Category: Health

  • Kerry Breen. What ails the national registration scheme for Australia’s 600,000 health professionals?

    In response to one element of a 2005 Productivity Commission report , the Council of Australian Governments (COAG) decided that the state and territory systems of registration of health professionals, some in existence for over 150 years, would be replaced by a single national scheme . The new scheme, based on a “national law” adopted by all jurisdictions, is run by the Australian Health Practitioners Regulation Authority (AHPRA) which commenced operation in July 2010. It now covers 14 health professions and 600,000 health professionals. By the end of 2016, AHPRA will have been subject to two federal parliamentary inquiries (see here and here), one state parliamentary inquiry and an independent inquiry commissioned by the COAG Health Council. Such a record must lead to the question as to what is wrong with the scheme.

    First, it is not truly a “national” scheme as NSW declined to join in, other than to participate in the national register. This has been euphemistically deemed a form of “co-regulation”. Three years later Queensland also opted to become “co-regulated”. The 2012 Victorian Parliamentary inquiry recommended that Victoria follow the same path.

    The interim agency that designed and built the national scheme informed the health professions that the new scheme would bring efficiencies with cost savings and also claimed that the scheme would adopt best practices from the existing state and territory systems. Neither proved to be true as the annual renewal of registration fees for doctors rose by approximately 50% in Victoria in the first year of the system. In its first iteration, the draft national law omitted mention of funding for doctors health programs, an omission only amended after vigorous lobbying. Even now, nearly six years later, AHPRA’s allocation is inadequate to fund the best practice example of the comprehensive Victorian program for distressed doctors.

     

    A recurring theme behind the four inquiries has been dissatisfaction from complainants, state health complaints commissioners and health professionals over the timeliness and fairness of the handling of complaints against health professionals. To quote from the most recent inquiry conducted for the COAG Health Council by Mr Kym Snowball :

    “It was apparent from the outset of the Review that there is widespread concern about the manner in which notifications have been managed under the National Registration and Accreditation Scheme (the National Scheme). These views were repeatedly raised with the Independent Reviewer by members of the public, health practitioners, ombudsmen, jurisdictions and professions.”

    The report then itemised nine separate concerns including:

    “• delays in the preliminary assessment or investigation of concerns raised by notifiers

    • delays in the finalisation of notifications
    • poor communication with both notifiers and practitioners
    • State and Territory Health Complaints Entities are generally not informed about the investigations and outcomes of cases handled by the National Boards and AHPRA
    • perception of inconsistent investigative processes and outcomes among participating jurisdictions.”

     

    It is noteworthy that the CEO of AHPRA has downplayed this strong criticism, as is exemplified in this exchange on Radio National in March this year. The Snowball report also identified the national scheme’s lack of accountability to individual health ministers in the respective states and territories.

    In the absence of any detailed analysis as to why the scheme should be so strongly criticised, I offer the following possible explanations, together with suggestions for improvement. I believe that there are both structural flaws and legislative flaws in the scheme. The key structural flaws are the size of the bureaucracy that has been created and its consequent remoteness from the people it serves, its expensiveness (for little or no additional return) and the lack of direct responsibility to each state and territory health minister. The legislative flaws have been discussed elsewhere and, as they are only peripherally related to the overall problems with the national scheme, they are not detailed here.

    The larger a bureaucracy, the more difficulty the general public and each health professional group will have in accessing its services and in obtaining information. Five years of experience of the mega bureaucracy that is AHPRA bears this out.

    The lack of direct responsibility of each health minister is very evident when one compares the new national scheme with the system it replaced. Under the national scheme, any health minister with concerns must work through the COAG Health Council and AHPRA and then eventually the relevant national board (for doctors it is the Medical Board of Australia) and finally his or her relevant state board. Under the previous system, each state or territory medical board, nursing board and the like reported directly to the local health minister.

    Similarly under the previous system (and focussing now just on medical practitioners), the state medical board employed its own staff to handle the receipt and preliminary assessment of complaints. Those staff, their necessary skills and the quality and timeliness of their work were all directly under the control of the state medical board. Under the national scheme, each state board has no such responsibility and must simply accept whatever staff AHPRA provides. Medical complaints can be sensitive and complex to handle and a high degree of knowledge, experience and skill is required if the system is to work efficiently and sensitively. In my time as President of the Medical Practitioners Board of Victoria, the Board employed both legally qualified and medically qualified investigating officers. While salaries were necessarily higher, the benefits of their skill and knowledge made this a sensible use of resources.

    By comparison, there is a sense that the new system seems to be back to front in the following way. Section 25 of the national law states that a key function of AHPRA is ‘to provide administrative assistance and support to the National Boards and the Boards’ committees in exercising their functions’.   In practice, it appears that AHPRA, via its administrative staff, dictates to the Medical Board and its state Medical Board branches (committees) the work flows and the quality and timeliness of the work done on behalf of the Boards. To gain access to this “administrative assistance and support”, the Medical Board of Australia has to spend resources each year negotiating a “health profession agreement” with AHPRA.

    Fortunately, built into the national scheme is a solution to these structural flaws, namely the New South Wales model of “co-regulation”. Under co-regulation, NSW kept its previous Medical Board, renaming it the Medical Council of NSW. The Council (working in close cooperation with the NSW Health Care Complaints Commission) handles complaints, performance and health/impairment issues, leaving registration and the maintenance of the national register in the hands of AHPRA. Although there would be some short term additional costs, it would be relatively simple for all states and territories to copy NSW and become “co-regulated”. If this were to happen, it is envisaged that the national law would remain in place and with it, the powers for the health ministers as a group to control workforce issues would also remain.

    The experimental national scheme can rightfully claim that it has successfully established a single national register and with it, ready portability of registration across Australia. These key elements must be retained. As NSW has 30% of Australia’s 103,000 doctors and 27% of Australia’s 370,000 nurses, the NSW experience demonstrates that a national register can readily coexist with co-regulation.

    Dr Kerry Breen is a past president of the Medical Council of Australia, a past president of the Medical Practitioners Board of Victoria and a past chair of the Australian Health Ethics Committee of the NHMRC.

  • John Menadue. Health reform and cooperative federalism. Part 2

    In part 1 of this series, I set out why I was attracted to the development of an option set out in a COAG paper on health reform which suggested the establishment of a commonwealth hospital benefit which would replace the PHI subsidy. 

    Regional Purchasing Agencies to address the’ blame game’ in health.

    In part 2, I examine another option in the federalism discussion paper which is for ‘The commonwealth and the states and territories to share responsibility for all health care through Regional Purchasing Agencies.’

    The discussion paper outlines the proposal as follows:

    Option 4: The Commonwealth and the States and Territories share responsibility for all health care through Regional Purchasing Agencies

    The Commonwealth and the States and Territories would jointly establish regional purchasing agencies. These agencies would purchase a range of health services for individuals in their catchment, defined by a minimum service obligation including primary and specialist care, hospital (both public and private), and allied health services. Agencies could be accountable to the Commonwealth and the State and Territories, or just one level of government.

    The Commonwealth and the States and Territories would pool funding to make payments to the purchasing agencies based on demographic and health characteristics of catchment populations and the mix of services covered by the minimum service obligation. Agencies would then be responsible for managing the purchase of health services from within this fixed budget.

    Catchments for regional purchasing agencies could be based on existing structures, such as Primary Health Networks and Local Hospital Networks, or their equivalent State or Territory health service authorities.

    High level health policy, including setting minimum standards of care and quality, and funding roles would be shared between the Commonwealth and the States and Territories. Regional purchasing agencies would be responsible for funding and commissioning primary care and the MBS would no longer operate in the same way—for example, it could be cashed out to help fund the regional purchasing agencies. The impact on other roles would need to be considered.

    Various options could be considered for the establishment of regional purchasing agencies. They could be government or semi-autonomous government bodies, they could be managed by private organisations, selected through a competitive tender process, or there could be a mixture of different approaches. One option would be for the role of the Commonwealth to be limited to funding and setting minimum standards of care and quality, with the States and Territories taking responsibility for governance and system management.

    The Commonwealth and the States and Territories would agree to jointly fund regional purchasing agencies from existing health funding.

    This option would increase areas of shared responsibility between the Commonwealth and the States and Territories. It could seek to build on existing governance arrangements.

    Responsibility for service delivery and the commissioning of services would lie with the purchasing agencies. This would allow for greater competition in the market for services.

    This option would address system fragmentation and may also better respond to local circumstances. This is consistent with the principle of subsidiarity and should result in better services for patients, so long as adequate arrangements are in place to ensure provision of quality services in remote and disadvantaged regions.

    Pooled funding arrangements would need to be established in a way that would reduce incentives for cost shifting between governments. This approach should also increase incentives for investment in prevention and early intervention. There would be an incentive to ensure services were provided cost-effectively within allocated funding to avoid unnecessary (and costly) hospitalisations.

    This option would include many of the benefits of individualised care packages … It would need to be supported by well-designed and clearly defined roles to minimise the risk of blurred accountability and blame-shifting, resulting in service gaps.

    This option involves large-scale reform. It would present particular challenges for rural and remote areas where there are fewer existing services. Consideration would need to be given to the size of purchasing agency regions, to ensure they cover a large enough population to manage risk, realise economies of scale, and ensure availability of suitably skilled staff. This could be an issue for smaller States and Territories.

    Consideration would also need to be given to the role of private health insurers.

    Once implemented, this option would be durable as the health system would contain incentives to provide people with the care they need in a cost-effective manner as agencies operate from a fixed budget. It would take some time to implement and would require a significant up-front investment, in addition to ongoing operational costs.

    This option is a variation of a proposal I have been making for some time, that the commonwealth and the states establish a Joint Commonwealth State Health Commission in any state that would agree. In effect the Commission suggested would be a joint state wide purchasing agency. See link https://publish.pearlsandirritations.com/blog/?p=3810.

    This commission that I have proposed would pool all commonwealth and state health funds in that state, develop an agreed health plan in that state and purchase services from existing agencies, both public and private. The Regional Purchasing Agencies proposal in the draft federalism paper is a more modest approach, being regional and not state-wide, but it may be a more practical way to proceed. Perhaps establishing regional pilots would be a useful first step. A pilot project involving the whole of Tasmania would also be a useful first step given the small size of Tasmania.

    To address the blame game and improve health efficiency and equity, it is necessary that there is effective coordination of all health services, particularly those delivered by hospitals and non-hospital agencies. The great inefficiency in our present health arrangements stems from the fact that the commonwealth government has responsibility for primary care but the states operate the hospitals. A Regional Purchasing Agency could be a very useful way to start resolving the blame game.

    A major aim of a good health policy for Australia must be to keep people out of expensive hospitals. The division of responsibilities between the commonwealth and the states makes that very difficult.

     

     

  • John Menadue. The health insurance lobby at work at the expense of the public interest.

    For many years, Ian McAuley and I have been highlighting the damage to our health system and the Australian economy as a result of the $11 b. p.a. subsidy to the private health insurance industry.  We have highlighted the following and never has there been a rebuttal by these vested interests.

    • The subsidy favours high income groups. Taxpayers money is being used to help the more wealthy jump the hospital queue
    • Through gap insurance PHI has underwritten enormous increases in specialist fees.
    • Despite the claims PHI has not taken pressure off public hospitals. It has made it worse by attracting salaried staff from public hospitals to private hospitals with much higher remuneration.
    • PHI discriminates against country people who have limited access to private hospitals. Yet the National Party supports the subsidy.
    • Premium increases for PHI over the last 15 years have been at more than double the CPI rate.
    • PHI has administrative costs three times those of Medicare.It aggressively conducts pointless advertising campaigns and sponsors organisations such as  the Public Health Association of Australia and the most surprising of all the Grattan Institute.
    • The PHI industry talks about the high cost of health care but weakens Medicare’s ability to control costs.
    • PHI takes us down the disastrous US private health insurance path. Which Warren Buffett has described as the tape worm in the US health system?

    Despite what I think is an overwhelming case against taxpayer funding of PHI I have not seen a serious response from the PHI industry…ever. I can only conclude that it has no confidence to defend its position, and if it attempted to do so it would open up a debate that it wants to avoid at all costs.

    Instead of joining in a public debate to justify $11 b. p.a. government subsidy, it relies on lobbying directly and secretly on the federal government, both ministers and officials.

    In 2007 Kevin Rudd made a secret deal with the PHI industry that a Rudd Government would maintain the taxpayer subsidy. We only learnt about it years later.

    Now CEDA’s Balanced Budget Commission has suggested revenue measures which the government should consider to achieve a balanced budget.  One revenue measure it suggests is ‘removing the private health insurance rebate exemption’. The CEDA Commission also suggests ‘cutting the private health insurance rebate’. This CEDA report is professional and supported by a cross-section of very senior academics and public officials including four former heads of PM & C. But once again I expect the PHI lobbyists will try to close down the ‘debate’ as quickly as they can.

    In so many areas of public life in Australia, vested interests are abusing their power and influence on government. It is a public scandal what the PHI industry has been doing at the expense of the Australian taxpayer and good health policy.  But it is not just health policy that is being corrupted; it is our democracy where vested interests exercise enormous and secret power.

     

     

  • John Dwyer. Structural reforms to healthcare – two major reforms.

    Does the government understand the structural reforms to health care needed by modern Australia?

     Political pre-election posturing at the moment has involved many debating the question that asks ’Do we have a spending or a revenue problem in Australia?” Certainly when it comes to our health system we should first be asking what structural reforms would make that question less important. 

    While the idea that States could tax their citizens to pay for hospital care vanished in a flash, there is a distressing significance to the idea ever having been floated in the first place. It means that the Coalition still does not understand the components of the structural reforms needed to improve both the health outcomes and cost effectiveness of our health system. Implemented, the proposal would have further entrenched the inefficiencies in a fractured health system.

    Equitable, cost-effective health care in modern Australia requires two major reforms.

    Informed opinion, generated by world-wide evidence, suggests that the first major reform requires us to appreciate that the funding for the total spectrum of health care, which includes hospital, community and the primary care funded by Medicare, needs to be pooled so that these services can be integrated. Funding flexibility is a crucial issue, as this would allow differential spending on various components of the system depending on regional need. For example, rural primary care is more problematic than rural hospital care. Sadly this imperative is obviously not in the conscious mind of a government that would enshrine a separation of hospital and primary care funding as demonstrated by their State tax proposal.

    The concept of regional funding is very important as different regions with very variable demographics and health priorities are readily demonstrated in our huge country. In our present system we have Local Hospital Districts and Primary Health Networks (PHNs) within a State boundary. While the latter are meant to improve the quality of Primary Care and better integrate individuals care and provider availability there geographical boundaries make this impossible. There is only one PHN for Tasmania and only one for the whole of Western Australia outside of Perth! New Zealand has 80 such organisations.

    If one agency held all the health dollars available for health care and logical health districts were established without reference to State boundaries a resource distribution based on local needs not just population density would markedly improve health outcomes and cost-effectiveness. Regional fund holding in the UK sees “Commissioning Agents” able to seek providers for that regions health needs. This was to be the approach taken by the short-lived “Health Care Commission”, established by the Whitlam government.

    Federation has failed our health system as it has prevented it being operated as one system in which three components are fully integrated (Primary, Community and Hospital care). This is our unique disadvantage within the OECD. Now, 40 years after the idea was first suggested there remains an urgent need for COAG to pool all our health dollars and establish a State/Federal “Health Commission” to disperse the funds. The COAG meeting of health ministers later this week should commit to a reform journey with this initiative as the destination.

    Currently our States are responsible for funding our public hospitals with a variable, oft insecure, contribution from Canberra. Hospital admissions continue to increase steadily and the growth in hospital spending far exceeds any increase in Medicare spending. Because of the responsibility/funding divide, States are at the mercy of the success or otherwise of Primary/Community care to reduce the number of people requiring hospital care. They have no levers to pull to control demand. Figures from the Australian Institute of Health and Welfare suggest that 600.000 admissions to public hospitals each year could be avoided by a better-resourced Primary Care system. It is clear that a future featuring affordable and excellent hospital care is dependent on reducing the demand for hospital care.

