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Health care: good, better, but for goodness sake give up on ‘the best’!

By Gavin Mooney - posted Tuesday, 14 March 2006


When I came to Australia over a decade ago, one aspect of the debate around Australian health care I found rather amusing was the insistence that Australia had a “world class” health care system and even that its health care was the “best in the world”. Now I am not arguing it is poor But rather how would, how could, one make such judgments?

Certainly in 2000 the WHO sought to draw up a league table of health care systems. They assumed all countries had the same goals and attributed all of these goals with the same weights in each country. That was nonsense on stilts. Health care systems are social institutions and each country legitimately wants different things from them. So we are into apples and oranges.

Again, why would Australians in any way be interested to know if our health care system was better than the Austrians’ or the Norwegians’? Trying to compare systems which are inevitably different by virtue of being culturally based is not useful.

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Now that sort of silliness maybe doesn’t matter too much, but the complacency and arrogance that go with it do. What we need in Australia, wherever we start from, is a better health care system.

It would matter, however, if we were comparing like-with-like in terms of say specific treatments and Australia came out badly. So it is worrying that, for example, our hip replacement failure rate is up to 25 per cent compared to the Swedes which is 7-8 per cent. That is a legitimate comparison and not a happy one.

Generally, how pervasive such high failure rates in our health care are, we do not know and I do not suggest we spend lots of time finding out. Rather, I want to argue that we spend less time saying how wonderful it all is and see how we can do better.

Without getting into relativities and comparisons, what we CAN say is we have an absolutely crazy funding and organisational set up. There is no logic in the states-Commonwealth split. None.

There are other absurdities in the system, for example, paying and judging hospitals by what they do by way of cases (usually “cost-weighted” cases) and not what they produce by way of health. This is some strange attempt to estimate the value of hospitals’ “output”. How can the cost of an operation be used as an indicator of benefit? “My operation was more expensive than yours so I get more benefit.” Is that the argument?

Likewise we pay GPs “fees for services”. This encourages them to do as many services as they can, to earn as much money as fast as they can, with almost no concern or incentives to make people healthy.

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And so we move closer and closer to the US model, which may be fine according to the American people’s values - in terms, for example, of its inequities - but it does not fit with Australian values (see below).

We have pretty good health overall but there is little that tells us how much this good health has to do with health care. There is a new survey of health which suggests lifestyle issues are more important than anything an acute expensive tertiary cathedral can deal with.

We know that inequalities are bad for our health but then we exacerbate them through our tax policies. Social cohesion is good for our health, yet we worship more and more at the altar of individualism. We have continuing appalling Aboriginal health but clearly as a nation do not really care about that.

So let’s skip to what to do.

The private sector needs to be reviewed and almost certainly scaled down - maybe severely. To try to run health services on the basis of the same values as one would a potato chip industry seems at best odd, at worst downright divisive and dangerous. If all or most of the money were in the public sector (as in various other countries such as Denmark), then the rich and powerful would be pushing for more and better public services thereby creating pressure to have more and better services for all.

Who wants private care? Well clearly many doctors do as it affords them excellent pay. Even those who do work, at least part time, in the public sector often tend to see that work as charitable. (That is perhaps understandable as one said recently he could earn in one day in the private sector what it took him the rest of a fortnight to earn in the public sector.)

Do the public want private care? Do we want “choice”? The government tells us we do. But do we? Where is the evidence?

OK there has been an increase in private health insurance cover but only in the wake of “kickbacks”, which are now costing the taxpayer $3 billion a year. Why do we need bribes to take out private health insurance?

What is crucial is to accept that there needs to be some agreement in Australia about what we, as a nation, want from our health care institutions; then we must decide how to get that; and then how to fund that.

There have been few attempts, however, to grapple with these issues. In particular we need to know what the nature of the “good” is that people want from the social institution of health care. That is the starting point for trying to do better.

My own experiences in facilitating citizens’ juries are relevant here. Ordinary citizens, randomly selected, given good information, want greater equity; more resources for Aboriginal health; more for public health and prevention; and more for mental health. These areas are not where the private sector is strong: they are where the public sector can excel.

The problem is that the public’s voice is drowned out by the medical profession, who see the determining of objectives and priority setting as being too important to be left to the ordinary punters. That is simply a statement about power. There is a need to get the public educated in the politics of health care; to recognise that while medicine is a noble profession, many doctors have lost faith both in the system and in their calling; that the public system can deliver what the punters want; and the private system cannot.

Too little debate takes place about priority setting in Australian health care. We need an Australian Romanow.

It is of note that this Canadian review was quite breathtakingly detailed and comprehensive. For example, as just one of 40 papers commissioned, (pdf file 1.08MB) together with a colleague I was asked to look at three questions:

  1. What should be the criteria for determining whether a program or service should be wholly, partly or not publicly financed?
  2.  Which Canadian policies and approaches are most consistent with these criteria and which are least defensible?
  3. Where in general should public financing be extended and where might it be reduced?

In Australia these questions need to be addressed but at the moment are not. There is no serious effort made in this country to debate and set priorities. Yet this is very necessary if we are to build a sensible, sustainable, rational, “better” health service.

Priority setting is not difficult. It involves looking at the economist’s notion of opportunity cost - the benefit foregone in the best alternative use of the resources. If spending more in program A results in greater benefit than in B, then spend it in A. If taking money out of B and spending it in A means overall greater benefit, then do so.

In Aboriginal health for example we can say that what is needed to be equitable in Aboriginal primary health care is to spend about four times what we currently spend. To do this we could halve the 30 per cent rebate the federal government introduced for private health insurance. We then need to debate which is the better buy. Again if the rest of us forewent 1 per cent of the spending on our health care, we could increase the spending on Aboriginal health care by 50 per cent.

Which is the better buy is what priority setting is all about, but currently such questions do not get asked. I can’t answer these questions. It is not my role to do so. I think the only people who legitimately can are informed Australian punters.

In one of the citizens’ juries I facilitated, in the wake of their desires for more funding for Aboriginal health, greater equity, mental health and prevention, when asked where the money was to come from, their answer was clear: from small inefficient hospitals and Emergency Departments. The people are not stupid and they can deal with priority setting. Yet, Paul Skerritt, the President of the WA AMA has argued leaving such matters in the hands of the public is not the way to “make big decisions”. Oh yeah?

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About the Author

Gavin Mooney is a health economist and Honorary Professor at the Universities of Sydney and Cape Town. He is also the Co-convenor of the WA Social Justice Network . See www.gavinmooney.com.

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