he proposes an independent Bureau of Health Information to monitor hospital performance, freeing doctors like Leslie from political pressure to fudge the loathed KPIs.
  
  The toughest challenge is how to make hospitals gentler. "The workplace culture in NSW public hospitals is characterised by lack of respect and trust, absence of empathy and compassion, inability to celebrate the success of others, failure to communicate, and a lack of collaboration," was Garling's damning verdict after his journey to the heart of the health system. Its anti-bullying policy had failed, dissent was quashed and persecution was rife.
  
  Garling recommends making individual employees - all 118,000 of them - more directly responsible for their behaviour, reorienting the system away from blame towards constructive criticism and strengthening complaints procedures.
  
  Last July, Leslie lodged a formal complaint about his treatment. Eight months later he has not been told how it will be resolved. Terry Clout, the area health service's chief executive, told the Herald he was seeking more information and would consider "any actions that may be required". He declined to comment further, citing, "procedural fairness" in the "personnel matter".
  
  Leslie said the delay was "a process to wear me down". He understands deliberations will not privilege Garling's account of events - despite the evidence the commissioner collected under unmatched statutory powers.
  
  Perhaps that is unsurprising. Garling said Leslie's situation went unresolved because Shellharbour managers "did not demonstrate … the slightest knowledge of what constituted bullying and unacceptable behaviour".
  
  When is a bed not a bed? Leslie has paid a price for trying to reconcile the internal logic of NSW Health's storytelling with empirical reality, and no one has ever apologised. He will now take his case to the NSW Industrial Relations Commission. If Leslie - with the inquiry's weight behind him - cannot bring NSW Health managers to account, possibly nobody can. "Mr Garling's put a fairly heavy burden on me," he said. "I feel an obligation not to let that go to waste."