    So a second major reform is long overdue. We need a major structural reform to change our outdated hospital, doctor and sickness centric system to one that focuses on the prevention of chronic illness, the reduction of hospital admissions and “team medicine”. A multidisciplinary team working in the one practice integrating all the care needed by enrolled patients. In much of the world this proven approach to better health care is referred to as the “Medical Home” model. It provides the needed components for modern primary care. Patients enrol in a practice populated by a team of health professionals from different disciplines to Improve patient’s health literacy and maintenance of a healthy lifestyle. Continuity of care allows for early recognition of problems that if not treated could become serious and chronic. The range of services needed by patients with established chronic diseases are provided in their “one stop shop” and the practice is resourced to extend care into the home/community to minimise the need for hospital admission.

    Such a model necessarily increases practice expenses, as the multidisciplinary team the patient needs has to be funded. However, doing so will reduce hospital admissions and so for the whole system is cost effective. The program will need more commonwealth expenditure and that should also include funding for prevention strategies. Having more water bombers available for the fire season would be welcomed but their availability should not mean that hazard reduction during winter is not prioritised. We can do a better job of coordinating care for patients with advanced, incurable chronic diseases but in focussing almost entirely on this priority we are doing little to turn off the tsunami of Australians who continue down the path to chronic avoidable illness.

    The tentative step towards introducing the “Medical Home “ model into Australia announced last week is welcomed conceptually but it is focussed entirely on the management of established disease not strategies for minimising the current flood of Australians developing chronic disease and the “Healthcare Home” as envisaged is a pale reflection of the fully developed model described earlier. A detailed plan needs to be presented before any judgement can be made on the likely success of this first step. The plan, as announced, would aim to provide patients with “multiple chronic illnesses”, who stick with one GP for their care, benefit from better-integrated care. A participating GP practice would receive fixed amounts quarterly for providing the enhanced care. While moving away from a fee for service model for the care of chronic illness and appreciation of the need to integrate a range of needed services is welcomed it is not clear how the GP conducting the orchestra will be able to fund the additional players needed. For a scheme said to involve 200 GP practices and 65,000 patients the suggested cost of $21 million seems totally inadequate and anyway, what does it mean when we hear the scheme is to be cost neutral?

    As usual, the devil is in the detail. How much will the practices be paid for the integrated service? Will this payment (capitation) vary depending on the number of chronic problems suffered by a patient? What level of morbidity will set the threshold for entrance into the scheme? How will the trial’s outcomes be measured? Who will determine the additional staff requirements and the skills they need as well as the financial compensation they will be offered in the scheme? Etc.

    All these questions can be addressed and have been elsewhere, but how much better would be this initiative be if it were to establish thirty or more fully resourced Medical Homes to prove their worth in the Australian context? We need to continue to advocate for that suggestion.

    John Dwyer is Emeritus Professor of Medicine at the UNSW.

  • John Menadue. The fake discussion about state taxes.

    Malcolm Turnbull’s ruse is obvious. He wants us to forget all about deficits and debt and the need for budget repair. To avoid these issues, he now tells us that if we want improved health and education services, we cannot have them because the states have refused his offer on state taxes and he will not increase commonwealth taxes.

    But we know that large increases in commonwealth government revenue are possible without any increase in income tax rates.

    There are numerous proposals on ways to increase revenue without increasing tax rates. The most recent was from the Committee for Economic Development of Australia (CEDA). That Committee suggested various ways in which revenue could be increased without increasing income tax rates.

    • Reducing the superannuation concessions.
    • Reducing the capital gains discount
    • Halving the fuel tax subsidy scheme.
    • Removing negative gearing.
    • Removing the private health insurance rebate exemption.
    • Reducing industry tax concessions.
    • Reducing work-related deductions.

    The other obvious way to increase revenue is to ensure that large multinational companies, private companies in Australia and trusts pay their fair share of tax. Many don’t pay any tax at all.

    None of this involves increasing tax rates. But these proposals would not be welcomed by the wealthy vested interests that support the Liberal Party.

    There is probably $20 b. to $30 b. of increased revenue per annum by addressing the issues above.

    All public surveys that I have seen suggest that Australians are prepared to pay increased tax, even increased rates of tax, if they believe that the tax system is fair and the money is spent efficiently.

    I have posted blogs earlier about the remarkable successes of the Nordic countries – Denmark, Sweden and Norway. These countries have some of the most successful economies and societies in the world yet they have very high rates of taxation. The Nordic countries have a basic trust in government. They broadly believe that the tax system is fair and services are efficiently delivered.

    It is something badly lacking in Australia.

    See links to two earlier articles on the Nordic successes – Postcard from Denmark on the Nordic success (17/1/2015);  Why are the Nordics so successful? (18/1/2015).

     

     

  • Mike Steketee. COAG and hospitals: look beyond the funding to fix our health system.

    Before Malcolm Turnbull and the states start haggling over hospital funding, it’s worth looking at why the system costs so much to run. Maybe it’s not just cash, but waste and inefficiencies that need addressing, writes Mike Steketee.

    Why do our hospitals cost so much to run? Like$55 billion a year and rising rapidly?

    It is the question worth asking before Malcolm Turnbull and the premiers start haggling at today’s COAG meeting over how best to pour more money into hospitals. Yes we are an ageing population and the health system is devising ever more clever ways to treat us.

    But that is not all that is going on. If you are 55 or over living in Fairfield in western Sydney, your chances of having knee arthroscopic surgery were 185 per 100,000 people in 2012-13. In Bunbury in Western Australia, the chances were more than seven times greater – 1319 in 100,000.

    Are there that many more dicky knees in Bunbury or at least ones that require hospital surgery? Or is it that many older people in Fairfield have been denied necessary surgery?

    Not likely on either front, according to the Australian Commission on Safety and Quality in Health Care, funded by federal and state governments. As it said in November:

    Despite the evidence that knee arthroscopy is of limited value for people with osteoarthritis and may cause harm, more than 33,000 operations were performed on this age group during 2012-13. Many of these people will have degenerative disease in their knees and will not benefit from this intervention.

    It added that, even if you argue the extremes distort the picture and take out the areas with the highest and lowest rates, hospital admission rates for arthroscopy still varied more than four times between local areas.

    The Commission found an overall variation of more than seven times for cataract surgery, which was performed 160,489 times on those 40 or over in 2012-13. Age differences between areas do not come anywhere near explaining variations of this size.

    For lumbar spine surgery for those 18 and older, the variation was 4.8 times. This included spinal fusion procedures, for which the Commission said there was limited evidence of its effectiveness for painful degenerative back conditions.

    And so on. Carried across a hospital system which saw 9.7 million admissions in 2013-14, this suggests that a great deal of money is spent unnecessarily.

    John Dwyer, emeritus professor of medicine at the University of NSW, has had a stab at estimating the waste generated by doctors across the whole health system and comes up with a figure of at least $10 billion a year. As they say, a billion here and a billion there and soon you’re talking serious money.

    A Productivity Commission research paper last year made a similar point:

    Governments and patients spend a considerable amount of money on health interventions that are irrelevant, duplicative or excessive; provide very low or no benefits; or, in some cases, cause harm.

    Despite all this, the Australian health system delivers some of the best outcomes in the world, other than for Indigenous people. But costs are rising rapidly, in part because of too little control over waste and too much emphasis on hospital treatment.

    Knees seem to be one particular problem. Knee replacement surgery was performed at the rate of 191 per 100,000 population in Australia in 2013-14 – 61 per cent higher than the average in 30 OECD countries.

    Overall, admissions for longer than day surgery in Australian hospitals are lower than some countries such as Germany but higher than those with which we often like to compare ourselves, such as New Zealand, the UK, the US and Canada. The last of these had a rate of admissions half of that in Australia.

    The Productivity Commission paper canvasses some of the weaknesses that apply across the whole health system but often culminate in expensive hospital treatment. It says governments subsidise many health treatments that have not been assessed for clinical and cost effectiveness.

    Often clinicians do not realise they are over-diagnosing patients, providing superfluous or harmful treatments or applying valuable treatments in the wrong way. Clinical guidelines … can be an effective way to promote high value medicine but they are often too complex, out of date, lack credibility or poorly implemented.

    Doctors are often resistant to change, including in acting on the findings of evidence-based medicine, arguing that their training equips them to know best the needs of individual patients. The way they charge – on a fee-for-service basis – is an incentive to provide more services than are necessary.

    The initiative announced by Malcolm Turnbull and Health Minister Sussan Ley on Wednesday to trial a different way of treating chronically ill patients, who often have multiple conditions, is an attempt to address some of these problems. At the moment, they said, such high users of the health system saw up to five different GPs a year, making it more likely they would fall through the cracks and end up in hospital.

    “Half of all potentially avoidable hospital admissions in 2013-14 were attributed to chronic conditions,” they added. Under the two year trial, one GP practice will co-ordinate the care of these patients and receive quarterly payments. This shifts the emphasis to improving the overall health of the patient, rather than charging for individual treatments.

    Turnbull and Ley hailed this as “one of the biggest health system reforms since the introduction of Medicare 30 years ago.” However, we shouldn’t get too carried away: various forms of co-ordinated care, including for chronic illnesses, have been tried for at least the last 20 years, with mixed results. Nevertheless, an increased emphasis on primary care – that is through GPs and including prevention programs – is crucial to keeping people out of hospital.

    These potential savings are before we even start talking about inefficiencies in administering the health system. With both the federal and state governments putting money into public hospitals, there is bureaucratic duplication on a large scale.

    Each level of government blames the other for deficiencies in hospitals. As well as blame shifting, each is constantly manoeuvring to shift costs on to the other. For example, hospitals, which are run by the states, are forced to keep elderly patients in beds costing $1200 a day because there are not enough places costing only $200 a day in nursing homes, which are funded by the federal government.

    Turnbull is right in suggesting this week that if the states raised more of their own revenue – for example, through his proposal to let them levy income tax – it would make them look more carefully at how money was spent. At the moment, it is much easier to beg Canberra for more money than to make voters cough up through taxes.

    It is just that experience suggests that the main effect of Turnbull’s idea would be to put even more pressure on hospitals. In most areas where they already have the power to raise taxes, the states have competed with each other to bid them down, such as through ever more generous exemptions for payroll tax and land tax.

    Of course, if Canberra stood firm on the states solving their own problems, it would force them to tackle some of the waste and inefficiency in their spending – either that or allow hospital and other services to run down and cop the wrath of voters. But then the states would just try to blame it on Canberra.

    Mike Steketee is a freelance journalist. He was formerly a columnist and national affairs editor for The Australian. This article was first published in The Drum 1 April 2016.

     

  • Michael Keating. The Turnbull Proposal for State Income Taxes

    Prime Minister Turnbull says his proposal for the States to levy their own income tax ‘is the most fundamental reform to the Federation in generations’. Well maybe. It certainly would be a significant change, but reform? Furthermore, even if this proposal were ever implemented, it is hardly new. For example, the Fraser Government actually legislated to allow the States to raise their own income taxes, but none took up the opportunity.

    In principal I agree that governments would be more accountable, and possibly more responsible, if they raised all or most of the revenue needed to fund their expenditures. Consequently, I accept that a move towards reducing the present degree of vertical fiscal imbalance and better match revenue and expenditure responsibilities should be seriously considered.

    At this stage, however, Prime Minster Turnbull is only proposing to transfer 2 percentage points of the income tax rate to the States; effectively an annual transfer between the Commonwealth and the States of about $14 billion. This compares with the $8 billion a year that the Abbott Government took away in the notorious 2014 Budget, and if nothing else changed this extra $14 billion would be quite a carrot to induce the States to agree.

    The Turnbull Government, however, is indicating that it is prepared to restore around $3 billion of these cuts to State payments, and so allowing the States to raise $14 billion in income tax revenue would leave the Australian Government Budget a net $9 billion down. Further savings would therefore be necessary, either from the Commonwealth’s own programs or from payments to the States. In this context it is not surprising that the Treasurer has floated the idea that another $6 billion could be clawed back by the Commonwealth ceasing its funding of State schools as part of the $14 billion package.

    But apart from this fiscal problem, realistically much more would be needed to realise the Prime Minister’s vision of the States taking over full responsibility for a variety of functions and thus ending the ‘blame game’. Indeed, the $14 billion a year that has so far been floated would not even cover the cost of the Commonwealth contribution to hospitals as well as schools.

    Most importantly, in this context, is that $14 billion is well short of the total of $50 billion paid each year to the States to cover all presently tied grants. For the States to be fully responsible for funding all their services would therefore require a far larger share of the income tax than has so far been mentioned, or alternatively allowing them much more freedom and capacity to increase income tax rates.

    But until the States get the taxable capacity to raise all or most of this annual $50 billion does anyone seriously believe that this relatively small change to give them a 2 percentage point income tax rate would make the States much more accountable and responsible?

    In my opinion there is some further scope to rationalise the respective roles and responsibilities of the Commonwealth and the States. For example, if Mr. Turnbull is fair dinkum why doesn’t he offer to return to the arrangements established by the Keating Government under which the Commonwealth was totally responsible for funding national highways, while the States and local government had total responsibility for all other roads. This arrangement was a sensible separation of responsibilities, but it fell foul of the pork-barrelling National Party, and so the Howard Government reversed it.

    As both John Menadue and I have emphasised, however, for many joint government programs there are good reasons why we have adopted our present shared funding arrangements (see my earlier article on Federalism, reposted on 31 March, and John Menadue’s post on the same day).

    Most importantly, in many cases the Australian Government has responsibilities that cannot be separated from those of the States. For example, education and training is vital for the future of innovation, productivity, employment participation, and economic growth, all of which are key Commonwealth responsibilities. While health necessarily involves both levels of government, as the Australian Government responsibilities for Medicare and aged care necessarily interact with the State Government responsibilities for hospital care.

    Indeed, the Turnbull Government seems to be prepared to acknowledge that separating the roles and responsibilities of the two levels of government presents a particular problem. According to some media reports the Australian Government may not withdraw from health funding, but it could withdraw totally from having any responsibility for Schools. Certainly the Australian Government has less at stake in schools, where its intervention has never achieved a great deal in the past. But in that case, maybe the Australian Government should take over total funding responsibility for vocational education and training which is necessarily closely related to the needs of industry, and where most of the funding is increasingly being provided to both private and public providers using a competitive model.

    Perhaps the most important Australian Government responsibility that would be compromised by the States setting their own tax rates would be the potential impact on fiscal policy. In the immediate future this is not expected to be a problem as the proposal envisages that the States would initially only be getting what would effectively be a share of the income tax, and the change would be revenue neutral. But once the States start setting their own income tax rates then this would compromise the necessary independence of the Australian Government to determine fiscal policy for the nation. Indeed, time is of the essence with fiscal policy and we cannot afford to have it run by some sort of Federal-State Committee. While on the other hand if governments set tax rates independently of one another, there is a risk that any time the Australian Government lowers its tax rates, then the States would seize the opportunity to take advantage of the extra taxation capacity available, and raise their own State income tax rates.

    In addition, although the Australian Tax Office would continue to be responsible for administering the tax system, and each taxpayer would continue to file only a single return, there would be a number of administrative problems with the Prime Ministers’ proposal that would not be easy to resolve. Thus, unlike the GST revenue, which has a common tax rate and can therefore be distributed on a per capita basis, this per capita distribution makes no sense for income tax revenue if rates of taxation differ among States. Accordingly, companies are already demanding that the states should not have a share of company tax because of this sort of complication. Many individuals, however, also derive income in more than one state, and it still remains to be worked out how their income tax payments can be distributed between two or more States where the rates of taxation vary.

    As John Menadue points out in his accompanying post, given its many problems and lack of clarity, this proposal by the Prime Minister is essentially a diversion from what is or should be the major concern of the Council of Australian Governments (COAG). The most critical challenge, which all Australian governments are facing, is first to repair the substantial Budget deficit, and in the longer-run to reconcile the demands for public services that are presently projected to run well ahead of likely government revenues.

