Health policy in the WA state election: it’s unfair!

Western Australia goes to the polls on Saturday. It is salutary to reflect on the campaign pronouncements on health policy from the perspective of the only real test in this state in recent years of what ordinary citizens want from the WA health service. This was the Citizens’ Juries held in Perth, with membership selected randomly from the electoral roll and set up under the auspices of the WA Medical Council, now sadly defunct. In 2000 the jury stated clearly that their priorities were first, equity and second, public health rather than acute care. The 2001 jury, within their concerns for equity, wanted increased spending on Aboriginal health and for rural and remote WA.

At this election the main parties’ pronouncements on health policy are remarkable in their emphasis on acute hospital beds and their lack of concern for issues of equity. Both the ALP and the Coalition are Perth-ocentric, hospital-ocentric and white-ocentric.

In this context it is important to acknowledge some of the issues raised in the Reid Report (pdf file 2.01MB)(2004), led by Mick Reid, one of the sharpest health service analysts in the country. This major review of the whole of the WA health care system reported less than a year ago. Inter alia it heavily criticised the way in which the financing and governance of the WA health service had been conducted.

Reform on this front is desperately needed. The chances of getting that have been jettisoned at this election as both major parties throw financial prudence to the winds and promise to build far too many tertiary hospital beds, all of them in Perth. Buying votes is all very well; attempting to purchase them with very expensive tertiary hospital beds is a senseless waste of money. Melodramatic it may be but money used badly in this sector does end up costing lives.

Reid identified that more than 80 per cent of hospital admissions to Perth’s tertiary hospitals do not need to be in these expensive five star facilities. Yet both major parties (but especially the Labor Party) have been hell bent on promising more and more tertiary beds. This is in no one’s interests but those of the AMA whose teaching hospital membership largely determines their “health” policy. Indeed one of the major problems here in the West is the political influence of the AMA.

This focus on tertiary hospitals results in major problems elsewhere, especially with respect to equity. Every unnecessary dollar spent on these high cost beds means fewer for community services which, with an ageing population, become yet more crucial to support not just the elderly themselves, but their carers. At the same time it means more money for Perth and less for rural and remote WA.

Even after taking out the tertiary hospitals’ spending, current funding in Perth relative to the rest of the state is too high. The existing allowance for the extra cost of delivering services to and in rural and remote areas is far too small. Further, the Commonwealth’s contribution to health services outside Perth is much smaller than in Perth. This arises because, while the Commonwealth pays for all GPs in the city, GPs in for example rural Exmouth are funded by the state. People in rural and remote WA (who are in general significantly sicker than Perth residents) currently get about 30 to 40 per cent less than their fair share of resources.

The financial position for rural WA health services is getting relatively worse, especially as budgets are determined largely on the basis of last year’s spending plus a bit on top. The overspending of Perth’s tertiary hospitals in recent years has meant that Perth has been rewarded with yet still greater funds.

In this campaign we have hardly heard the words “Aboriginal health” at all. To make a difference in this area, we need our political “leaders” to show leadership. They do not and seem to think that the WA electorate are such a mean spirited lot that to make real efforts to improve Aboriginal health would lose them votes. The Citizens’ Juries clearly showed otherwise.

The health of Aboriginal people in WA remains a disgrace. Not just because it is so bad but the bidding wars on tertiary hospital beds have drowned out the compassion needed to improve Aboriginal health. A shift of only 1 per cent of the health service budget from the rest of us would increase the spend on Aboriginal people by 50 per cent.

In this respect the AMA in this state is no better than our politicians. In the 35 media releases they have issued since October last year, they have used the word Aborigine once. Such a powerful body could and should use their voice to put the case to government for more resources for Aboriginal health.

Against this background, voters cannot entrust our health services to either of the main contenders for government. We cannot trust the AMA to put population health ahead of their own members’ interests. So where to turn? The results from the Citizens’ Juries indicate that there is a need for a commitment from our politicians of whatever colour to use the values of ordinary WA people for priority setting in our health services.

How to change things? We need as a minimum political leadership in health. We probably need higher taxes to pay for better health care in the public sector - and most of us would willingly pay more for a better health care system. That system needs to be driven by the preferences of the people and the people’s voices then used to drown out those of the AMA.

In WA ideally we need to hand the state health services over to the Commonwealth. It really is silly to have a health care system for a population of less than 2 million. We do not have the political leadership or enough good managers to run state based systems well.

But that is long term. Within the WA state health services one of the biggest mistakes made in recent years has been has been the setting up of "area health services" in geographical regions around the state. To succeed, such a system requires lots of high quality managers. We simply do not have them. What has happened - and it was totally predictable - is that instead of taking power from the centre and distributing it to the periphery (which was the theory) in practice it has led to yet greater power resting in Perth.

What is needed is explicit centralisation of management but married to a very clear system of decentralisation of preferences for health care priorities, in essence local citizens’ juries. There is no reason why management and the question of preferences must take place at the same level. The former can be centralised while the latter should be regionalised.

What of the minor parties’ health policies in this election? As we vote on Saturday, there is an argument that says well, let’s make whoever is the major party in the new parliament more accountable. That is best achieved by trying to ensure a hung parliament, giving more power to the small parties and independents. It is also the case that they are likely to be more answerable to the electorate. Indeed the Greens state in their health policy that “health and funding priorities should be decided by ongoing public participation processes at all levels”.

The politicians from the major parties are out of touch with the wishes of the WA population. The Citizens’ Juries wanted more equity geographically, more for Aboriginal health and more public health and prevention. What the ALP and the Coalition offer are more expensive hospital beds and greater inequities.

In WA we need a state-wide Citizens’ Health Convention, plus local conventions as well, where a random selection of ordinary people, suitably briefed by experts and given time to reflect, can decide the basic principles (such as with respect to equity) on which any future government is to run our health services. It is not hard to achieve. It is truly democratic. It is not too late for the major parties to endorse such a proposition.