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Perhaps it is better not to resuscitate

By Kevin Pittman - posted Monday, 27 March 2006


Emergency room doctors all eventually face the issue of refusal to resuscitate someone. If a patient is clearly frail and sickly, do you have a duty to resuscitate him or her? The same question might be asked of health care - so frail and sickly that maybe it would be better to cut off the oxygen and start again.

I’m going to focus on Queensland. If these issues aren’t on the front pages of your state’s newspaper, it’s only because they have more interesting news to publish. Health is in crisis across Australia. Queensland has only compounded the problems with the sheer incompetence at some hospitals, and by bureaucrats and ministers.

The objective of any health system is to promote and contribute to a healthy population.

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Some people define “healthy” as a state of physical and emotional well-being that goes way beyond anything that any health system can do. Here, we are simply talking about keeping people well. But health care in Australia doesn’t keep people well. It cures the sick.

Hospitals with the bulk of state health budgets do nothing to keep people well. Community health services do a little more but are notoriously underfunded, with long waiting lists for even the simplest of services. By the time you make the list, any problem will have escalated to the stage where you need to go to hospital. And in general practice, there are thousands of items on the Medicare Benefits Schedule for curing people but few to stop them getting sick.

People seem to have no real interest in their health. After years of advertising about the effects of cigarettes, a quarter of the population still smokes. Drinking and non-prescription drug use are continually increasing. But smoking, drink and drugs pale into insignificance when compared with what people eat.

There used to be a phrase “he’s eating himself into the grave”. This society is eating itself into the grave. Fast food, fat and sugar consumption goes up each year while rates of exercise fall. Unsurprisingly, obesity also goes up each year. And right behind, again unsurprisingly, diabetes, heart attack, kidney problems, cancer and other diseases continually go up.

Hello! This doesn’t sound like rocket science. But when I tell parents their children’s diet means they won’t live as long as me, I watch the parents take the family off to a fast food outlet to talk about it.

In the end, we have a health system focused on fixing people who are sick and a society focused on getting sick. The two really suit one another extremely well. Unfortunately, we are rapidly running out of both the health care workers and the money needed to maintain this uneasy balance.

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Let’s talk about health care workers. The argument that we aren’t training enough of them needs nuancing. More would be good but a major part of the problem is that many now don’t want to work full-time. The loss of doctors and nurses through a reduction in average working hours is even more significant than numbers lost through retirement. Where do we draw the line? How many can we afford it if training more health care workers just allows them work shorter hours?

Reluctance to work full-time affects specialist numbers. Research says many doctors choose general practice rather than becoming specialists solely to work part-time. Hence we have a shortage of specialists. Similarly, many nurses aren’t interested in becoming nurse practitioners because they don’t intend to work the hours that would justify the investment in study.

The second point we need to stress is that every trade and profession in Australia is desperate for people to take up training. From carpenters to engineers, we are short of teenage entrants. That’s just one of those things that happen in an ageing society.

Roughly 10 per cent of Australian teenagers don’t get entry to their first or second choice of university course and most of that 10 per cent would be incapable of sustained high level study. That’s a fact. Tertiary entrance scores can’t tell us who would make the most empathic doctor or dedicated nurse but they’re usually pretty good at telling us who is capable of handling the study needed.

So there’s really not a huge untapped pool of teenagers just waiting to be trained as doctors or nurses: and persuading those who are available is not easy. They’re aware that it’s often dirty, unattractive work, dealing with life-threatening cases while the family stands by, ready to sue at the first opportunity. Much easier to just be an engineer or public servant.

Money is an issue because most politicians like giving away things - it costs them nothing personally and makes them popular with the electorate. So every federal health minister since Neil Blewett stood up in Federal Parliament in 1983 to introduce Medicare has told people they can get their problems cured. For free. Right now. No matter what. However trivial. However expensive. And right behind the federal minister has always been a state minister or premier bragging about how wonderful their free state health system is.

The community can hardly be blamed for believing them and for becoming hooked on “free” treatment. Trying to rein in overuse and inappropriate use of primary and secondary health care, so that we have some resources to devote to preventative health care, will not be easy. Look at the fuss every time the Pharmaceutical Benefits Scheme changes.

So that’s the gloomy side. We have an ageing and increasingly unwell population with an insatiable appetite for free healthcare on one side, and on the other side, we have a rapidly shrinking health workforce and a health system focused on fixing up problems after they happen, at enormous and unsustainable cost.

Is there anything that’s positive? Well, not much. Certainly not at the political level. Politicians like facile answers and proposals. They pretend that waving money around will cure the problems. And senior bureaucrats, chosen to defend the minister’s party line, aren’t a good deal better.

But the people who do know just how bad things are and who see the importance of “real” answers are the current health care providers. More and more of these people are looking at the problems and solutions. Role reallocation is clearly part of the answer: using nurses to maximum advantage; GPs and even specialists handing over part of their roles to others and each group focusing on what it is best skilled to do.

Better integration between the public and private systems is crucial. Having private doctors and appropriately funded community health services jointly focus on preventative health care will be a major part of the answer.

Training as many people as we can is also part of the answer but we aren’t yet completely sure just what we should best be training them as. That’s something we’ll have to respond to gradually as we work out the answers.

Encouraging and even obliging the community to take some responsibility for their own health is mandatory. Eliminating “free” public health care, except for very tightly targeted disadvantaged groups, will give better pricing signals to the community and income can be spent on providing incentives and support to the community to further improve their own health management. Unfortunately, of course, that will demand a bi-partisan approach since it would be political suicide for one party to do this.

None of these answers are easy. However, they’re ones that will work. Better community health, better use of available resources - human and financial - and better integration between private and public health. Without such answers, we are looking at a system sinking further and further into crisis with poorer and poorer outcomes except for those wealthy enough to afford something better.

Better in the end to not resuscitate.

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Article edited by Patrick O'Neill.
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About the Author

Kevin Pittman is the principal of Solomon Reynard Pty Ltd, a boutique consultancy specialising in health and organisational management.

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Creative Commons LicenseThis work is licensed under a Creative Commons License.

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