    What COAG should therefore be discussing is how to raise more revenue and/or reduce the demand for services or improve their efficiency. Personally, and as I have argued in other postings, I think it will prove to be impossible to meet reasonable demands for future services without at least some increase in overall taxation in the decades ahead (see, for example, my recent article posted 28 March).

    In this regard the response by the Labor leader, Bill Shorten, to any suggestion that income tax might rise sometime in the future was most unhelpful. Mr. Shorten has already ensured that the possibility of raising the necessary extra revenue by increasing the GST was taken off the table, and now he seems to be intent on doing the same to any possible increase in the income tax in the decades ahead. One wonders how Labor could deliver its vision of society, and what it has supported, without increasing the overall tax take in the future – certainly Mr. Shorten has so far not told us.

    By contrast, allowing the States to determine their own tax rates raises the risk that at worst the States may enter a new race to the bottom. This is what happened after payroll tax was handed over to them by the McMahon Government in 1971. The States have since dropped the payroll tax rate and increased the tax threshold and exemptions. Ostensibly this was in response to tax competition generated by a perceived need to attract new firms, but most of the changes did little to attract industry because they mainly helped small business which is not geographically mobile.

    On the other hand, this time the Australian Government may force States to raise taxes by further squeezing their remaining tied grants. In that case the Australian Government would continue to solve its own fiscal problems by short-changing the States so that they are forced to raise taxes and thus take the blame for solving a problem of the Australian Government’s own making.

    A better alternative would be to adopt the proposal by SA and NSW that the States all get a fixed share of the income tax. This hypothecated share of the income tax could then be increased if all governments agreed to raise the rates for this purpose. Furthermore, by thus achieving an agreed increase in the overall level of taxation nationally, it would help to resolve Australia’s most important longer-run fiscal problem.

     

  • John Menadue. State income taxes – another political diversion?

    Malcolm Turnbull’s suggestion of states entering the income tax field may please ‘state rightists’ in the Liberal party, but it will damage our national aspirations and our national society and economy.

    In the repost below, Michael Keating, almost two years ago emphasised the importance of the commonwealth government’s domination of income taxes since 1942. This commonwealth government supremacy has been a key factor in building our successful national economy and society. Or as Paul Keating has said, the commonwealth’s income tax monopoly ‘is the glue that holds us together’.

    We federated to overcome the confusion of six different state tariff regimes. Do we now want eight different incomes tax regimes?

    The commonwealth’s supremacy in income tax is critical for economic management across the country. Do we want to weaken that national leadership and responsibility?

    We have national markets in every field and with a very mobile workforce. Do we now want to put up state barriers to this?

    Malcolm Turnbull’s proposal would put pressure on the states to reduce their own tax rates. Perhaps this is what his ‘state rightist’ supporters would like. We saw that in the 1970s when Queensland reduced state taxes and abolished death duties. All other states followed and we are now much worse off as a result. If states decided to introduce their own income taxes, we could see another race to the bottom.

    What Malcolm Turnbull is trying to do was tried forty years ago by Malcolm Fraser. The details may be different, but the Fraser proposal went nowhere.

    The Turnbull government has become very agile in diversionary tactics. The Abbott government spoke of a debt and deficit disaster but the Turnbull government wants to divert attention elsewhere. A GST was deliberately floated but then our attention was directed elsewhere. One critical issue above all else is budget repair. The Committee for Economic Development in Australia (CEDA) and others have suggested options for overcoming our persistent budget deficit, including increases in revenue. But the government doesn’t want to hear about that, so our attention is diverted to state income tax.

    I believe that strong national economic and social leadership is essential for the commonwealth government in the 21st Century, particularly in the global world economy in which we live. That globalisation will continue to grow. Why should we handicap ourselves in meeting such a challenge?

    I have always believed that ‘cooperative federalism’ although less sexy and requiring hard work, is the much better way to proceed. In the health field where states spend up to 30%of their budgets, I have proposed for many years a joint commonwealth-state health commission in any state that will agree. Perhaps a joint commonwealth-state health purchasing agency in regions would be a more practical way to start. I will be writing more about cooperative federalism in the health field.

    Tony Abbott has left us with many unfortunate legacies. He abolished the COAG Reform Council which had been trying to lead an informed debate on ways that the commonwealth, state and territory governments could cooperate to harmonise their responsibilities. One task of that Reform Council was to build a ‘seamless national economy’.

    Malcolm Turnbull seems to want to pull the seams apart.

    Michael Keating will be writing further on this subject.

  • John Menadue. Budget repair and private health insurance.

    Readers of this blog will be aware that I have been expressing concern about the serious consequences of the government subsidy costing $11 b. p.a. for the private health insurance industry. This subsidy has serious budget consequences:  it is skewed in favour of high income earners; it has not taken pressure off public hospitals; it has underwritten a dramatic increase in private specialist fees; it penalises country people who have very limited access to private hospitals; it weakens Medicare’s ability to control prices; it’s premium increases for over a decade have been at three times the rate of CPI increase and steadily takes us down the disastrous US health path.

    Yesterday, the Balanced Budget Commission of the Committee for Economic Development of Australia (CEDA), outlined various options to increase revenue and to reduce outlays

    . In its options, CEDA suggested ‘removing the private health insurance rebate exemption’. In my blog of 19 November, I estimated that the government loses about $3 b. p.a. as a result of the revenue foregone through exemption from the Medicare levy surcharge.

    CEDA also suggested ‘cutting the private health insurance rebate’. In my blog, I estimated that the cost of that rebate in the last budget was $6.3 b.

    The CEDA Balanced Budget Commission which made these recommendations includes Paul McClintock, former Howard government Secretary of Cabinet; John Edwards, Reserve Bank of Australia board member; Professor Rodney Maddock from Victoria University; Michael Keating, former Secretary, Prime Minister and Cabinet and Finance; Terry Moran former Secretary Prime Minister and Cabinet,Ian Watt,former Secretary Prime Minister and Cabinet and John Langoulant, former WA Under-Treasurer.

  • Jonathan Karnon. No-one should get dud hospital care.

    In 2013-14, Australian governments spent A$105 billion on health; A$44 billion of that was on public hospitals.

    The Commonwealth government is increasingly concerned with the size of the health budget and has acted to reduce the inappropriate use of Medicare benefits. But the Commonwealth government has less influence on public hospitals because the state and territory governments control their expenditure.

    State governments are facing tighter budgets as demand for heath care increases due to an ageing population, greater rates of chronic disease and more service use generally.

    The collection and analysis of data on the performance of our health-care system can be used to improve the quality of health services and maybe also reduce costs.

    At a national level, the clinician-led Choosing Wisely campaign is developing lists of specific tests, treatments and procedures that may be unnecessary and sometimes harmful for individual patients. Recommendations include reducing use of CT scans in the emergency department and not ordering x-rays for patients with uncomplicated acute bronchitis.

    But while improving the decisions made by individual doctors is important, there remain other causes of substantial variation in the safety and quality of care provided in Australian hospitals. This needs to be addressed.

    Varied quality and safety

    Efforts to improve the quality of care in hospitals have traditionally been left to individual hospitals and their managers. But we now have the data to compare different hospitals. We can identify the best and worst performers and, most importantly, determine how to boost the performance of the stragglers.

    Identifying and intervening to improve low-quality care requires financial investment. But there are significant potential long-term savings, due to improved efficiency and better patient outcomes.

    In New South Wales, the Bureau of Health Information has developed and tested methods for comparing the death rates within 30 days of treatment for heart attacks, strokes, pneumonia and hip fracture surgery.

    For stroke patients, ten hospitals had noticeably higher-than-expected death rates for these conditions. An additional 16 deaths were observed in every 100 patients treated at a low-performing hospital compared to a high-performing hospital.

    Clinical auditors and review panels should investigate differences in the care provided at the high- and low-performing hospitals and approaches to improve care quality.

    Other data show the costs of treating similar conditions varies dramatically. A Grattan Institute analysis shows the average cost of performing a hip replacement at different hospitals ranges from under A$10,000 to more than A$30,000.

    Further investigation may find the higher costs are due to the use of more expensive prostheses and to keeping patients in hospital for longer after surgery. Assessments can then be made about whether more expensive prostheses or extended lengths of stay produce better patient outcomes, which justify the additional costs.

    We have analysed hospital data to compare costs, outcomes and the care pathways of patients treated for similar conditions at the main public hospitals in South Australia.

    After adjusting for differences in the types of patients presenting at emergency departments with chest pain, seven in every 100 patients presenting at a particular hospital were readmitted or died within 12 months. This compared to four to five patients at the other hospitals.

    The same hospital spent up to A$669 more on each patient than the other hospitals. Over one year, these additional costs amount to almost A$1 million.

    Analysis of the care pathways showed that the hospital with the highest rates of re-admission, premature death and costs, discharged more patients from the emergency department. This hospital also kept patients who were admitted to an inpatient bed in hospital for longer than the other hospitals.

    This suggests some patients may have been inappropriately discharged home from the emergency department, while other patients could have been discharged earlier.

    Further investigation might look more closely at how and why decisions are made to admit patients from the emergency department and at what might be causing admitted patients to stay longer in hospital.

    Investing in improvement

    State governments are increasingly interested in improving quality. The Queensland government has set up an Integrated Care Innovation Fund to invest in initiatives to improve efficiency and value. NSW set up a similar Translational Research Grants Scheme. In South Australia, the Transforming Health initiative aims to improve the quality and consistency of health care across all metropolitan public hospitals.

    But while individual efforts to improve quality may have some effect, it is more likely that co-ordinated, systematic approaches will have a greater impact.

    Data should be analysed across hospitals on an ongoing basis to identify areas of clinical activity with the greatest potential for improvement, such as the examples above. Findings that quality could be improved should be fed back directly to hospitals.

    Specialist teams should be set up to work with hospitals to further investigate areas of concern and to develop and implement improvement strategies.

    Rather than going back to the drawing board on health reform, governments need to improve what we’ve already got and bring the poor performing hospitals and departments in line with their better performing peers.

    Jonathan Karnon is Professor of Health Economics, University of Adelaide.  This article first appeared in the Conversation on 21 March 2016.

  • Peter Gibilisco. Disability support services – effectiveness and efficiency.

    Let me be frank. There are many stringencies that have to be faced in the provision of disability support services. We all know this whether we are recipients of in-home one-on-one support, residents, workers or management of disability support services, or even as officials of the Department of Health and Human Services (DHHS). We all are under the pump in an economic climate where there is widespread political anxiety about budget blow-outs and a possible collapse of our financial and economic system. We all know this. So when I make my professional contribution, as a resident of such a health-care facility, my recommendations and pleas are complex.

    Many of the problems in the disability support services arise because it seems that efficiency demands a certain generalized procedure. In this case “efficient” means something like: (a person) working in a well-organized and competent way.

    And when dealing with disability support, effectiveness  is also a crucial characteristic to be balanced against any “efficiency”. This is the meaning of “effectiveness”: the degree to which something is successful in producing a desired result; success.

    I would ask that readers appreciate that I too am a citizen, a member of this polity, one who has paid my taxes, one who has worked persistently to promote the common good. Yes, what I am about to say is framed in my own interest but it is not only that. I am just as much concerned morally as any other non-disabled professional person about the serious state of our disability support services. Unless that is understood then my point will not be appreciated.

    There have been developments at the level of Federal and State Government funding – negotiated through the Council of Australian Governments (COAG) – that have brought about significant changes to the delivery of human services more generally and disability support services in particular. I do not have access to a research facility to adequately assess and evaluate all of these. I regularly seek advice from those who may know but I do not want readers to presume that I have mastered all the details of all the complex agreements, contracts and policies that are now in place.

    In all this, within the political sphere dominated by neoliberalism comes the mechanism that can negatively impact on social decisions, and that is the way in which policies are freighted with a seeming over-riding criteria introduced by this question: but what is this efficient and effective procedure doing to enhance individual profit?

    Some social decisions, concerned with human-related social services are, and should be, unrelated to efficiency.

    But there are some gross inefficiencies, I believe, that are part of the disability support sector that have very little, if anything to do, with disability support. More likely is it the support of the organisational and managerial structure that claims to be supportive of disabled people that is benefiting. The management of service providers are required by their own charters to turn a positive result in their financial returns . There are some unscrupulous service providers in the not-for-profit disability sector, like my own, who charging me $647.54 per fortnight in rent, including some shared transport – if it be available – and for food. The provision of food money is allocated to certain support workers at approximately $14 per day for residents in this facility, even though in recent times, I have complained to management about their failure to disclose provision money in their accounts.

    Such not-for-profit enterprise will follow the model of service provision that I would call the neoliberal streamline model: to put it simply it interprets organisational and managerial reality in terms that instinctively require financial profit to have precedence over people’s welfare.

    One will ask, bewildered, why should a not-for-profit organization need to show a profit? We are a shared supported accommodation residence and we are said to be in the not-for-profit disability sector. Are we simply to roll over and allow an abstract efficiency with little or no room for effectiveness, to prevail? Are we really wanting a neoliberal perspective that affirms that efficiency means money saved, while effectiveness means costs and hence a challenge to ongoing future viability?

    This state of affairs prods me to drive home an ethical perspective about residents in shared supportive accommodation. In this house we have 9 individuals with high support needs. In other words what is required for  residents in shared supportive accommodation are processes and resources that overcome a lack of human support. There are a lot of funds paid and even more is required for unmet needs of disability support. But I have come to my matured and well educated perspective, having developed it over many years living in the face of a progressive disability for over forty years.

    My conclusion is this: the disability sector has lost its way being caught up in the self-interest of an overloaded pool of management. Instead of alleviating the need for support such a sector is in danger of exacerbating the need for greater assistance!

    But all is not doom and gloom. There is a plausible and workable solution within reach to many of the failures to provide efficient and effective disability support. Through the attainable cost savings people with disabilities can actually be empowered. This is evident from schemes of direct employment techniques that have been widely used to positive effect by both DHHS and the National Disability Insurance Scheme (NDIS).

    Direct Employment has just been formally introduced into Victoria. I was involved in the initial pilot program. This is a key reform with the Disability Services that many Individual Support Package (ISP) users should consider due to its numerous benefits. It is a person-centred approach to disability, being more positive in allowing one to contribute to the community, enhancing community inclusion.

    In July 2013, I was keynote speaker at the Disabilities Support Professionals Conference at the University of Sydney. There I spoke with my computer voice about; Cindy, a 46 year old lady with a severe intellectual disability. She is involved with Direct Employment, her self-planning carried out by family members. As a result Cindy lives a more inclusive life. She is supported by three workers whose rosters, pay, training and other work conditions are managed by the O’Loughlin family, with sister-in-law Christine and brother Darren managing the accounts and finances. Cindy, and her mother Lesley, take responsibility for the recruitment, training and day-to-day management of Cindy’s workers. Thanks to Direct Employment, Cindy is receiving the support she needs, she is happier and is living as an individual in the community the way she chooses to live. Cindy’s family are the professionals involved in her support.

    The encouragement of such forms of disability support derived from their logic with a focus upon social coherence.  It is important to ensure that this kind of arrangement is flexible enough to allow some changes in a day-to-day sense, even if complete change does not take place.  The aim is to re-build trust and flexibility in disability supports, thereby creating both community inter-dependence and independence.

    Direct Employment offers flexibility, allowing people with disabilities to choose the support staff they prefer, helping them lead their own lives and make decisions for themselves. Direct Employment is better suited to cater for individual needs and lifestyles: it is, after all, an important concern for people with disabilities. Hence it allows for a more personalised approach that is better suited to meet individual support needs than the efficiency-driven of not-for-profit organisations constrained to make a profit. As a person-centred approach, I believe Direct Employment is an important reform that will be the key to the future lives of many disabled people and their families!

    Let’s hope so.

    Special thanks to, Christina Irugalbandara, Bruce Wearne and Cunxia Li

    Peter Gibilisco, B Bus (Acc) Ph.D. (Melb), Honorary Fellow University of Melbourne.

