Owning our own health

The “health” debate in Australia is awful. It is not about health at all. It is about illness and the loss of health.

The giving of advice about weight and exercise, exhortations about smoking, immunisations, vaccinations and routine health checks are all good preventive activity. So it is wrong to say that there is no preventive activity at all. However it is not enough. Moreover many of the procedures we regard as preventative are in fact not. Breast screening, pap smears, faecal occult blood tests, measurement of blood pressure and blood sugars, for example, are all means of making early diagnoses when disease is present. They are not true preventive activity.

We know what is needed to keep us healthy. But instead Australians are increasingly obese, are undertaking less exercise, are still exposing themselves to too much sun, drink and smoke too much and are as subject to sexual excess as anyone else. No wonder then that we are unhealthy.

But that is not what community discussion is about.

Certainly one only has to consider the reduction in smoking, moderation in the use of alcohol, balanced diet, exercise, the importance of cleanliness, as well as the “non-medical” interventions that include better roads, provision of clean water, provision of sewerage, to see how many advances have occurred outside the recognised curative areas.

Discussion is too often about how to restore our well being when health is lost - when instead we should be talking about how to remain healthy. We could do much more in this direction.

It is the old story about the fence at the top of the cliff making better sense than a fleet of ambulances, even a fleet with bells and whistles, down at the bottom of the cliff. Mind you, I met a good doctor who told me he intended to stay at the foot of the cliff and that he was a good ambulance driver!

There are other major problems too. The current “debate”, poor as it is, is about how to provide everything for everyone, at all times, when they are sick. Much discussion occurs just before elections when people who should know better outbid each other with fantastic promises that cannot be redeemed.

Politicians make utopian promises to provide for all the sick, and to do it quickly, when it is not possible. Indeed they understand this truth so what they say is difficult to excuse. They need to come clean with consumers because they cannot deliver.

They have never been able to deliver. And they never will be able to deliver.

Providers should also be ashamed. Too often they are self-interested, putting their own interests ahead of those of the community, and they object to propositions that might assist the community, but which might not be in the interests of their own particular guild.

There are long queues to see many providers, and yet there is a demand, from many provider organisations, for the monopoly provision and control of particular services. Standards are high in Australia, but those high standards are obtained at a cost - in our case a cost of chronic under provision and an impoverished debate. High standard qualifications will always be sought by those who are good or ambitious.

Meanwhile, as the current provision means chronic shortages then some other form of mass provision must be thought about: possibilities should not be dismissed out of hand with cries that the sky is about to fall in. Providers should remember that our society dictates its own rules and human care monopolies could end as quickly as the wheat marketing monopoly.

Many patient representatives do not really understand the problems and some only speak for disease specific groups (this latter fact is the reason that the Oregon experiment was not a complete success).

Medical research is directed towards achieving immortality and is Cartesian in its intellectual basis - as if the human body is a machine which just needs “fixing” to keep it running perfectly. Too often those doing research do not consider or discuss the consequences of any possible successes. And the consequences can be great, for example, the ethical consequences of genetic engineering. But from the community’s perspective these expensive fix-it solutions do not address the basics - that prevention is better than cure.

The media is also guilty. Too often there is talk of “breakthroughs” when what has been found is not a breakthrough at all, but rather a thinly disguised bid for money. The “breakthrough”, whatever it is, is often five years away. What the media never tell you is that a cure for one set of illnesses may leave you to suffer and die from another set of worse illnesses later.

Expectations in Australia are high and many customer complaints occur when these high expectations are not realised. The most serious failure occurs when services are not available. Less serious, but still significant, failures occur when queues are used to limit access to services.

For example, some hospitals have a budget limiting the provision of prosthetic joints; or a specialist has a four-week waiting time for consulations for serious conditions; or the waiting times for radiotherapy can be as long as the median life expectancy for someone with malignant brain tumours; or a general practice has a three-day waiting time before you can be seen for a routine consultation; or community services to help the aged are offered less frequently than is requested by experts; or there are not enough specialists (in some specialties), nurses or trained technicians to provide the care that has been promised.

These are all just crude and arbitrary ways to ration services.

Vicious inequalities have made matters worse. Health is poorer where people are poorer and access to services is easier if you are rich. That might offend those with egalitarian principles, but it is true. That partly explains the poor health of Aboriginal people - they are also poor.

What the debate should be about is how to make rationing decisions well by making the best use of limited resources. Those with the budgets make these decisions daily, which affects the public who has to live with the decisions.

Rationing decisions should be made deliberately, openly and by the public. The experiments with citizen juries has demonstrated one way that good rationing decisions can be made.

Health Areas make rationing decisions every day and providers make rationing decisions most days. They have people queuing for appointments, or procedures, and they put the urgency of some conditions ahead of other conditions.

Early in my career we decided unilaterally that certain people over a certain age should not have access to a particular procedure. This decision was a hidden one which was never validated. It was never tested publicly and it was never justified. We just did it and it was inappropriate.

The rationing of health is a fact of life and it is time the public that bears the outcomes becomes part of the decision making. It can be done. It has been tried (successfully) in Western Australia. Premiers and Prime Ministers should be working together for the public good.

At the same time the absurdity of a country our size having health responsibilities divided between two levels of government should be addressed along with the ridiculous position where only about 3 per cent of our expenditure goes on prevention.

What occurs now is a shifting of costs and blame between levels of government - and that should be fixed by one or other level of government taking the money and the responsibility for the area.