The unhealthy state of health

Lately we have done a lot of inquiring into the state of our health system. In the last 12 months the Queensland Health system, especially the public health system, has been in the spotlight like never before.

The Davies-Morris Inquiries into events at Bundaberg and other public hospitals and the Queensland Health Systems Review by Peter Forster highlighted many serious systemic issues of concern. The recent national Health Workforce Review conducted by the Productivity Commission also highlighted key areas of reform. Other national inquiries into health related areas have been numerous and include: a Senate Inquiry into Nursing, a national review into nursing education, a Senate Inquiry into public hospitals and another into Medicare.

The problems and potential solutions have largely been identified in these reviews - what has been missing has been a co-ordinated political will, at the state and federal government levels, to take action to address these concerns.

While looking at the problems of our health system it is essential to maintain a balanced perspective - to remember that despite the many and varied problems that exist the system continues to function and good work is done every day. In large part this is due to the hard work and dedication of nurses, allied health professionals, doctors and other clinical and non-clinical health workers.

Nurses, working 24 hours a day, 7 days a week, particularly play a vital role as stewards of safety and continuity of care in the health system. As the most numerous of the frontline health workers, nurses also bear the brunt of community anxiety and fear about the state of our health system. Continual undermining of community confidence in the system can have the effect of severely damaging morale and can lead to wastage of staff from a system that cannot sustain such losses. It is a “Catch 22” situation.

Good sense and balance must be maintained in this important debate about the future of our health system. All contributors must be aware of the likely impact of their actions and inactions and the community must develop their skills of critical thinking. The motivations and interests of all players in the debate must be in the forefront of all our minds.

I will declare the interests of the Queensland Nurses’ Union (QNU) upfront. As the largest health union in Queensland (with over 33,500 members) covering all levels of nurses (Registered Nurses, Midwives, Enrolled Nurses and Assistants in Nursing) working across all sectors of health and aged care our interests are many and varied. The objectives of our union place a particular emphasis on both industrial and professional matters - our mission is to “Promote and defend the industrial, professional, political, social and democratic interests of our members”.

Our brief is therefore quite broad and complex and there is often considerable overlap between objectives and at times there may be competing interests. For example, increasingly we are finding that industrial and professional boundaries are being blurred. The issue of ensuring safe workloads for nurses and their patients is both an industrial and professional matter. It also is a social interest of our members, as nurses are not only providers but “consumers” of health services, and therefore have a dual interest in ensuring that safe, patient centred quality care is delivered to the community.

A central role of every union is to improve the wages and working lives of their members. Nurses don’t want to receive the pay of merchant bankers - they want fair and consistent pay outcomes. No matter where they work (hospital, community, aged care, doctors surgery, school, factory, prison or elsewhere) or what sector (public or private) or what geographic location (within Queensland or interstate) nurses want pay parity. Nationally consistent rates of pay were achieved for nurses for a brief period in the early 1990s. Then with the advent of enterprise bargaining and nurses’ pay and conditions now differ across each distinct health “enterprise”.

We maintained from the outset that a system such as enterprise bargaining (one predicated on conflict and disputation) is not well suited in a sector such as health and that another approach is required. Unfortunately, the Howard Government’s extreme WorkChoices legislation will see industrial relations in this country further de-regulated and as a result hard fought for conditions will be under threat. Although this is a topic for another On-line Opinion piece it is a significant contextual factor to keep in mind when we consider the state and future of our health system.

The interests of our members often coincide with the interests of the community. For example, the QNU’s legal costs associated with the Davies-Morris Inquiries last year were in excess of $500,000. The QNU had to maintain a strong presence throughout these inquiries in order to represent the interests our “whistleblower” members, who felt duty bound to protect the community by “going public” with their concerns. The QNU and its members take seriously our responsibility for working in partnership with the community to improve nursing and health services in Queensland. This is evidenced by our co-sponsorship (with the Queensland Nursing Council) of the Social Charter for Nursing in Queensland. We see the need for a significant shift in the health paradigm and power relationships and we see the social charter as being one starting point for such change.

There are two interests the QNU must be declaring. The QNU is a strong believer in and defender of our universal health system. Equity of access to health services and equality of health outcomes must be principles that underpin our health system. Access to care must be determined by clinical need and not ability to pay. We also believe it is more efficient, effective, equitable and sustainable to fund health services through our taxation system rather than through a “user pays” approach.