    New Book: The Politics of Disability

  • Ian Webster. Drugs and the problem of pain

    At the centre of the drug problem is the problem of psychic and physical pain

    People with mental illness turn to alcohol and drugs to lessen their distress. When adolescents and young adults use a substance to ameliorate their social anxieties a pattern of lifelong alcohol and drug misuse can be set in train. People managing to live in the community with psychosis have high life-time rates of alcohol and cannabis/illicit drug abuse/dependence – 40% to 60% – with males at the top level.

    About one in five people experience continuing pain. Access to a specialised pain clinic is virtually impossible for large segments of the population. Where a public clinic exists, waiting lists are 5 to 6 months before an initial assessment can be made. Who then can blame a person turning to a drug to manage their unremitting pain?

    The common image of homelessness is the “derelict alcoholic”. Think for a moment of how a street-living person has to survive the problems of rough sleeping, pain and mental illness. Legal and illegal drugs, especially cannabis and alcohol, become the way poor people and homeless people manage their lives as they have few other options. Crystalline methamphetamine “ICE” is often used to deal with physical pain as well as mental pain.

    This area is complex for clinicians. It is not helped by the way pain-relieving drugs are classified and controlled. Opioid analgesics are on the Poisons List of governments; the emphasis is on harms and penalties not therapeutic value. Unfortunately, legislation of this kind frames the clinician’s approach to managing patients experiencing chronic pain.

    A recent global study of the barriers to accessing opioid analgesics sponsored by the UN and International Narcotics Control Board described the impediments to access, some of which are relevant to Australia – inadequate health professional training, fear of dependence, fear of diversion to others and onerous regulation.

    Contrary to common belief, patients taking opioids to control pain would prefer not to be taking these drugs and resent being labelled as addicts, as they commonly are. On the contrary, the level of addictive behaviour in these patients is relatively low – of the order of 5 to 10% – and very few of these patients divert their medications to others in Australia.

    Drug problems should not be seen as issues of pharmacology, or the legal status of a substance, but as inherently people problems and the problem of suffering. Our response should be shaped by pragmatic humanistic principles not by heavy-handed legislation. In doing so, much of the unintended consequences, the harms, which typify our current approaches to pain, drug regulation and mental health should be reduced.

    Ian Webster is Emeritus professor of Health and Community Medicine at UNSW and patron of the Alcohol and Other Drugs Council of Australia.  He was formerly a National Mental Health Commissioner and Chair of the Australian Suicide prevention Advisory Council. 

  • Rosemary Breen. Living Water Myanmar

    Five years ago, when I started this project of building large water tanks to collect water during the rainy season in the Dry Zone of Central Myanmar I had no idea how many lives would be changed because of this simple concept. To date 114 water tanks have been built for villages and schools due to the generosity of so many donors in Australia, the USA and the UK.

    As the Australian coordinator, I have given talks and shown a Powerpoint presentation to many groups in order to raise funds, while Saya Toe, the coordinator in Myanmar, organises the team of builders who go from village to village building the tanks with help from the local people. Each time I visit there are requests for tanks from the village headmen or head teachers of schools and seeing the poverty and great need, it is hard to refuse. There are over 650 villages in the Dry Zone and the government has done nothing over the last sixty years to alleviate the situation.

    In January, 2015 I visited a school and the head teacher showed me a small concrete container filled with brown water from the local dam (there were even leaves floating in it) It was the drinking water for the schoolchildren. She said simply: “Please help us – we are so thirsty!” When I returned in October, 2015, I was shown the same concrete container filled with sparkling, clear water which had been piped from the large tank built several months previously. It was a moving moment watching the children come and drink there.

    So once again I am making an appeal for these children and their families in one of the most impoverished parts of our world (a country which has been shut away from the rest of the world by its repressive military regime for many years) Any donation, however small, would be gratefully received and a tax-deductible receipt given.

    Living Water Myanmar partners with Global Development Group for Project J812N Living Water Myanmar. Donations can be made online (simply google Global Development Group) but it is really important to put the project name and number.

    Cheques can also be sent to GDG,

    56, Goorari St, Eight Mile Plain, Qld 4113 (with the project number and name on back of cheque.

    It is a great help if donors could also email me (rosemary.breen6@bigpond.com)

    Saya Toe has recently set up a Facebook page (Living Water Myanmar) for anyone interested to see some of the recent work. Each village or school which receives a tank is committed to planting ten trees to help the environment.

    Each time we have a drink of water, take a shower, flush the toilet, water the garden, turn on the washing machine or dishwasher, may we remember our brothers and sisters for whom clean water is a luxury and may it remind us to share generously with them.

    In gratitude,

    Rosemary Breen

  • David Isaacs. As bad as Guantanamo

    If I liken the immigration detention centres on Nauru and Manus Island to the US facility on Guantanamo Bay, even passionate advocates for those seeking asylum such as human rights lawyer Julian Burnside dismiss my concerns: “Oh we’re not as bad as that.” I will argue that we are indeed as bad as that, possibly worse.

    Many people fleeing persecution to seek asylum have been subjected to psychological trauma in the countries they are fleeing and in the often highly traumatic journeys they take to reach ‘freedom’. However, people seeking asylum who are subjected to prolonged immigration detention are significantly more likely to suffer severe mental health problems than people seeking asylum who are not detained. Furthermore, the incidence of mental health problems increases with duration of incarceration. The United Nations defines torture as “…any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions”. Since prolonged detention without trial is unlawful under international law, Australia’s immigration detention policy clearly fulfils the key elements of the UN definition.

    Arguably what makes Guantanamo so bad is four things: lack of due process for imprisoning people there, lack of accountability (limited information, no transparency), indefinite imprisonment without due process (seemingly arbitrary legal processing, lack of clear end-point to imprisonment); and severe physical and mental maltreatment. Nauru and Manus share the first three characteristics with Guantanamo. Nauru and Manus, like Guantanamo, are ‘black sites’, out of sight and mind of the public, shrouded in secrecy, with severe restrictions on reporters. The Australian Border Force Act means employees including doctors, lawyers, teachers and guards who report the truth face two years imprisonment. Yet, for an Australian offshore detention policy to be successful in deterring people-smuggling, the stated intention, none of these four things are necessary. Therefore, even if you accept the Government justification for the Australian asylum seeker policy, the current treatment is unethical.

    Guantanamo is arguably worse in one respect: we know men are systematically tortured physically using techniques like water-boarding. However, Nauru is worse than Guantanamo in one hugely important respect: it includes children. When we surveyed Australian paediatricians, over 80% said immigration detention of children is child abuse. Successive Australian Governments have outdone the US Government in cruelty by torturing and abusing innocent children, all with the immoral aim of deterring other innocents.

    Furthermore, those imprisoned on Manus and Nauru are not terrorists; indeed, they are not guilty of any criminal offence, since seeking asylum is not a crime. Although the occasional innocent man was interned on Guantanamo, most knew what to expect when they went to war. In their autobiographies, Primo Levi and Nelson Mandela both astonishingly attempted without rancour to understand the motives of their captors; when they took up arms to fight injustice, they both knew the consequences if caught. On Nauru and Manus Island, in contrast, the injustice is being perpetrated against the very people seeking asylum. There can be few worse things than to be imprisoned unjustly and kept there indefinitely without right of appeal. Australia tortures innocent men, women and children who come begging for mercy. No wonder we are reviled internationally.

    When I worked on Nauru in December 2014, the predominant emotion was of utter despair and hopelessness. What would you do if you were imprisoned unjustly and indefinitely without right of appeal? In the current culture of victim-blaming, if you get depressed and self-harm or attempt suicide, you are accused by the Government of seeking preferential treatment. If you subsequently kill yourself, you had pre-existing mental health problems. If you get angry enough to riot, you are accused of violent ingratitude, with no mention of the extreme provocation that causes normally placid people to get angry enough to resort to violent protest.

    Gillian Triggs and the Australian Human Rights Commission have tirelessly and courageously exposed the harms done to children in immigration detention. The harm is also to adults, of course. But the very term ‘human rights’ implies an obligation, which risks being somewhat confrontational. Australia’s reprehensible treatment of people seeking asylum is as much a question of human decency as human rights. No civilised country should behave like this to fellow human beings. We treat refugees with respect and generosity. We treat people seeking asylum with contempt and cruelty. We talk of showing compassion, and in the same breath tell the meek to go back to where they came from. Australia is traditionally the land of the fair go, but in the words of president of the Australian Medical Association, Brian Owler, current asylum seeker policy is tearing at the moral fabric of our society. We, the public, need to prevail on all our politicians to listen to our pleas to find a new moral direction. Please help us re-discover our soul.

     

    David Isaacs is a consultant paediatrician in a University teaching hospital in Sydney, where he has run a Refugee Clinic since 2005, and is Clinical Professor at the University of Sydney

     

     

     

     

  • Kerry Goulston. Postcard from Vietnam. Health and medical cooperation with Vietnamese doctors and nurses.

    In 1998, Dr Phillip Yuile visited Professor Ton That Bach, Rector of Ha Noi Medical University, with a letter of introduction from Professor Kerry Goulston, Associate Dean of Medicine at the University of Sydney who had been appointed by the then Dean, Professor John Young, to explore possible links between the two universities. Subsequently Professor Ton That Bach invited Professor Goulston to Ha Noi to discuss a collaborative association between Sydney University and Ha Noi Medical University which had been established by the French in 1902..

    Professor Ton That Bach was highly respected by colleagues and beloved by his students, all of whom he knew individually by name. After he died suddenly in 2004 at Lao Cai he was given a state funeral and thousands paid their respects in the streets of Ha Noi.

    A meeting was held in Ha Noi in November 1998 between Professor Ton That Bach and Professors Kerry Goulston, Professor Bruce Robinson and Associate Professor Phillip Yuile from Sydney University. The purpose of the meeting was to formalize ties between the two institutions and to begin planning future activities. At an inter-country level this process was facilitated by the Australian Ambassador to Vietnam at the time, Mr Michael Mann. A warm relationship quickly developed with Professor Ton That Bach who stressed that he foresaw a continuing association centred on young doctors and nurses between the two Universities. He said that, although traditionally there had been medical linkages with France, he would like to see new links develop with Australia.

    Subsequently, in December 1998, an exchange program commenced with five students from the Sydney University Northern Clinical School spending an elective term in Ha Noi. Sponsorships were provided by the Sydney University Northern Clinical School, Ramsay Health Care, the Australian Returned Services League and private individuals.   In February 1999 the exchange relationship between the two countries commenced with Vietnamese doctors visiting Sydney hospitals under the auspices of the Sydney University Faculty of Medicine .

    In December 2001, Professor Ton That Bach, his wife Dr Nguyen Thi Nga, Head of the Blood Transfusion Service in Ha Noi and Dr Dang Van Duong visited the Northern Clinical School and the University of Sydney where Professor Ton That Bach was made an Honorary Fellow of the Faculty of Medicine and met with many academics and clinicians and signed a Memorandum of Understanding between the two Universities.

    Also in 2001, Hoc Mai, The Australia Vietnam Medical Foundation was established as a non-profit Foundation of the University of Sydney with Professor Marie Bashir, Governor of New South Wales, as Patron. The name “Hoc Mai”, meaning “forever learning”, was proposed by three young Vietnamese doctors, Trinh Binh Giang, Nguyen Van Bay and Ha Phan Hai An.

    Since 2001, over 300 Vietnamese doctors and students have spent time in Australia under the sponsorship of Hoc Mai. These have included postgraduate degree students, participants in short formal courses and doctors on short clinical placements.  In turn, over 200 Sydney University medical students have carried out their Elective Term in Vietnam under the supervision of Professor Dang Van Duong. There have also been numerous visits by individuals and teams of Sydney University academic clinicians who have lectured and taught short courses on a wide variety of topics in Ha Noi and at other centres in Vietnam.

    Further Memoranda of Understanding between Ha Noi Medical University and Sydney Medical School have been signed by Professor Nguyen Lan Viet as Rector of Ha Noi Medical University in 2005 and by Professor Nguyen Duc Hinh who was appointed Rector of Ha Noi Medical University in 2008. Professor Nguyen Duc Hinh has visited Sydney a number of times and has been made an Adjunct Professor of the University of Sydney.   He has cemented the longstanding close relationship between the two universities.

     Medical English

    In 2007 the first of many short courses in medical English was held at Bach Mai Hospital in Ha Noi. The aim of these free courses is to give Vietnamese healthcare workers who have basic English language competence the opportunity to hear conversational English spoken in a medical context and to assist them in speaking English. These interactive small group courses are intended to help with grammar, pronunciation, syntax, expression and medical vocabulary. Since 2007 many hundreds of Vietnamese doctors, nurses and other health care professionals have participated in these courses which have been held at several hospitals in Ha Noi. In 2011 this English language program was extended to include nursing students in the Ha Noi Medical University Advanced Nursing Program. These courses are held over four days in February and in September and are taught by Australian volunteer doctors, nurses and others who travel to and stay in Ha Noi at their own expense.

    New methods of medical teaching

    A one-day workshop was held  at Ha Noi Medical University in December 2009, attended by the Rector of Ha Noi Medical University, senior academic staff, clinicians and educators with the aim of determining educational priorities to which Hoc Mai could contribute. Four areas were identified: (a) teaching medicine and medical skills in English (b) defining learning objectives (c) introducing new teaching methods (d) introducing new methods of assessment. Subsequently, visits by Sydney Medical School academics helped to introduce new methods of assessment such as Scorpio and Mini-Cex for students and young doctors at Ha Noi Medical University and Ha Noi Hospitals.

    Advanced Course in medical teaching and research for talented Ha Noi Medical University graduates

    This course, which is conducted in English, is intended to provide a select group of outstanding recent Ha Noi Medical University graduates with ideas and tools to enable them to introduce and lead change in medicine and health care in Vietnam in the future. The course, which has been held yearly since 2010, was originally funded by Atlantic Philanthropy but in the past five years has been supported by competitive grants from AusAid and the Australian Department of Foreign Affairs and Trade and through the generosity of several private individuals.

    The course  has three components: (a) periodic four-day visits to Ha Noi Medical University by small teams of Australian clinical academics from a wide variety of specialties  (b) on-line interactive tutorials held approximately every 3 weeks (c) a four-week visit to Sydney involving two weeks of intensive tutorials and a two-week  clinical placement in Sydney hospitals.

    Each year, around 60 potential participants are chosen by Professor Nguyen Duc  Hinh, Associate Professor Ha Phan Hai An and Associate Professor Van Dang Duong on the basis of their academic record. All are then interviewed in Ha Noi by Australian Hoc Mai members using a structured interview to assess their ability to understand and speak English. Applicant’s curricula vitae and referees’ reports are also taken into account. Through this process around 20-25 are selected to attend the four-week immersion course in Sydney.

    The curriculum of the entire Advanced Course covers topics which are essential for future health care in Vietnam but which are not widely taught at present. These include but are not limited to: evidence-based medicine, communication skills, patient management plans, assessing clinical skills, effective clinical handover, medical ethics, professionalism, disability , leadership management, clinical errors and patient safety, child protection, pain management, hospital infections and hygiene, smoking cessation, health workforce, research methods, medical statistics, using the internet for clinical purposes, presentation skills, publishing a research paper and preparing a curriculum vitae.  Individual course components and the program as a whole are evaluated anonymously by the participants and reported to the teachers. At the end of the course, depending on the availability of funding, a number of participants are selected for an intensive four-week program of further teaching and supervised placements at Sydney Medical School and associated hospitals in Sydney. In addition to this program, Professor Owen Dent has conducted three day-long workshops on the use of the SPSS statistical computing package in clinical research and in February 2016 year a workshop on hospital management and leadership was held in conjunction with the February session of the Advanced Course in Medical Teaching and Research and the Medical English program. This was organised by Professor Huong and was attended by 140 participants.

    Kerry Goulston is Emeritus Professor of Medicine, University of Sydney.

