On a busy Friday afternoon in late 2002, Jillian Skinner was one of only a few people to notice the inconspicuous media release slip into mail boxes after 5pm.
There wasn't much to it - just six lines, short on detail, from the director-general of NSW Health Robyn Kruk dated November 15. It referred to unsubstantiated allegations about management practices at Campbelltown and Camden hospitals. It was the kind of press release the government puts out when it wants to keep something quiet.
Had it been overlooked, as the government of the day under Bob Carr would have hoped, a major political disaster may have been avoided.
But after Skinner, the NSW opposition's spokeswoman for health, picked it up, and three nurses spoke out about unnecessary patient deaths at the two hospitals, the political career of the then health minister Craig Knowles effectively ended. At the time, Knowles was considered Carr's heir as future premier. But the Campbelltown Hospital crisis, which dragged on for years, destroyed that promise.
He was one of seven Labor health ministers - including Carmel Tebbutt, John Della Bosca, Reba Meagher, John Hatzistergos, Morris Iemma and Andrew Refshauge - who Skinner shadowed between March 1995 until she became health minister last year.
Ironically, it was Knowles's approach to engaging hospital doctors that she embraced.
Skinner is now relying on senior doctors and local health districts to find ways of cutting $775 million from the health budget over the next four years in addition to finding $2.2 billion in efficiency savings.
This while having to care for an extra 50,000 patients through emergency departments this year, bringing the total to 2.65 million. Hospitals will also have to provide an extra 30,000 overnight hospital stays and 2000 elective operations.
Skinner spent most of her 16 years in opposition building relationships with powerful doctors.
When she and Knowles attended a farewell dinner for the intensive care specialist Malcolm Fisher a week ago, some people remarked on how similar her approach was to Knowles's. ''Craig did listen to clinicians. He gave a lot of time to focusing on what they wanted and how they saw the world and that has certainly been my approach,'' Skinner says.
''In opposition I was really almost restricted to speaking to clinicians who I've got very, very sophisticated relationships with.''
Skinner is confident more can be done with less money without impacting on patient services. But serious questions have been raised about whether it is possible to stretch an already overloaded health system any further.
''I am confident it can be achieved,'' she says. ''It is not money taken out of the system. It is money that stays within health but has to be used more efficiently to improve patient care.''
Among those she is listening to is Stephen Leeder, a professor of community medicine at the University of Sydney and chairman of the Western Sydney Local Health District Board.
''There are alternative ways of doing what we do that are probably better for the patients and also less expensive,'' he says.
Skinner has asked local health districts not to cut front-line services. ''That's up to them though,'' she says. ''The only ones that are exempt by industry group are nurses.''
But the NSW Nurses Association says some area health districts, such as Hunter New England, are offering redundancies to senior nurses.
Skinner admits she will have to take ultimate responsibility for any failure to deliver budget savings.
''If the system can't manage within its budget, I will be wearing the flak for that,'' she says.
She will also be judged on hospital performance data which she pushed to make public. The Bureau of Health Information now provides regular online updates on surgery waiting lists and emergency department waiting times. A recent snapshot from the bureau showed 63 per cent of patients who arrived at hospitals by ambulance between April and June were transferred to emergency department care within 30 minutes, well below the national target of 90 per cent.
In March 2003, Skinner revealed Nepean Hospital was fudging its figures to play down critical overloads in the emergency department.
''In fact, there was not only figure fudging … there were policy directives that prevented doctors from putting patients on the waiting list,'' she said.
''One of my absolute commitments was to be more open and transparent, to be more rigorous in accounting for what was happening. If that makes it uncomfortable for me and other people at times, so be it.''
Just as the former premier Nick Greiner fell victim to his own creation - the Independent Commission Against Corruption - Skinner's push for greater transparency is risky because it could ultimately reflect her own underperformance.
''I will have no regrets … it is only by providing the real picture that you provide the real solutions,'' she says.
Her opposite number in Parliament, Dr Andrew McDonald, a paediatrician who worked at Campbelltown Hospital during its crisis, is pressing for details on how the budget cuts will affect patient services.
''Jillian Skinner is not going to achieve the savings,'' McDonald says. ''It is clearly mad because the whole hospital system is so busy, virtually all the inefficiencies have already been weeded out.
''The staff she is looking at cutting are therapists, ward staff and cleaners who make the system more efficient. This is all about money not efficiency.''
In Canberra, Labor is portraying the health and education budget cuts in NSW and Queensland as a taste of what could come under a Tony Abbott leadership.
''If we can make a link between what is happening in NSW and Queensland in health and education and what people can expect from Tony Abbott, that's good for us,'' a Labor worker told the Herald.
The president of the NSW AMA, Dr Brian Owler, is also campaigning against the budget cuts, saying there are few staff in public hospitals who could be described as ''surplus''.
''Not only do hospitals need doctors, nurses and allied health professionals but we need clerical staff, security, cleaners and even administrators,'' he says.
Owler cites the case of a busy maternity unit where a midwife was forced to abandon a patient in labour to do the paperwork required for hospital admission.
Cleaners also play an essential role in infection control and efficient turnover of patient beds, as demonstrated recently when the service failed at Royal North Shore Hospital.
Skinner gives multiple examples of how the health system is - and can be - running more efficiently.
Procedures which once involved long hospital stays are increasingly being delivered in day-surgeries and more patients are being treated at home to save hospital budgets about $4000 a day for each patient.
Cliff Hughes, who heads the health department's Clinical Excellence Commission, says programs reducing the risk of blood poisoning can save $4408 per patient per day.
Removing an intravenous drip and giving a patient oral antibiotics in 5 per cent of cases can save the health system $400,000 each year.
Skinner says she can rely on doctors to make more in savings. ''They want those extra dollars so they can treat more patients, so it's in their interests, just as it is mine,'' she says.
