Health - an awful 'debate' and meaningless 'reforms'

The health debate in Australia is awful

The wrong language is used. Wrong choices are made. The real problems are ignored. No courage is shown. There is too much spin and pandering to the popular press and to the shock jocks. Our dedicated medical practitioners are working against the odds.

There is no morality in advocating tax cuts when there is hunger, homelessness and unmet need in so many areas. We need decent services - and should be willing to pay for them.

In place of focus groups we need leaders who tell us something new and who inspire us.

People are waiting too long for admission to hospital and people are being discharged from hospital prematurely. Staff morale is low. There are not enough trained people.

Doctors see problems in terms of the needs of the patients they interact with every day. Everything rotates around their patients: "If something can be done, it should be done." or "If this is done elsewhere, then it ought to be done here - and done now". But they show too little understanding of the resource implications of what they may be proposing.

Medical associations sometimes behave like militant trade unions - Painters and Dockers in white coats.

The bureaucrats are often obsessed with process and not with outcomes. They do what political leaders tell them to do - and sometimes it is the wrong thing to do. They are very aware of the power games that go on in Canberra and Macquarie St and they play in those games. For them it is the budget balance than counts - whatever the social effects.

For decades political leaders have been making silly promises in the health area - mostly close to elections, and expecting health workers to deliver on those promises.

Some initiatives just skew the system. We only became really knowledgeable about the exact costs in the months following an accounting period.

There are many good features about what we do have - particularly our universal insurance arrangements which were introduced only after a joint sitting of the Parliament, and over the angry protests of the AMA, the then Federal Opposition and the medical profession. But we do not have as good a system as we sometimes think.

In a recent study conducted by the Commonwealth Fund and involving eleven nations, Australia did poorly.

• We were second worst in the numbers who skip tests or follow up.
• We were the third worst in the numbers who do not fill prescriptions or who skip doses.
• We were third worst in the numbers who pay more than $US1000 for their care in one year.
• We were the fourth worst in the numbers of people who do not see a medico when they are sick.
• We were fifth worst in being able to access after- hours care.

Added to that we have black Australians living twenty years less than white Australians and with worse levels of almost everything that can be measured.

If we want a better system we need to get this awful debate back on track.

Coherent rationing is essential if the system is to survive and if the system is to have the capacity to introduce anything new.

We do not have an honest debate about rationing now. No-one talks openly of what we can and cannot do, what we will and will not pay for - and essential rationing decisions are made "off stage" by people the general public might not select and away from the people who bear the effects of the decisions.

For example, a decision that only so many hip joints will be made available to orthopods in any month, rations the number of hip replacements any hospital can do, or the Victorian decision a few years ago that uncomplicated cataract removals could not be paid for in public hospitals, was a rationing decision.

Queues are a form of rationing. The non availability of beds is a form of rationing. Waiting times in emergency departments or for tests are forms of rationing. Limitations on operating time are a form of rationing. And so on.

In some overseas jurisdictions citizen juries listened to learned counsel arguing for or against certain interventions - after which they voted on the alternative initiatives. A much better idea.

However there are necessary but unpopular interventions - things like treatment of drug addicts, or the care of people afflicted with HIV/AIDS, or measures to prevent unnecessary hepatitis C infection, or mental health expenditure. These are interventions that people may not want to vote for - but which a compassionate society should provide.

Some publicly funded procedures will have to go or be limited in number so that other procedures can be accommodated or introduced. I call this rational rationing. And as our clientele becomes older, we might have to consider withdrawing public funding for some procedures at certain ages. For example, we might decide to withdraw public funding for certain cardiac procedures at (say) the age of seventy-five. There are many more examples.

A friend was told that if he had been two years older, his cardiac valve replacement would not have been done. So age-related procedure withdrawal already exists. This approach might outrage some people, but it frees resources to treat others - to do hernias and cataracts and prostates and varicose veins and provide good quality palliative care for more people.

We cannot do everything possible for everyone. That unpleasant reality must become part of the public discourse. The sooner we decide what we will do and for whom we will do it, what we will not do and for whom we will not do it, the better off we will be.

Some initiatives such as "hospital in the home" or community based palliative care or more money for prevention, have benefits for the whole society - but at an additional cost.

Society can be better off - but only with more health funding. However, treasury officers say that the way to save money is to close beds. Health workers cannot understand the thinking.

Now let us look at the so called health reforms that are upon us

The dual federal/state provision of hospital funding has been a problem recognised for at least forty years. The money also comes, in lesser amounts, from other sources like the health funds and private pockets. An extra amount might have to come from private pockets.

The current system is characterised by:

• Big deficits in area health services.
• A "blame game" in which each level of government blames the other for deficiencies and shortfalls.
• Cost shifting as each level of government tries to shift costs to the other level. (A Premier once told me that his job was: "To take the socks off the Commonwealth at every opportunity". Nothing about desirable social objectives. All about money.)

So opening new facilities is not going to solve the problems if we do not have enough doctors or nurses or therapists or physicists to service new facilities.

In March 2010, the prime minister, Kevin Rudd, bullied the states into accepting a package which was taken to a subsequent election by Julia Gillard - who won the election. Now Julia Gillard has changed it.

There will be no GST clawback. There will be an eventual 50% funding from the Commonwealth. There is some talk of an extra $16.5 billion - but details are sketchy. She has abandoned a Rudd promise to fund 100% of primary care in hospitals. As there is already a 43% commonwealth contribution, the new offer is not worth much.

The process started by Kevin Rudd would have had to involve reform of primary care to eventually include a greater emphasis on prevention. It would end the blame game, eliminate waste and provide a basis for dealing with rapidly rising health costs.

The health debate in Australia is awful

Real reform would come only if one level of government took over total funding responsibility. Now the promise is of 50% Commonwealth funding.

With all that said let us look at some of the effects of the so-called reforms.

• There will be no end to cost-shifting. The state will still be responsible for up to 50% of agreed costs and the imperatives to cost-shift will be almost as great as ever.
• There will be no end to the blame game. The Commonwealth will claim that state and territory systems are not good enough, not robust enough and not efficient enough. The states and territories will deny this and say that the Commonwealth is heartless, is bleeding them dry and does not understand.

Conclusion

The states and territories surrendered their taxing powers in 1942, but kept their constitutional responsibility for the health system. Now the constitutional responsibility should be passed over to the Commonwealth. All funding and all control should be from one level of government. That would end cost-shifting and the "blame game".

But until that happens, waiting times will be just as long in emergency departments and surgical waiting lists will be just as long.