  • Renee Bittoun. Postcard from Hanoi. Smoking in Vietnam

    Unlike Australia today where the prevalence of smoking is about 15%, Vietnam remains a country where smoking is widespread. About 60% of the men smoke and about 5% of women. The burden of diseases related to smoking is therefore extremely high. On visiting a Hanoi hospital respiratory ward last week, most of the 100s of inpatients were patients with acute exacerbations of COPD (Chronic Obstructive Pulmonary Disease), and visiting the cancer hospital also showed that most of the cancers were also smoking related. There are efforts to reduce uptake of smoking however there is little supporting funding.

    Vietnam_SmokingMy role in the short week of visiting these sites was to teach the staff about smoking cessation. The medical and allied health staff were very keen and eager to learn about our approaches. However there was a great deal more to address. Cigarettes are very very cheap and readily available. The tobacco industry is local and tobacco is grown in Vietnam, with probable conflicts of interest for the government. The math has been done however that shows the enormous loss in health costs versus the gain in income.

    There are particular goals that might make a difference relatively quickly. Increasing the cost of tobacco and hypothecating the income to smoking related tobacco control and treatment services is known to have a significant effect on prevalence. Improving the awareness of health workers of the huge financial and health burden that smoking has on the well-being of the population would commence a trickle-down effect to the community. This along with a multifaceted intensive and prolonged anti-smoking media campaign would be very cost beneficial.

    There are things, however, we may learn from the prevalence of smoking in Vietnam. Most intriguingly it would be helpful to understand why so few women and girls smoke. It is highly inappropriate for Vietnamese women to smoke. A study of the cultural and environmental influences may show results that might be translated to other nation’s groups in order to reduce the prevalence of smoking elsewhere, and not just in women and girls.

    Renee Bittoun is Adjunct Associate Professor, Clinical School, Smoking Research Unit, Faculty of Medicine, Brain and Mind Centre, Sydney Medical School, University of Sydney.

  • Stephen Duckett. Blood money: pathology cuts can reduce spending without compromising health

    The Mid-Year Economic and Fiscal Outlook (MYEFO) set the cat among the pathology pigeons late last year. One of the government’s flagged changes, estimated to save around A$100 million a year, was to abolish the bulk-billing incentive Labor introduced in 2009.

    The industry mobilised, threatening to charge consumers significant out-of-pocket co-payments for pathology tests for blood, tissue and other bodily fluids. The threatened increases were well in excess of the A$1.40 to A$3.40 cut to the bulk-billing incentive, which companies received for not charging patients out-of-pocket charges.

    A campaign was organised, focusing on the increased cost of pap smears. It included apetition supported by more than 200,000 people.

    Health Minister Sussan Ley escalated her rhetoric, pointing out that Medicare was notdesigned to be a guaranteed bankable revenue for corporations, nor a taxpayer-funded payment to cross-subsidise pathology companies for other costs of doing business.

    The minister noted:

    … complaints from stock exchange-listed pathology companies about this MYEFO decision have revolved around impacts on ‘shareholders’ – not patients – exposing what is really motivating these criticisms.

    The MYEFO-induced furore about bulk billing provides context for a wider “root and branch” review of pathology payments. As the Grattan Institute’s report, Blood Money, published today, shows, there is money to be saved in pathology. This can be done in ways that don’t affect patient access to needed tests.

    Industry profit

    The Blood Money report addresses several questions. First, why is bulk billing on the agenda for pathology tests at all? All out-of-hospital pathology tests should be bulk-billed.

    There should be no “incentive” for pathology corporations to bulk-bill. Rather, bulk-billing should be a requirement to participate in this market.

    The place of co-payments in health care is highly contested. Those who argue for co-payments say they help to reduce demand, particularly for frivolous use of health care.

    But consumers almost never initiate pathology services. Professionals order tests to assist them to make a diagnosis or to track a patient’s condition. In those circumstances, there is no theoretical argument to use financial disincentives for consumers, in the form of co-payments, to limit demand.

    Industry consolidation and technological advances have completely reshaped the pathology industry over recent decades. But the way governments pay for pathology services hasn’t kept up.

    Fee-for-service was originally a way for individual consumers to pay their medical practitioner for professional services. Health insurance then evolved to provide insurance for those costs. Medicare, when it was introduced, followed the same model.

    But what was suitable for cottage-industry medical practice is not necessarily appropriate as a payment system for big corporations. More than three in every four Medicare-billed pathology tests are analysed by one of two big corporations: Sonic Healthcare and Primary Health Care. Both companies suffered a share price drop when the MYEFO cuts were announced.

    Many parts of the pathology schedule are now highly automated. The large corporations benefit from economies of scale as the costs of an additional test to run through an analyser are trivial. But Medicare pays the same for the tests processed by the machine for the thousandth patient as it does for the first.

    Same service, lower costs

    A 2011 discussion paper on pathology funding proposed that Medicare negotiate with providers to share the benefits of technological change by discounting the schedule for high volumes by, say, 5%. The Commonwealth Department of Health should dust off this paper and use it as a basis for proper commercial negotiations with the big pathology corporations.

    The bulk-billing incentives should be in the mix as well. Serious negotiations of that kind would save taxpayers about A$175 million per year; A$100 million from bulk-billing incentives, the balance from a 5% trim.

    The government should also consider going to tender for the right to bill Medicare for out-of-hospital pathology. In other words, companies would bid to be involved in the out-of-hospital pathology market by offering to provide tests at particular prices.

    The tender specification might incorporate provisions that the price to be paid by government goes down after a particular number of tests is performed.

    A pilot scheme of tendering should be established in Victoria for 2017, with the scheme allowing for multiple successful winning bids to ensure continued competition in the pathology marketplace. Tenders could be rolled out in other states after an evaluation of the Victorian experience.

    Tendering should generate greater savings than the 5% trim.

    Tendering introduces price competition into the pathology market. Rather than companies responding to a government-regulated price, they would have to specify the prices at which they think they can operate. If a company bids at too high a price, they may not be among the group of successful tenderers.

    The 2011 pathology discussion paper notes strong savings from other departments tendering pathology services:

    • Victoria has tendered out most of its regional
      public pathology services for more than 20 years. Negotiated prices are 65-75% of Medicare fees, equating to a 10-20% saving.
    • Defence tendered pathology services for military personnel. It settled at 80% of Medicare fees, without patient initiation fees. This was equivalent to a 5% discount.

    Neither paid the equivalent of a bulk-billing incentive. Further savings, on top of a negotiated trim, could therefore be achievable.

    There are savings to be made in pathology payments and they should come from narrowing the margins of profitable corporations, not from cutting services to the ill and vulnerable.

    In a time of increasing deficits, the government must prioritise reforms that reduce spending without compromising the health of Australians. Pathology payment reform provides an opportunity to do this – an opportunity that should not be missed.The Conversation

    Stephen Duckett is Director of the Grattan Institute‘s Health Program. 

    This article was originally published on The Conversation. Read the original article.

  • Which country has the world’s best healthcare system?

    On 9 February, the Guardian published a report on health systems around the world. It drew particularly on analysis of ratings by the Commonwealth Fund and its correspondents around the world. The UK’s national health service was ranked number one in the world. Australia was ranked number four.

    For Guardian article, see link below:

    http://gu.com/p/4f6vb/sbl

  • John Menadue. Making the Federation work better.

    The Abbott Government decided that over the next decade commencing in 2017 the Commonwealth Government would reduce grants to the states for education and health by $80 b. This is likely to produce a major and concerted campaign by the states to protect their hospitals and schools. It does provide an opportunity for more effective cooperation between the Commonwealth and the States in the health sector. I have reproduced below an article on this subject which was posted in May last year as part of the policy series co-edited with Michael Keating. I argue for the establishment of a joint Commonwealth State Health Commission in any state that will cooperate. In addition to this state by state approach, it might also be possible to build cooperation on a region by region basis. I do not think that a major change in constitutional arrangements is possible or that the Commonwealth will concede completely to the States or vice versa. But I believe that a pragmatic and step-by-step approach could be successful.  See repost of article below.

    Repost

    State governments spend about 25% of their budgets on health and another 25% on education. A cooperative arrangement between the commonwealth and state governments in one of these areas would greatly improve the operation of our federation. This article will focus on possible cooperation in health.

    A State handover of health services to the Commonwealth, as suggested by Tony Abbott many years ago, would be one way to overcome the waste and buck-passing between the Commonwealth and State governments in health. Kevin Rudd suggested that his government might take over state hospitals. Opinion polls suggested that the public would support this approach. But Kevin Rudd backed away. In passing it should be noted that the Commonwealth has no recent experience in running hospitals. It is not an easy task.

    But as a Commonwealth takeover is most unlikely, an alternative would be to establish a Joint Commonwealth/State Health Commission (Joint Health Commission) in any State where the Commonwealth and a State government can agree – a coalition of the willing, a Commonwealth/state partnership on a state by state basis.

    It is envisaged that the joint commission, with shared Commonwealth/State governance would be responsible for funding, planning and integrating all health services in that State. Consistent with an agreed plan, the Commission would then buy health services from existing providers – Commonwealth, State, local, NGO and private.

    A political agreement between the Commonwealth and any State is essential. If this political agreement is achieved, we would see a more cohesive and integrated health service, delivered much more efficiently. Once the benefit was clear in one State, hopefully other States would follow.

    I believe that this proposal would have strong public support. We are tired of the blame game.

    Either the Commonwealth government or any State government could initiate the breaking of the impasse.

    Background

    The Commonwealth Government provides about 43% of national health funding and the State Governments and territories 26 %. Another 31% of funding is from non-government sources (mainly individual users of health services).

    In both the NSW and SA health reviews that I chaired some years ago, a view was widely expressed that it’s all very well for State governments to review their health systems, but a major problem is the inefficiency, fragmentation, gaps, cost and blame shifting which results from the different roles of the Commonwealth and State governments in health’. This view was expressed, not only by those working in the health system, but also by the community generally. It was also frequently expressed by the media. The problem of divided responsibilities is well understood. The public doesn’t really give a hoot who plans and delivers health services. The public’s real concern is that the services are provided efficiently and equitably.

    Integration of commonwealth and state health functions are essential. Professor John Dwyer, in this blog, estimated   that more than 600,000 state hospital admissions per year could be saved if there was more timely community intervention which is funded by the Commonwealth.

    A solution requires a political agreement between the Commonwealth government and at least one State. The political issue cannot be avoided and attempts to get around this issue are likely to be unsuccessful, time-consuming and cumbersome. A bureaucratic or organisational response to a political problem will be unsatisfactory. The issue must be addressed politically. If there is political agreement, governance, financial, administrative and other issues could be successfully managed.

    Such an approach would not produce a unified national health system, but six (excluding the territories for the moment) joint health systems which are State-based. Nonetheless, this would be superior to the present division and fragmentation. The six State-based joint commissions may also better reflect the different history and needs of respective States. One size doesn’t necessarily fit all.

    The states may also be now more interested in what is proposed here because the 2014 budget suggests that over the next 10 years the Commonwealth will contribute $ 50 b less to state hospitals than the outgoing Labor government proposed. There was no certainty that this 10 year funding would have remained in place but I don’t think there is any doubt however that the Abbott government will attempt to shift more responsibility to the states for hospitals and schools.

    A Joint Health Commission in any State where the Commonwealth and the State could agree would have the following characteristics.

    1. Coverage of Joint Health Commission

    The wider the coverage the better to ensure real and comprehensive resource allocation and integration of services across the full continuum of care. The following programs should be included as the planning responsibility of the Joint Health Commission.

    • State Health (including Health Care Agreement)
    • High level residential aged care
    • Department of Veterans’ Affairs (DVA)
    • Home and Community Care (HACC)
    • Commonwealth Regional Health Services in rural and remote areas.
    • Medical Benefits Scheme (MBS)
    • Pharmaceutical Benefit Scheme (PBS)
    • Aboriginal Health
    • Local Government health
    • NGOs (e.g. nursing services)
    • Public health

    State Health, HACC, etc. would tender for the provision of services to the Joint Health Commission. Similarly, local government and NGOs would tender, although allocations to them would probably need to be made through the State Health department.

    Private hospitals could probably be excluded from this coverage, as they depend on private contributions rather than direct government funding – except for occasional seed money. But provision should be made for private hospitals, along with local government and NGOs, to tender for supply of services to a Joint Health Commission, (see 3 below). The private delivery of health services should be encouraged where it is consistent with the state-wide plan and is delivered efficiently.

    Importantly, existing providers would continue to operate and provide services, and where appropriate, ministers – both Commonwealth and State – would continue to be responsible for their own services. But those services would be purchased by the Joint Health Commission as part of a state-wide plan, which I refer to under ‘functions’ below.

    2. Pooled Funding of Joint Health Commission

    The Joint Health Commission would receive a negotiated pooled allocation of funds from the Commonwealth and the State government. which reflected the coverage of programs for which it would be responsible (see 1 above), with appropriate population growth and cost indexation add-ons. As a starting point the shares of the two governments would reflect their current funding shares. Changes in the shares and total funding would be subject to the advice of the National Health Performance Authority (NHPA). That Authority would provide public advice to the two governments. The two governments would need to agree on annual funding arrangements.

    Whilst confidence in the funding formula is developed, it might be useful to consider shadow funding in the first 3 years and move to actual pooling of funds thereafter.

    3. Functions of Joint Health Commission

    1. a) Shared Resource Allocation through the purchase of various services from providers – Commonwealth, State and local government, and NGOs as part of a joint strategic plan.
    • In this case, shared resource allocation can be achieved through the establishment of a minimum set of Commonwealth and State programs.
    • The major changes associated with the JHC would provide an opportunity to move from producer dominated health care delivery to an output/patient focussed delivery system. So many of our health programs reflect provider interests; the MBS reflecting the interests of doctors and the AMA, the MBS reflecting the interests of the Pharmacy Guild and Big Pharma and public hospitals reflecting the interests of their providers, state governments. Patients are a secondary concern. We need to shift to a patient focussed health system in such key areas as chronic, acute and occasional care.
    • Funding would be allocated with agreed short and long term integrated outcomes, rather than siloed program outcomes, with specified standards and levels of performance.
    1. b) Shared Performance Management

    Oversee continuous improvement of the health system, monitor progress and establish reform targets and timelines:

    • Development of standard measurement
    • Benchmarking
    • Patient-centred best practices

    The NHPA provides an excellent opportunity for the establishment of a system that can meet the needs of consumers, community and health services. The NHPA can provide an approach that examines health status and outcomes, determinants of health, and health system performance.

    The NHPA should facilitate the mapping of progress for the population of a State, region or service. It could also be used to examine progress in tackling a particular health problem (e.g. aboriginal health), and to take a wider look at the interface between health and other government departments, the private sector and non-government organisations.

    4. Joint Health Commission Governance

    The following features could be included, and would ensure full Commonwealth and State government input into the state-wide plan:

    • Membership of the board should be high level to enable strategic decision-making on broad and longer-term issues.
    • Maximum transparency and disclosure of the Joint Commission’s work and final recommendations in order to neutralise special pleading and vested interests and to ensure public understanding and support.
    • The board of directors must have clear ‘governance’ responsibility and not a junior role. They should reflect the broad interests of the whole community and not be seen as representative of the Commonwealth or State or ‘insider interests’ that so dominate health systems in Australia.
    • Independent chair appointed by the two Ministers from a short list provided by the respective Commonwealth and State Health CEOs. It might be useful to have the chair from another State.
    • Apart from the chair, no jurisdiction to have more than 50% representation.
    • Representation could include other Commonwealth and State jurisdictions (e.g. Indigenous Affaires) and people having experience in the private sector.
    • The board would appoint the CEO who would be responsible to the board and not the two jurisdictions.
    • The board would approve the strategic plan and budget.
    • A constitution may be useful to provide more user-friendly objects, role, function and operating procedures, including engaging the private sector.
    • Subsidiarity should be an important principle for governors in developing the state-wide plan. Management and service delivery should be driven down to the lowest and most local level possible, consistent with state and nation-wide standards.
    • The Board should have a small secretariat, but rely on Joint Health Commission for planning etc. It must avoid a new level of bureaucracy.
    • Board costs would be shared by Commonwealth and State.
    • The Commonwealth and State minister would be responsible for negotiating high-level policy principles, including overall funding on the advice of the board. This would help reduce the risk of the board dividing on Commonwealth/State lines. Ministers must reach broad agreement if the Joint Health Commission is to work.
    • The board should be responsible to the Commonwealth and State minister, with one financial report to both. If there is not agreement between the two ministers, there would be a public dispute resolution procedure which would encourage cooperation and dialogue between the two ministers. This would encourage public trust in the integrity of the process. I would expect that this would produce an agreement in almost all cases. If resolution is not possible, the Commonwealth minister would prevail; given the need for a stronger national role and that the Commonwealth Government provides 43 % of national health funds compared with 26 % by the states.

