A regional private hospital should do fewer things, alongside the public one

Every regional private hospital I have worked with carries a service it cannot afford and cannot bear to close. Sometimes it is maternity, sometimes intensive care, sometimes an after-hours medical admitting service. The service usually opened when the town was growing, when more families held private cover and when specialists wanted to live there. It remains because closing it feels like abandoning the community, and because the hospital's identity has become attached to it. I understand that instinct. I have come to think it often produces care that is less safe, more expensive and less useful to the town than the alternative.

My view comes from both sides of the line. For five years I ran eleven small public hospitals and multipurpose health services in central Queensland, where the first rule of safety was to know exactly what each site should not attempt and to have a dependable route to the place that could. Since 2017 I have worked for a private operator with five regional hospitals. The same rule applies to us, but the commercial pressure to keep everything open makes it harder to follow.

The cost of a service nobody wants to close

The first cost of a low-volume service is clinical. Skills that are used rarely decay. A midwifery team delivering fewer than a baby a day sees few of the emergencies it must be ready for. An intensive care unit that admits a handful of patients a week struggles to keep its nurses confident with complex ventilation. Accreditation and credentialing can confirm that staff are qualified; they cannot manufacture the repetition that keeps a team sharp.

The second cost is the roster. Safe birthing needs an obstetrician, a midwife team and an anaesthetist available at any hour. In a town with three obstetricians, that means each is on call one night in three, indefinitely. When one leaves, the remaining two cannot sustain the roster, and the hospital starts paying premiums for locums who do not know the team. At Kelvarra Rockhampton we reached that point in 2022, when births had fallen from 640 a year to 270 and maternity was losing A$4.6 million annually.

The third cost is invisible on the hospital's own accounts. A service that loses money is funded from somewhere, usually by margins on elective surgery. In a not-for-profit group, that means fewer replacement beds, older equipment and thinner staffing in services that are used far more often. The subsidy feels like generosity to the town. It may be a transfer from the many patients who need common care to the few who use the rare service, with no one having decided that it should be.

Partnership is not a polite word for retreat

The alternative is not simply closure. In most regional towns the public hospital is larger than the private one and already provides the emergency department, intensive care and specialist cover around the clock. It often needs exactly what a private hospital can offer: elective theatre capacity, short-stay beds and staff with surgical experience. A partnership can match those needs.

In Rockhampton we ended private births in June 2023. Thirteen of our twenty-one midwives transferred to the public maternity unit with their service recognised. Every woman already booked with us kept her obstetrician, who gained admitting rights at the public hospital. We converted the maternity floor into a short-stay surgical unit and now perform 2,100 public elective procedures a year under a state contract. The hospital moved from a loss of A$3.9 million in 2021–22 to a surplus of A$1.4 million in 2024–25, and the public maternity unit gained staff to absorb the additional births.

The partnership works only because its terms are explicit. We agreed transfer protocols for patients who deteriorate in our care, a shared anaesthetic roster for after-hours emergencies, data sharing on complications and readmissions, and a joint committee that meets every quarter. Clinical governance cannot be implied between two organisations; it has to be written down, owned and reviewed. Both sides also need executives who understand the other system. I spent seventeen years in public health services and still had to learn how the regional health service now plans its capacity.

I should be careful not to overclaim. A partnership does not suit every town. Where the public hospital is itself stretched or the distances are great, keeping a private service may be the safer choice, provided its volumes and outcomes are reviewed honestly. My argument is that the review should happen, every year, for every low-volume service, instead of only when a crisis forces it.

What a town is owed when a service moves

The Rockhampton decision was right, and we handled one part of it badly. Our board decided before the town had seen an independent clinical review. The review existed, but we published it afterwards. A community petition gathered 5,200 signatures, and one of our own directors, who lives in the district, voted against the proposal. People did not, in the end, reject the reasoning. They rejected learning about it last.

A town is owed three things when a service moves. It is owed the evidence before the decision, in plain language: volumes, staffing, outcomes and what happens to patients under each option. It is owed continuity for anyone already in care, which we provided, though too quietly. And it is owed a commitment that the change will be measured afterwards and reported publicly. The public maternity unit has reported no increase in transfers or adverse outcomes in the two years since, and we should have promised that report from the start.

Regional private hospitals will matter more over the next decade, not less, as public systems struggle to meet elective demand outside the cities. They will be most valuable if they stop imitating city hospitals and start designing their services around the public hospital down the road. That requires boards willing to close things that carry sentiment, and executives willing to explain why in the town hall before anyone has decided anything.