Health reform being held hostage by its masters

Andrew Macdonald, a pediatrician from south-west Sydney, is the only doctor in a New South Wales Parliament of 140 MPs. The only one, in a state which spends about a third of its budget on health care. Surely there is something wrong with the way political candidates are chosen if both parties have managed to find only one doctor to hold statewide political office.

Macdonald was helped to preselection by Morris Iemma, a keen supporter of the outspoken physician, after he came to prominence through years of advocating better health resources.

The inadequacies of previous health ministers such as Reba Meagher, who quit after the Royal North Shore Hospital miscarriage affair, are further evidence that factional dynamics play a bigger role than merit in determining key positions. As if any were needed after recent events.

Macdonald feels that one in 140 is a reasonable representation, but I don't, and nor does Andrew Laming, a former ophthalmologist and Queensland federal MP. Laming thinks a handful of professions - like medicine, law and the lucrative financial services sector - disproportionately skim off our best talent to the detriment of the nation.

"Our country's best and brightest are poorly distributed," he says.

He thinks a number of his medical colleagues would make superb politicians, but believes many doctors don't become politicians because they are usually ensconced in a practice and become indispensable to their patients. The long time it takes to train as doctors means they are often too old to make a meaningful contribution elsewhere by the time they are established.

At a time when health spending threatens to strangle our national accounts, it is a problem that doctors are not more involved in the health debate. Beyond political office there are also strained relationships between doctors and administrators. The most common complaint coming from frontline staff is the growing disconnect between them and management within hospitals.

Recently, the president of the Australian Medical Association, Andrew Pesce, underlined how doctors feel their clinical decision-making is being interfered with by administrators trying to minimise costs. In spite of steps taken by the Federal Government - GP super clinics and a preventive health taskforce, for instance - its own evidence suggests emergency departments are clogged up by frail, elderly patients who require high-level care.

The clinics and public health agenda will have little impact on the high proportion of costs that occur in the last year of life, much of it consumed by machines plugged into electrical outlets - respirators, feeding tubes and defibrillators. The longer we live, the longer we take to die.

The crux of our policy sickness that is the health sector remains at the public hospital level, and the ongoing distance between clinicians and those who oversee the system continues to hold reform hostage.

Most doctors hold hospital administration in contempt, seeing it as an obstacle to their heroic role in striving for better patient care. This partly reflects the narrow education medical training entails, spending decades learning highly specialised technical skills.

Trying to bridge this gap is Emma McCahon, a pediatrician armed with an MBA. She has begun teaching courses for senior registrars this year to improve their understanding of health systems, group behaviour and management skills. Her efforts seem well overdue and are being enthusiastically supported by NSW Health.

Macdonald spoke to the inaugural group of graduates last month, emphasising that most are vocationally doctors who struggle with the application of administrative or political skills. "It's like going from soccer to rugby," the politician said.

While doctors have the advantage of exposure to human suffering and social problems, most lack finance or executive experience, a major obstacle to increasing their contributions to big-picture decision-making.

In the US, a Gallup poll this year showed the public prefers the opinions of doctors about health policy; almost three-quarters said they trust doctors most when it comes to health-care reform. I assume Australians feel the same way.

Doctors have always been players in activism and politics, from the modern symbol of revolutionary activism, Che Guevara, to the less revolutionary Brendan Nelson.

But the nature of medical practice, a broad culture of suspicion towards management combined with the vagaries of major party preselection are conspiring to sideline the crucial involvement of doctors in decision-making. This is to the detriment of all.