    These governance arrangements could be reviewed in 5 years.

    Summary   

    A Joint Health Commission established upon agreement of any State with the Commonwealth would be a substantial improvement on the present arrangements. It would help break the impasse on federalism and better integrate health services. It requires a political decision between the Prime Minister and premier.

    The public is tired of the blame shifting and fragmentation in health and would respond to a sea change such as this. Such a joint health commission in any State that agreed would help achieve what both of them are seeking in health – a better integrated health system and a favourable community response, A committed Commonwealth government could use its financial leverage to make such an offer attractive to the states.

    A Joint Health Commission in any one State could begin to address the ‘big ticket’ problems in health delivery – the Commonwealth/State fragmentation, an eroding primary health care system, an antiquated workforce structure and obvious system failures in safety and quality.

    Of course, the fragmentation in health is not just caused by Commonwealth-State fragmentation. The two big Commonwealth programs – MBS and PBS – are not effectively integrated.

    All these big-ticket issues are lost sight of in the argy-bargy of Commonwealth/State blame and cost shifting.

    Not only would a Joint Health Commission in one State be a substantial improvement, it would also be very symbolic, demonstrating that governments can address hard political issues in a cooperative way.

    We must stop asking continually for more money or tweaking the health dollars, when many problems are structural. A lot of health spending is counter-productive – throwing money at problems to get them out of the media or for short-term political gain, rather than solving systemic problems. Any increase in health dollars must be accompanied by system change. A Joint Health Commission starting in one State is a sound way to begin breaking the impasse.

    The key is political will by ministers. If there is the political will, the governance problems can be resolved.

    There is no reason that the principles proposed above in health could not be applied in other fields such as education.

    John Menadue AO was formerly Secretary Department of Prime Minister and Cabinet, Secretary Department of Trade, Ambassador to Japan and CEO of Qantas.

  • Alex Wodak. Endgame in the protracted drug policy debate: are we there yet?

    The long running debate about illicit drugs policy has moved a great deal in the last five years. But social policy reform is a different matter from a debate. Actual reform usually takes many decades.

    The recent growing consensus regarding the abject failure of a criminal justice dominated approach to drugs is very encouraging. Retired and even serving police commissioners have been lining up before the microphones to acknowledge the comprehensive failure of efforts to date. The seizure announced 16 February of 720 litres liquid methamphetamine, said to be worth $1.2 billion, represents the largest drug bust in Australia’s history. But there was little optimism that even a seizure of this size would make a difference to the market. In 2014, 91% of Australian drug users surveyed reported that ice was ‘easy’ or ‘very easy’ to obtain.

    In 1994, I went with Ms Ann Symonds, a (then) member of the NSW parliament, to see the (then) Minister for Health, Senator Graham Richardson. My message was that the drug policy he was responsible for could never be effective. I showed him a report written by a US coast guard operator who had estimated the numbers of pedestrians, cars, trucks, buses, containers, ships and planes entering the USA every year. The official had also estimated the volume of cannabis, heroin and cocaine entering the US every year. He showed that US authorities had a better chance of finding a needle in a haystack than finding most, let alone all, of the drugs entering his country.

    Seventeen million passengers and several million containers arrive in Australia every year. Only three in every 1,000 containers are searched. Containers carrying frozen food have to be thawed out before they can be searched and this involves potentially considerable financial loss and inconvenience as the once frozen food has to then be discarded. Somehow Australia’s 27 thousand km coast line has to be watched 24 hours a day, 365 days a year.

    Senator Richardson seemed to accept the logic of the presentation. As he showed us out, he suggested that Australia could not move faster than the international community would allow us to do, that the attitude of leaders of the medical profession to any change in drug policy would be critical and that change would also not be possible without widespread community support.

    Twenty-two years later, the shape of future global drug policy is becoming clearer. The international drug policy consensus is now irrevocably broken. Consequently, countries now have much more freedom to design a drug policy that the community and its politicians believe is appropriate for its circumstances rather than accept the one size fits all approach required till now.

    The threshold step required is to redefine drugs as primarily a health and social issue. Several steps then follow. First, criminal sanctions for the production, sale and use of drugs will have to be reduced and, where possible, eliminated. Second, drug treatment will have to be expanded and improved to reach the same level as other health services. Third, as much of the drug market as possible will have to be regulated. Parts of the drug market are already regulated including methadone treatment for heroin users, the needle and syringe program and Sydney’s Medically Supervised Injecting Centre. Fourth, the community will have to ensure that life for young people should not require intoxication to be bearable. This means reducing poverty and improving the housing, education and employment conditions for our young people, especially our disadvantaged youth. When life is bleak and without hope, a few hours of chemical vacation becomes quite attractive. Policy change should occur in small increments with rigorous evaluation of policy effectiveness and adverse effects.

    It is easy to dismiss the complexities of a political resolution of our current drug policy mess. But our politicians have at times achieved wonders. In the 1980s, politicians from all the major parties put aside their differences and worked together to prevent Australia being over run by HIV. Australian politicians also excelled themselves in tobacco control. These were world-class achievements against huge obstacles. Australians owe our politicians a debt of gratitude. The introduction of heroin-assisted treatment in Denmark was brought about by all the country’s political parties agreeing privately to jointly support the decision. The political gridlock of recent years in Australia is not encouraging but that will eventually pass.

    The costs of political action on drug policy are falling while the costs of inaction are rising. The time for ever-more gesture politics on drug policy is slowly coming to an end. When dealing with communities locked into dysfunctional policies, just as when dealing with alcohol or drug dependent patients or loved ones, it is critical to retain a sense of hope.

    It is important to remember our history. Australia permitted medicinal use of heroin until importation and production was banned in 1953. Edible opium was taxed and regulated in Australia until 1906. Medicinal cannabis was used lawfully in Australia until the 1970s. In the US, Coca Cola contained cocaine until 1903.

    The required changes in drug policy are substantial. But we and other countries have made equally substantial changes before. Faced with such momentous change it is easy to convince ourselves prospectively that the reforms required are unachievable but we may end up reflecting in retrospect that change was inevitable.

    In a recent Essential poll (16 February), 68% thought the ‘Federal Government should do more’ about illicit drugs followed by obesity (57%), food safety (50%), smoking (46%), Zika virus (36%), HIV (34%) and Ebola (27%).

    Respondents also rated illicit drugs (44%) as their most serious concern followed by food safety (26%), obesity (25%), smoking (23%), Zika virus (16%), HIV (14%) and Ebola (12%). This suggests that voters expect Australian governments to act effectively on illicit drugs sooner rather than later.

    Dr Alex Wodak AM is President of the Australian Drug Law Reform Foundation

     

  • Peter Gibilisco. Neoliberalism and its Perceptions

    Politics has changed so much over the years; our political climate is unstable, since 2007 we have had five different prime ministers. A person in my position would ask how does this affect people with severe physical disabilities?

    Neoliberalism has its aim to put into question all collective structures capable of obstructing the logic of the pure market. Such a belief allows one to question the ideology behind the welfare state, progressive taxation and other social policies that can lead to an egalitarian society. Their ideology harvests the sentiment that many welfare recipients are lazy and should do more to help grow the economy. But rather neoliberals are persistently oriented towards supporting a society in which self interest prevails and that is why they give all their energy to policies that claim to further the individual pursuit of wealth. That is, the individual pursuits that are deemed worthy of government support are those that are beyond those living on the “other side” of the great divide between the rich and the poor.

    I am lucky enough to live in Australia but even with my poor eyesight I am still able to witness the degradation of impoverishment upon ordinary people whenever I visit my local community, Noble Park.

    Individual pursuits, whether of the rich or the poor are always, at least to some extent, justified in terms of one’s self-interest. And this goes a long way to explaining the powerful and dogmatic reasoning behind the powerful ideology as it is supported by those who are very rich. And that is confirmed by the equally dogmatic phrase: ‘power is money’.

    Liberal political and economic policies are dominated by this ideological viewpoint. Such policies have been integral to political economies all over the world, in both developed and developing countries. The re-birth of Liberalism as Neoliberalism was seen as the answer to the western world problem of stagflation, which reared its head in mid 1970s. Hugh Stretton put it well:

    Alternative strategies for dealing with the offending stagflation would advantage different classes, parties, industries. Economic reform was as usual a political task. Other interests saw opportunities to change the direction of development to improve the mixed economies’ efficiency by means which would incidentally make the rich richer, business freer, welfare cheaper and the poor more self reliant. Those means were described as de-regulating, privatising, restoring competition, cutting welfare, “rolling back the boundaries of government” (Stretton, 1986:7).

    Neoliberalism is a political economic theory and practice that has emerged with greater and greater appeal since the 1960s, and since the 1980s it has increased in prominence at the level of public policy formulation. The neoliberal approach rejects social democratic doctrines. Neoliberalism focuses politically on the establishment of a stable medium of exchange, the reduction of localised rules, regulations and barriers to free-ranging commerce, and the privatisation of state-run enterprises. This contemporary and dominant economic ideology of most western countries is referred to with a “neo-“ prefix because it is a latter-day version of the classical liberalism that initially arose in the 18th century. Moreover, neoliberalism claims to be a political system designed to highlight both the political limitations of the market economy in the nation-state, and the economic efficiency and effectiveness of the market economy when it is freed to operate on a global scale.

    Classical liberal economics was developed by Adam Smith, and we can sense its appeal at what we now say was the beginning of the industrial revolution. Smith argued that government intervention disrupted the natural order of society. According to Smith, the natural order of society can be defined as a society left to its own devices. Smith based his economic beliefs on the argument that most economic self-interest is altruistic. This can be noted in his famous quote from The Wealth of Nations:

    ‘It is not from the benevolence of the butcher, the brewer, or the baker, that we expect our dinner, but from their regard to their own interest. We address ourselves. Not to their humanity but to their self-love, and never talk to them of our own necessities but of their advantages.’

    Now, after thinking about this for some years, I come to the view that something like this principle is working itself out in my own relationship with what is now referred to as the “disability sector”.

    As it is commonly understood altruism is about selflessness, it is a principle or practice of concern for the welfare of others. But my situation seems to be endorsed by Smith in the above quote. In the social service delivery to which I am a recipient, involving a personal care attendant, the “altruistic effects” that actually work themselves out in the workplace becomes a friendship circle – workers and clients are mates. This workplace is actually our home in which the residents are actively welcoming the visitors to their “space”, under their private “roof”. It is not only those paid for their work in this workplace who have an interest, a general self-interest, in forming what takes place. After all it is also a place sustained by the friendships that are generated.

    According to Smith, this classical liberal system would provide for an economic infrastructure that could not only provide economic benefits, but also help promote a proud, virtuous and motivated society (Gibilisco). Amartya Sen portrays the mixed emotions of self-interest:

    ‘Can you direct me to the Railway Station?’ asks the stranger. ‘Certainly,’ says the local, pointing in the opposite direction to the post office, ‘and would you post this letter for me on your way?’ ‘Certainly,’ says the stranger, resolving to open it to see if it contains anything worth stealing (Sen, cited in Stretton and Orchard, 1994:51).

    During an interview with me, Hugh Stretton explained his dissent from this ideological interpretation of Adam Smith. He pointed out that Smith never said that the interests which prompted people’s economic decisions and behaviour were all selfish. Smith’s first book The Theory of Moral Sentiments was about our feelings, and concerns about other people’s needs, safety and happiness, as well as our own. When he said, in The Wealth of Nations, that he owed his breakfast to his baker’s self-interest, there is good reason to think that Smith meant the baker’s joy in his skills and work, and pride in the quality of his bread and the pleasure it could give his bread’s consumers, as well as the money it earned him.

    Smith certainly believed that people’s generous feelings, and concern for others’ safety and prosperity, as well as their own, could join in determining their market choices and their social and political values and behaviour. Because it comes from the neoliberal ‘bible’ (i.e. Smith’s The Wealth of Nations) I think this observation must play a vital part of any effective attack on the neoliberals’ assumption that material self-interest is the sufficient cause of market efficiency, which in turn, they then suggest, is a necessary condition – many even think of it as a sufficient condition – of a good society.

    Meritocracy

    Meritocracy is defined by government policies promoting the principles of merit. The actions pursued by advocates of meritocracy are fundamental to the belief that people get out of the system what they put into it based on what they deserve according to market based principles – i.e. what they produce and how what they produce performs in the market. It is a political vision for the future based on merit, and opposed to the traditionally conservative theories of the aristocracy. However, Michael Young a well-known writer on the subject has argued that “meritocracy is even worse than aristocracy because it attempts to acquire plus points because it connotes power and privilege as merited rather than born with”. He further argues that meritocracy is detrimental to those with disabilities. Young in his 1998 article titled: “Meritocracy revisited: assessing the social implications of meritocracy” puts it like this:

    … showing how sad, and fragile, a meritocratic society could be. If the rich and powerful were encouraged by the general culture to believe that they fully deserved all they had, how arrogant they could become, and, if they were convinced it was all for the common good, how ruthless in pursuing their own advantage.

    As a result, today we may have the worst of both worlds. Social reality, as portrayed by today’s media, tells us that the rich are getting richer, while the poor are getting poorer. In the case of people with disabilities, their capacities, under such a system, are rarely deemed meritorious or worthy of reward.

    Moreover, this brings into question, possible deplorable links between meritocracy and equal opportunity.

    However, we need to keep in mind that the concept of individual merit had been introduced as far back as Michael Young’s 1956 book The Rise of Meritocracy. In a more recent article, he has suggested that:

    [a] line of argument that is also made much of in the book is that a meritocracy can only exist in a full form if there is such a narrowing down of values that people can be put into rank order of their worth.

    This connects with a political insistence on the rise of a new form of meritocracy, which can also be prejudicial and ultimately discriminatory against those with socially defined lesser abilities or different abilities. Young argues that what one is born with, or without, is not of one’s own doing. To put it in a more crude form of discourse, being a member of the “lucky sperm club” confers no moral right to advantage. But such a view of “luck” does seem to align with the political-economic doctrines of some advocates of neoliberalism

    This article is dedicated to the memory of my friend and mentor, Hugh Stretton.

    I would like to thank Bruce Wearne and Christina Irugalbandara.

    I would like to promote this worthy new organisation http://www.uvpd.org.au/index.html

  • Jonathan Page. The Inspiration of Vietnam

    Postcard from Hanoi:

    I have been an oncologist for some 35 years, treating adults with advanced cancer. Despite a far greater understanding of the disease, with the discovery of quite remarkable “targeted” therapies, most patients still die of this disease. Many are not suitable for these treatments, many don’t respond or respond poorly and briefly, and of course many simply present very late in the course of the cancer.

    As an oncologist I am thus confronted by uncertainty, sadness, despair and grief on a regular basis, as are all the members of the oncology team, but at times leavened by the joy of success, the gratitude of families and the deep insights into the human “soul”.

    Through my own adult life I have had a mixed relationship with death, particularly my own, beginning with a simple non-acknowledgment, then noticing an increasingly intrusive terror, with quite visceral reactions to certain patients as they moved towards their own demise under my care. I was in my forties at that time and would experience profuse sweating, tremors, nausea and a curious clouding of consciousness. I thought I may have malaria (a noble affliction) but to whom should I go for wise counsel? There was little wisdom to be found. Over time my symptoms evolved into a depression, but this only became clear to me years later, in retrospect.