The QNU works with other like-minded organisations to promote debate on these matters through our membership of the Public Hospitals Health and Medicare Alliance of Queensland (PHHAMAQ) and the Australian Health Care Reform Alliance (AHCRA). The other interest that we need to declare is that the QNU is currently affiliated to the Australian Labor Party (ALP). This relationship has not prevented the union from engaging in debate and critical analysis on health policy or inaction by government and we have done so without fear or favour. For example, the QNU opposes the federal government’s 30 per cent rebate for private health insurance on equity, effectiveness and sustainability grounds. We believe it is poor public policy and will continue to argue against the federal ALP’s support for this initiative.

Why all this talk of interests? I think it is essential to go back to basics and look at both interests, objectives and values before we consider the unhealthy state of our health system. The debate about the future of health must be framed in terms of interests and values.

Every person interested in the current health debate must first ask themselves what are the interests of the many and varied players in this debate - the community, governments, organised health labour groups such as the QNU and the Australian Medical Association (AMA), the media, professional organisations, regulators, educational institutions, opposition parties, health bureaucrats - to name a few. Of course there are competing interests at play here, even within each of the groups mentioned. We all need to critically look at each argument that is put to us - what are the interests at play here and are there any hidden agendas.

Health is intensely political and this must be actively acknowledged and factored into the health debate. Don’t swallow everything you hear uncritically - yet at the same time it is also important not to be paralysed by undue cynicism. An open mind and healthy scepticism are important tools for embarking on an examination of the current state of our health system.

The other vitally important issue that needs to be considered is values. What are the values that underpin health policy development? What are the values of each of the key stakeholders in health and how and where do these differ? The QNU believes our community must be active in determining our collective values that will underpin health service policy and delivery. To date, debate on such matters has not occurred in a large scale, structured and co-ordinated manner in Australia as it has in other countries: for example, in the Romanow Inquiry into the future of health care in Canada conducted a few years ago. The final report of this ground breaking inquiry (Building on Values: The future of health care and Canada) explicitly positions the health care debate within a values framework.

Such a framework has been absent from the Australian debate, at least from our politicians. To us, this is a critical failure that must be addressed. It is essential that the community be genuinely engaged in an informed, structured and rational debate on health needs and expectations and how these are best funded. The shared values of our community must inform such a debate.

There is no doubt there are many problems facing our health system - the multitude of reports from recent times highlight these. In our 2005 submission to the Forster review of Queensland Health the QNU discussed in some detail what these problems were but more importantly potential solutions for many of these problems. It is easier to throw rocks rather than play a constructive role in the rebuilding of our health system. Many of the problems that beset our public health system apply equally to the private hospital and aged care sector. Public hospitals aren’t in this “crisis” alone - we are all in it together and we all have a stake in ensuring the future sustainability and quality of our health system.

Similar problems exist in all Australian states and territories and indeed internationally. We believe they arose first and in such a spectacular way in Queensland last year because Queensland has historically under funded health services and because of particular cultural issues peculiar to Queensland.

Rather than focus on what is wrong with the current health system the QNU believes we need to re-frame the debate and instead ask what sort of health system do we want and need and how do we achieve it.

From the QNU’s perspective we believe we need a health system where:

• the system is patient and staff focused - this requires a shift in focus to quality and effectiveness from efficiency and budget bottom lines;
• there is equity of access to health service and equality of health outcomes - where access to health services is determined by clinical need and not ability to pay;
• services are integrated across settings and there is support for innovation and improved service delivery;
• a safe and supportive environment for staff and patients is provided;
• community and staff have genuine input into decision making and health service planning;
• openness, respect, transparency and accountability are the principles that underpin the operation of the system;
• words are matched with action and expectations matched with appropriate funding;
• evidence underpins all decision making and a culture of critical analysis and debate flourishes;
• there is consistency of approach and sound systems upon which to base decision making;
• staff and patients are treated fairly and with respect and are valued for their contribution;
• workloads of staff are fair and enable the delivery of high quality patient centre care;
• health workers receive fair remuneration and conditions of employment - there is pay parity with interstate counterparts and work value is consistently and appropriately determined;
• there is a rigorous, simple and open complaints system established for staff and patients that enables concerns to be promptly and appropriately addressed.

The QNU is committed to working with government and other key stakeholders to achieve our vision for the health system. Reform is needed if we are to ensure that our health system delivers equitable, high quality outcomes and is sustainable. Nurses are strategically placed across our health and aged care system to drive a positive collaborative reform agenda. We all have a role to play in the debate about the future of our health system and we must all be prepared to take on this task constructively and enthusiastically.