    Technically I had been suffering “thanatophobia”, that is “fear of death”. A common complaint, but rarely considered (in our society) since we prefer a “cultural denial”. Thus, more recently, over 15 years or so I have pursued a deeper understanding of death, my own and that of others. This universal phenomenon unites us all. As John Donne reminds us: “any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls: it tolls for thee”.

    I have learnt much from Joan Halifax who wrote “Being with Dying: Cultivating Compassion and Fearlessness in the Presence of Death” and the late Stephen Levine who wrote both “Who Dies? An Investigation into Conscious Living and Conscious Dying” and also “A Year to Live: How to Live this Year as if it were your Last”. I have completed a one year course based on this latter book.

    Death has now become less fearsome to me and more interesting! As Buddhism has told us for 2,600 years, a regular meditation on one’s own death will invigorate one’s life and shed some light on the true nature of the world and the meaning of our own experience.

    The complete practice of oncology requires some exploration of one’s own mortality, to more deeply understand the experience of each patient, to be of service and, importantly, to learn. There is a long history in most cultures of a specific “companion to the dying”. Medical practitioners including oncologists are ideally placed to occupy this role.

    Over the years I have been greatly supported by a mindfulness practice including regular meditation. Again, this cultivation of mindfulness, bringing one’s mind into the present moment with awareness and “heartfulness”, is an ancient Buddhist practice, taught also in other spiritual traditions and in more modern secular environments. This practice enables a deeper understanding of one’s inner emotional life, allowing one to be more “available” for patients, rather than locked within a defensive carapace. The risk of “burnout” and depression is far less.

    Strangely (or perhaps not) these skills have never been a substantial part of medical education or the oncology specialty, with some notable exceptions such as the programme at Monash University in Melbourne and the long-running “The Healer’s Art” course developed by Dr Rachel Naomi Remen at University of California, San Francisco School of Medicine.

    What about Vietnam?

    I have had the privilege of visiting this astonishing country many times, firstly as a medical student in 1974, then more recently with colleagues, supported by the Hoc Mai Foundation, travelling to Hanoi to teach Medical English, oncology and other specialty topics. However, at a deeper level, I (and I suspect my colleagues also) travel to Vietnam to learn from this resilient, gracious and warm-hearted people. I feel there is a spiritual nature to the Vietnamese society, reflecting elements of Buddhism, Confucianism and Taoism.

    It is helpful to leave one’s ‘ego” or one’s “sense of an important self” at home and thereby immerse oneself in this enriching and restorative culture. The Vietnamese (to my eye) seem to embody a friendly mindfulness, a universal respect, remarkable patience and lack the reactivity so often seen in more “Western” cultures.

    I am looking forward to a further visit to Hanoi, to renew friendships and, importantly, to imbibe the pervasive spiritual vitality in that city that now has a direct positive impact on my work.

     

    Jonathan Page, Medical Oncologist, Manly and The Mater Hospitals, Sydney, NSW.

  • John Menadue. Postcards from Hanoi.

    I will be in Hanoi from February 17-26, attending a Hoc Mai Foundation workshop on learning from each other about health issues in Vietnam and Australia, and assisting in the learning of English in the health field. Hoc Mai means ‘forever learning’.

    The foundation was established in the late 1990s. University of Sydney was a very active partner.  Over 30 groups of Australian clinicians and others interested in Vietnam have travelled to Vietnam since the late 1990s. 29 Australians will be in our group in Hanoi.

    Emeritus Professor Kerry Goulston will be leading our group. He has made almost 30 visits to Vietnam as part of the Hoc Mai Foundation.

    During this February visit, a few of us will be sending ‘postcards’ from Hanoi. The first postcard  from Jonathan Page, a medical oncologist, follows.

  • John Menadue. Hoist with their own petard

    Private health insurance funds like NIB are complaining about high specialist fees. But these very same funds are major contributors to the problem. And it is a problem. In the last 30 years we have seen a dramatic increase in specialist fees.

    A major contributor to this increase in specialist fees is the ‘gap insurance’ that private health insurance firms offer. Gap insurance effectively underwrites specialist’s ability to increase fees and weakens Medicare’s ability to cap fees. In the AFR today, NIB gives two examples of how this is done. For prostatectomy (surgical removal of prostate) the Medicare Benefit Schedule Price is $1,939, but with gap insurance NIB offers to cover this up to $2,941. For knee replacements, the Medicare Benefit Schedule Price is $1,318, but with gap insurance NIB offers to cover this up to $2,014.

    But that is not the end of the story by any means.

    The growth of private health insurance makes it more difficult for Medicare to control fees. Instead of the Medicare Benefit Schedule Price capping fees, the Medicare price is just the first stepping stone to higher fees. Whilst NIB will pay up to $2,941 for a prostatectomy, compared with the $1,935 in the Medicare Benefit Schedule, the AMA has a recommended fee of $4,465. And on top of that AMA recommended price, NIB tells us that some surgeons are charging another $6,000. Yet we have a Royal Commission on Trade Union behaviour!

    NIB reveals the same pattern for knee reconstructions. The Medicare Benefit Schedule Price is $1,318 but that is ratcheted up to $2,014 through NIB gap insurance. And then it goes up to $3,960 to the AMA recommended fee. To top this off, NIB advises that some surgeons are charging between $4,500 and $5,500.

    There are many reasons why health costs are rising. Private health insurance companies like NIB and specialists are major contributors.

    The ‘market’ that economists talk about does not work in the health sector. Providers, doctors and hospitals, have the power to set prices as the above figures show.

    With the ‘market’ not working there are really only two ways for governments to avoid price and fee gouging. The first is through price control. That is largely the way that Japan keeps its healthcare costs down. But that approach is unlikely in Australia given our constitution and political situation.

    The second is to have a single public payer to counter the power of providers. That is generally what countries with successful health schemes do.

    Medicare was designed as a single payer. But its power has been diluted by the growth of private health insurance with gap insurance. We are steadily moving down the disastrous US path. And the Australian taxpayer is paying $11 b. p.a. to subsidise these destructive private health insurance funds.

    We should have no sympathy for NIB, BUPA and Medibank Pte about rising costs. They are major contributors to the problem. And they get bundles of money from taxpayers despite the damage they do.

  • John Menadue. Part 2. How we deliver healthcare is as important as the funding of healthcare. Medicare has degenerated into a payments system.

    In Part 1 I focussed on the importance of improving the delivery of health care and not just funding.

    In Part 2 I will focus on specific areas where costs should be reduced.

     

    Part 2

    Getting costs down

    • The government should abolish the subsidy for private health insurance which costs all up about $11 billion p.a. This welfare subsidy is one of the fastest growing areas of Commonwealth government health expenditure. We have never had high income welfare recipients on such a scale before .PHI is the Damocles sword hanging over our health system. PHI is the reason for the disastrous American health system. High levels of private health coverage in Australia are achieved not through the attractiveness of the products on offer but mainly through the carrot of the tax subsidy and through the stick of penalising the uninsured. The subsidy favours the wealthy, is inefficient, has underwritten rising specialist fees through gap insurance, has not taken the pressure off public hospitals and has weakened Medicare’s ability to control costs. PHI discriminates against country people where there are few private hospitals. The immediate abolition of this subsidy would do more to improve our health system than anything else. This is welfare big time- far more than the welfare we used to pay to the motor industry. The abolition of the $11 b. subsidy would more than fund a universal dental scheme. Alternatively, say $5 b. of the saving by abolishing the subsidy could be paid directly to private hospitals through an activity based funding arrangement. It is absurd that public funds should be churned through high cost private health insurance rather than being paid directly to hospitals. Before the Howard government, Commonwealth government funds were paid directly to private hospitals, but this was discontinued. Direct Commonwealth funding for both public and private hospitals would also substantially improve the integration of hospital care. But private hospitals would oppose this because they find it much easier to twist the arms of private health insurance companies. And some of the major hospital groups, particularly Ramsay, are generous donors to the Liberal Party.
    • We need a more productive workforce. Health is the largest and fastest growing sector in the Australian economy. Despite all the talk of improving productivity in Australia no-one has been game to take on the entrenched privileges in the health workforce.Where is the honesty and consistency here? The blue collar workforce is fair game but not doctors and lawyers. We need expanded roles across the board particularly for nurses, pharmacists, allied health workers and ambulance officers. The Productivity Commission in its February 2007 report estimated that a 5% improvement in the productivity of health services would deliver savings of about $3 billion p.a. This is a very conservative estimate. The health sector in Australia is rife with demarcations and restrictive work practices. eg 5 % of normal births in Australia are delivered by mid wives. In the Netherlands it is 70%, in the UK 50% and in NZ 95%. We have a few hundred nurse practitioners when there should be thousands. The work practices in most industries are light years ahead of the work practices in the health sector.
    • Fifteen years ago 45% of doctors were GP’s. It has fallen to about 35% yet we know that care is most equitably and efficiently delivered by GP’s. Specialists are reactive and we all know they have become very expensive thanks to gap insurance provided by private insurance companies.
    • We could save about $2 billion p.a. in drug costs if we paid drug suppliers the same prices that are paid in NZ. We also pay a high price for the protection of pharmacists through the 5000 limit on the number of community pharmacies and the restrictions on where new pharmacies can be located. Pharmacies cannot be established in supermarkets.
    • We need to raise productivity in our hospitals. The Productivity Commission suggests that the productivity gap in best practice in public hospitals ranges from 3% to 89%. In private hospitals the range is 22% to 37%. There are major governance problems in many hospitals with a dis- connect between management and clinical functions. Running hospitals is very difficult with clinicians coming and going from private practise like the cottage industries of old.
    • The Commonwealth/State fragmentation in healthcare results in blame-shifting, the evasion of responsibility and higher costs. If for example the Commonwealth Government or a joint Commonwealth/State body had responsibility for all health care funding in a state or region, there would be a clear incentive to focus on treatment in the community and in homes to ensure that the high cost hospitals are really a last resort. The National Health Performance Authority found that in 2013/14 over 600,000 hospital admissions for 22 conditions could have been avoided with timely interventions in the community, mainly by GP’s. But the problem in doing this is that the Commonwealth government funds general practice and state governments operate hospitals.
    • The real elephant in the room in health care cost reduction is avoidable mistakes, including deaths. They are euphemistically called “adverse events”. But Ministers, clinicians and managers do their best to avoid the issue. Based on earlier surveys in NSW and SA I estimated, very conservatively the cost of avoidable mistakes in our health sector at $5b pa (see my blog of June14, 2013). Despite a great deal of money and effort there is no sign of improvement. Insiders won’t solve the problem Good people are caught in a bad system.
    • Only last week, Medibank Private said that $800 m. p.a. could be saved if a reference pricing system with Australian and global benchmarks was introduced for prostheses such as for hip and knee replacements, plates and pacemakers. Medibank Private said that prices for identical products could be 45% lower in the public system compared with the private system. With differentials like that it is no surprise that private health insurance premiums have increased at three times the rate of inflation.

    The quality of our health care is generally good but waste and inefficiency is deep and widespread.

    We need to address waste and costs in a measured way. We should not panic, but we should get it done. Australian healthcare costs are 9-10% of GDP. This is not high by world standards. It is below the OECD average. A major reason why we have been able to do better than others is that we have Medicare as a public insurer. One lesson is clear all around the world. The countries that have high levels of private health insurance, like the US, have high costs.

    A fundamental problem in the health sector is the way we deliver healthcare. But we keep focusing only on funding. We have a horse and buggy health delivery system that is unfit for the 21st Century. Medicare takes that horse and buggy delivery system as a given.

    I have almost given up hope that the ALP will restore Medicare to what was intended, a single payer and a strong public insurer.

    The vested interests don’t want change in the way we deliver health care. They must be delighted to see how gutless the ALP is.

    More and more money will not necessarily improve the delivery of health care and neither should we expect it to. It will mainly entrench a lot of bad habits and the position of vested interests.

     

  • John Menadue. Privatising Medicare’s payments system and the erosion of Commonwealth Public Service capability.

    The government has apparently accepted the advice of the Commission of Audit that Medicare’s payments system should be reviewed with the possibility of privatisation. The payments system includes Medicare, the Pharmaceutical Benefits Scheme, Aged Care Services and Veterans’ Affairs.

    It sounds like another expression of neo liberalism, that only the private sector can be efficient and cost-effective.Let us see whether that is so through market testing. I remain sceptical.

    As a regular user of Medicare services and payments, I am not aware of problems in the payments system. But if there are problems, the government should fix them.’.

    This proposal on privatizing Medicare payments is part of the continuing trend to degrade government capability in both policy and administration of programs. The Australian Public Service is becoming short of senior people who understand the complex world of business strategy and those things required in commissioning the delivery of services or planning infrastructure investments and their delivery. In social policy it is not at all clear that the Commonwealth now has the people who understand the big systems that are so essential to a large part of what the public sector does.

    In between jobs, the new Secretary of PM & C put the problem this way in an interview with Laura Tingle in the AFR in May 2015. He said:

    ‘I think our institutions are being eroded in their capability and eroded in public trust. … Over time large parts of the public service have lost their policy development edge.’

    He has been replaced in Treasury by John Fraser, most recently a banker. Yet much of the governments’ deficits around the world have occurred as a result of governments having to bale out the banks for poor decisions and poor risk management.

    The problems that we apparently have with Medicare are common to many agencies. Good accounting in government has been abandoned and replaced with narrow financial metrics. Outside a few agencies, there just isn’t the capacity to do proper cost/benefit analysis. Many decisions are made on the run on the basis of cash outlays over four years.

    This failure of government administration suits private providers who exploit ministers’ and bureaucrats’ lack of analysis capacity and the domination of short-term cash outlays in the public presentation of the budget.

    It also suits neoliberals to get as much off the budget as possible even if the community is worse off. This is happening in the health sector. Some government expenditure is relieved by pushing business towards private health insurance, but we know that administrative costs of private health insurance are three times higher than Medicare. Furthermore we know that the growth of private health insurance makes it harder for Medicare to control fees. So whilst the budget may look a little better, the community is much worse off.

    We have had glaring examples of how government policy, capability and operations have been run down to the benefit of accounting and consulting firms who come and go with projects and their ‘economic models’, but there is little building of intellectual capital in the process.

    Staff numbers in the Australian Taxation Office have been cut back at a time when we have record tax avoidance and hundreds of our major companies paying no tax at all.

    I have rarely seen a root-and-branch criticism of a department as we saw with the Australian Public Service Commission Capability Review of the Department of Health and Ageing last year. The Secretary of the Health and Ageing at the time is now Secretary of Finance.

    The Department of Immigration and Border Protection has become securitized with a focus on border protection and control at the expense of nation-building and humanitarian programs. Senior and competent people with knowledge in nation-building and refugee programs have left the department. We see the result most graphically in the snail-pace response to settling 12,000 refugees from Syria. Less than 10 have arrived! Canada has put us to shame.

    The Attorney General’s Department failed to tell security agencies about the risk of Mann Haron Monis weeks before he entered the Lindt Café. The Attorney General’s Department has carriage of the policy and implementation of ‘meta data’ through the Data Retention Act. We were told at the time it was urgent because of the terrorist threat. But the policy cannot be introduced until the end of 2017at the earliest because of flawed implementation. AG’s department has just not been up to the job.

    One reason for the pink batts problem was the loss of  implementation capability in the Department of the Environment. That same department has bungled the approval of the Carmichael mine.

    The Department of Defence is subject to very little effective checking of its very expensive capital projects. It keeps making the same mistakes. As John Stanford put it in this blog on 11 December last year

    ‘Our defence acquisitions keep repeating the mistakes of the past, from mixing and matching systems inappropriately and accepting excessive risks, to allowing political judgements to override efficiency considerations and the proper regard for the public purse. In the new submarine acquisition, we seem to have learned nothing from the Collins Class procurement’.

    When the new submarines are delivered China and India will have nuclear submarines.

    The Department of Defence has a one-line budget appropriation which effectively denies rigorous examination of mega-dollar projects by the Department of Finance and others.

    The sorry story continues with the mega funding of roads. As Mike Keating and Lucas Fraser pointed out in the policy series in last year’s blog

    ‘A reasonable projection of planned road expenditures indicates that the accumulated stock of debt to FY 2023-24 could be of the order of $114 b. When added to the already accumulated debt, this amounts to a total accumulated road-derived public sector debt of $140 b. within a decade, a matter than until now has been entirely unreported’. Where is the Department of Transport or Infrastructure Australia when we have such gigantic and wasteful expenditures on roads”?

    There is a dismal and concerning story about how the capital of government is being deliberately eroded.

    We are paying a very heavy price for neoliberalism and the down-sizing of government that goes with it. The selling of Medicare’s payments system may be another step along this path.

    The coinage of the Australian Public Service is being seriously devalued. Can the threads of good policy development and administration be recovered? It is getting late.

  • John Menadue. Part 1. How we deliver health care is as important as the funding of health care. Medicare has degenerated into a payments system

    Part 1 of these articles will focus on the inefficient way we deliver health care, the many perverse incentives and the power of vested interests to resist reform in health care delivery.

    Part 2 will focus more particularly on examples of waste and inefficiency in health care delivery

    Part 1

    We have been told many times that our health system is unsustainable.

    To justify its case for an increase in the GST, the government was telling us that an increase was necessary because of rising costs in health and education. Now the GST is apparently off the table as Malcolm Turnbull retreats on yet another issue.

    Some premiers and commentators suggested that an increase in the Medicare levy was best because it was fairer than an increase in the GST. And we will hear a lot more from the premiers about health because the Abbott Government said it would cut $ 80 b from grants to the states for education and health over the next decade commencing in 2017

    But what is being avoided in all this confusion about budget repair and health costs is that there is no real discussion about the waste, inefficiency and low productivity in our health sector. We continue to focus on the funding of our health sector, but refuse to debate how the delivery of care – its cost and safety – can be improved. Medicare is overwhelmingly discussed in terms of funding only. It should also be about how those funds are spent to improve the delivery of health services. Basically Medicare funds an existing system of health care delivery. That needs to change.

    There are three main reasons for our failure to address the delivery problems in health care.

    The first is the power of the vested interests. These vested interests fight doggedly and selfishly to maintain their privileged position in health delivery. The principle vested interests in health are the AMA, the Pharmacy Guild of Australia, Medicines Australia and the private health insurance sector. In an earlier blog I said that the Health Ministers may be in office, but they are seldom in power. The vested interests –the providers- are really in power.

    A second reason for the failure to focus on delivery of health services is that politicians are afraid of the vested interests – doctors, pharmacists, pharmaceutical manufacturers and suppliers, and the private health insurance sector.

    The third reason is the failure of economists and other commentators to consider efficiency in the delivery of health services. These economists talk continuously about the need for appropriate incentives, but in the health sector many of the incentives are quite perverse – such as fee for service.

    As Ross Gittins put it in a recent SMH article, ‘Like so many of the interest groups, econocrats are obsessed with funding education and health rather than ensuring both systems are working in ways that have found a good trade-off between fairness and efficiency, and effectiveness.’ … See link to article.

    These economists that we hear and see so often in the media are mainly employed by the banks. They have little or no knowledge or interest in health economics. They tie themselves in knots over the need for IR reform and improvements in productivity in the workforce generally. But over the years I have never heard any of them address the appalling work practices and demarcations in our health sector which really go back to the 19th Century. Yet our health and welfare sectors employ 13% of our workforce, the largest sector by far. It is also the fastest growing. At its worst, our waterfront never had the appalling work practices and demarcations that still persist across our whole health sector. Clinicians justify our archaic work practices on the grounds of safety when it is really territory they are defending.

    Economists are yet to grasp that health consumers have little power over prices or quality of care. Power is with the providers-doctors, pharmacists, drug distributors and private hospitals. That is why a strong public insurer is essential to counter the power of providers. If there is not a strong public insurer we will follow the disastrous path of the US that has the most expensive and unfair health system in the world. But our economists who say they believe in markets will not recognise the failure of the health ‘market’.

    On 4 Corners several months back, Norman Swann suggested that waste in health expenditures could be as high as 30% of our total health expenditures. I think that estimate may be on the high side, but it is clear that there are excessive costs. – see link to article ‘Four Corners: No wonder we’re wasting money in health care – we got the incentives wrong’ by Jennifer Doggett, Ian McAuley and John Menadue.

    In a paper in July 2007 I estimated that there was at least $10 billion in possible savings and productivity improvements in health. That represented about 10% of our total health costs in that year. I think it would be nearer 20 % or $ 30 b per annum. I have spoken and written extensively on this matter.

    The lack of accountability in health

    Despite the rapid increases in costs and escalating demand in the healthcare industry, there is no accountability in any meaningful way for what the health industry delivers. Doctors are accountable for malpractice but not for their overall performance particularly in general practise. Accountability is patchy in many private hospitals. Taxpayers have a legitimate reason to ask – ‘Are we getting value for money particularly when we pay 80 % of doctor’s incomes.’ In a survey several years ago by the Health Council of Canada, 97% of over 1,800 senior respondents said that healthcare providers should be required by law to reach certain service benchmarks in such areas as patient outcomes , the use of preventive strategies like screening and waiting times. There is the same lack of accountability in Australia.

    The Council also asked the group ‘Do you believe healthcare in Canada will improve if the government spends more money on healthcare?’ 58% said ‘no’.

    Managing the demand for health services

    The demand for health services is increasing rapidly across all age groups and not just among the old. We are over-diagnosed and over-treated. In 1984-85, medical services per head were 7.1 per annum. In 2007-08 they were 13.1 per annum – about double. The trend continues.

    • We must accept that we cannot have all that we want in health and that governments, in consultation with the community, have to set priorities. Can we afford continuing existing levels of funding for IVF and end-of-life treatments at the expense of funding for mental health and indigenous health?
    • We need to rationalise our co-payments to make them efficient and equitable. We all should take more responsibility for the way we use health services, particularly as we are now much wealthier than we were 30 years ago when Medicare was introduced. A universal health scheme does not have to be free. But it must be fair and efficient. But co-payments are a dog’s breakfast! We pay about 18% of health costs out of our own pockets, but there is very little rhyme or reason in how this is done.
    • The best way to curb the long-term growth in health spending is through prevention in such areas as alcohol, smoking, junk food and obesity. Our sporting, alcohol and junk food sectors are in a joint enterprise to promote poor health. But the first action of the Abbott Government in its first budget was to abolish the Australian National Preventive Health Agency which was focussing on lifestyle risk factors.
    • We need to change the perverse incentives, such as fee-for-service, which is associated with bulk-billing. Clinicians are rewarded by the number of transactions rather than health outcomes. It promotes what is called ‘turn style medicine’ FFS is particularly inappropriate for chronic care, mental health and services with high fixed costs and low variable costs, such as imaging. The government should move away from fee for service and set budgets for general practitioners when they prescribe drugs, order pathology tests or imaging services. We need more doctors on salaries and capitation payments for caring for patients-not on a service by service basis. Hopefully, the Medicare review will grasp this nettle.
    • We need to tackle the wide variations in the incidence of clinical practice across the country, e.g. caesarean sections and cataracts. In the Australian Atlas of Health Care Variations the Australian Commission on Safety and Quality in Health Care found ‘substantial variations in health care use in areas such as antibiotic prescribing, surgical, mental health and diagnostic services’ Medicare should be much more proactive in exposing and limiting very expensive and inexplicable variations in clinical practice. .It also needs to publish the enormous variations in doctors fees and particularly the fees of specialists. Better public data for greater transparency is essential.

     

     

     

  • John Thompson. Fiona Nash and private health insurance for rural Australians

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    A few nights ago on Q&A, the Minister for Rural Health, Fiona Nash, undertook to drop out of private health insurance while she was in office. Ms Nash lives in Crowther, a small town about midway between Wagga Wagga and Bathurst. Foregoing private health insurance makes a lot of sense for her because, like most rural and regional people, she pays a large amount to private insurers and has very limited access to private hospitals and related private services in her area.

    The map above shows why rural people are especially short changed with the private health system. The brown markers indicate public hospitals and the private hospitals are shown by purple markers. Crowther is almost in the middle of the map – 180 kms from Wagga Wagga and 141 kms from Bathurst.  There is one private hospital in Wagga Wagga and one in Bathurst, and neither has an emergency department. [On my count, there are about 30 public hospitals in this area. JM]

    The private health system is one of the most expensive Commonwealth Government programs.  In 2016/16 direct outlays by the Commonwealth Government will be $6.3 billion and income tax foregone will amount to $4.2 billion, a total of $10.5 billion for the year.

    Ms Nash, as a Nationals Party representative, should recognise that the private health system is particularly costly for her rural constituents because they are getting such a very raw deal. They are paying large sums directly to the private insurers and similarly large sums in taxation to support those insurers.  And they are getting very little in return.

    Rural Australians should ask themselves what they are getting for the large sums they are paying, both directly and through their taxes, to private insurance companies, and perhaps follow the lead of their elected representative, the Minister for Rural Health.

    John Thompson is an economist with an interest in health policy.

  • Michael Gracey AO. Grappling with the Indigenous health gap.

     

    By most recognised markers of socio-economic status, Indigenous Australians fare badly compared with their non-Indigenous counterparts. This is certainly the case where health standards are concerned. For example, rates of infections and hospitalisation for these and many other illnesses are much higher; chronic diseases like heart disease, stroke and diabetes are more prevalent; and hearing loss and blindness rates are increased as are a multitude of other disabilities. Illnesses and deaths linked to alcohol and drug abuse, and accidents and violence are more frequent, as are disorders associated with psychosocial stress. Death rates are increased across the life span and Indigenous people tend to die younger and have a life expectancy which is somewhere between 10 and 17 years shorter than that of other Australians. The statistics are stark and this situation represents one of Australia’s worst embarrassments internationally.

    But we need to understand how this situation evolved, what has and is being done about it, and whether these inequities in health and wellbeing are being corrected. It may come as a surprise to readers aged below 50 to realise that the divide between health standards among Indigenous and other Australians became generally recognised and acknowledged only within their lifetimes. The earliest reliable reports about poor Aboriginal health appeared in the mid-1960s after it was recognised that Aboriginal infants had very high rates of gastroenteritis, malnutrition and high death rates and that the life expectancy of Aboriginal people was much shorter than for other Australians. When the media reported these findings there was a public outcry and a quick but poorly organised political response was provoked to try to fix the problem. By then this was labelled the “Aboriginal Health Problem”.

    The late 1960s and early 70s brought many rapid changes into the lives of Indigenous Australians. These included: the 1967 Referendum which allowed the federal parliament to enact laws relating to Indigenous people and to include them, for the first time, in the national census; the federal court decision to grant “equal pay for equal work” for Indigenous workers; the establishment in Sydney of Australia’s first Aboriginal Medical Service in 1971; the gradual relaxation of restrictions on access to alcohol by Indigenous adults; and a rapid shift of Aboriginal people in rural and remote areas into towns and their fringes. In 1979 a federal parliamentary committee acknowledged the poor standards of Indigenous health and identified their root causes as being in deprived socio-economic circumstances and sub-standard living conditions. By that stage almost two centuries of marginalised living and social exclusion had reduced the original inhabitants to being an under-class in Australian society; the late Professor Rowley called them “Outcasts in White Australia”. This group of people by then had an entrenched core of ill-health, chronic disease and premature deaths which would be extremely difficult to correct.

    The social determinants underlying the patterns of ill health that affect Indigenous Australians must be addressed before significant and sustained improvements in health and wellbeing will occur. These contributing factors include poverty, overcrowding, unhygienic living conditions, low education standards, under-employment, social stigmatisation and marginalisation, disengagement from mainstream society, and their inadequate participation in decision-making processes which affect health and wellbeing. It must be appreciated, also, that some of the factors which have strong negative impacts on Indigenous health are trans-generational. For example, prenatal under-nutrition and impaired growth can adversely affect pregnancy outcomes over multiple generations; this means that those negative effects may take 50 years or more to be eliminated.

    In 2005 Tom Calma, then Aboriginal and Torres Strait Islander Social Justice Commissioner, released a report which called on Australian governments to commit to achieving equality for Indigenous Australians in health and life expectancy within 25 years. The Federal Government then made a formal Statement of Intent in 2008 to ensure that Indigenous people would have ”equal life choices”. The target date of 2030 was set for the various goals to be reached. This ambitious strategy and program was warmly received but within a year it was being questioned whether the targets were achievable in the time allotted; in particular, the goal of removing the life expectancy gap between Indigenous and non-Indigenous people was considered to be “probably unattainable” (https://www.mja.com.au/system/files/issues/190_10_180509/hoy11300_fm.pdf . These reservations were soundly based. By then there were many thousands of Indigenous people with long-standing chronic diseases like diabetes, chronic respiratory and cardiovascular diseases, late-stage kidney failure, irreversible visual and hearing loss and a range of other permanent disabilities. Added to that formidable burden was the increasingly heavy load of illnesses, social and stress-related disorders, and premature deaths associated with cigarette smoking, alcohol and drug abuse, in Indigenous people as well as those linked to accidents and violence. Quite clearly this wide-ranging and massive range of illnesses, disabilities and premature deaths would have no simple, single solution as, for example, could be applied to successfully control or prevent an infectious disease outbreak by a community-wide immunisation program.

    Yet, despite the timely and nationally published cautionary advice cited above, the Close the Gap Strategy and program continued. Each year a formal report has been released in parliament outlining progress towards the stated targets. There have been some improvements in Indigenous health over the past decade or so but it is difficult to attribute them to this strategy alone. For example, improved pregnancy outcomes such as heavier birth weights, suppression of childhood infections by immunisation, and lowered infant and maternal mortality, were achieved largely by other programs based on sound public health principles; that work began well before the Close the Gap initiative began. Annual report cards have mostly shown what is often officially called “mixed outcomes” – this usually means that the reporting agencies and their bureaucrats could find little that would attract a favourable headline in the press. This is disappointing because most Australians, black and white, want to see Indigenous people share the high levels of health which most of us take for granted. These mixed results in health, wellbeing, living standards, education, employment and productivity among Indigenous people have left them feeling let down. When the seventh annual Close the Gap report was presented by Prime Minister Abbott in February 2015 he acknowledged that the results were “bitterly disappointing”. Why didn’t he grab the nettle then, acknowledge that the strategy was failing, indicate that it had been introduced by former Prime Minister Rudd, and then ditch the policy and start again? That opportunity was lost and yet another year passed until the next Prime Minister, Turnbull, reported this month that the results of the eighth annual report were “mixed”.

    One of the key targets of the Close the Gap program all along has been to equalise the life expectancy of Indigenous and other Australians. However, the 2016 report acknowledged that the improvements that have occurred so far are not happening fast enough for that target to be reached within the next 20 years. Even in some instances where improvements seem to have been encouraging, closer scrutiny of the details exposes otherwise hidden obstructions. Take infant mortality rates for example. While the rates of Indigenous children dying in their first 12 months of life have dropped substantially over the past 15 years, the rates among non-Indigenous infants have also been dropping. When the relative rates, that is Indigenous compared with non-Indigenous rates, are examined it is evident that Indigenous infants are dying at about double the rate of other infants before their first birthday. Prime Minister Turnbull conceded that achieving the target to close the life expectancy gap by 2030 remains “a significant challenge” (ABC News item, 10 February 2016). Regrettably, other aspects of the 2016 Close the Gap report which have significant impacts on health were also disappointing; they include educational attainments, employment rates and housing standards.

    Repeated and protracted disappointments like these leave people feeling angry and frustrated, particularly the Indigenous community who have so much at stake for themselves and their future generations. Nationally prominent Indigenous leaders like Patrick Dodson have said recently that the Closing the Gap initiative is doomed to failure unless it is radically reformed. He added that the Prime Minister has not yet put his stamp on Indigenous affairs and has not paid sufficient attention to these issues.

    Resolving the inequities in health between Indigenous and other citizens must be done with an all-inclusive approach to all of the inter-related issues that are involved. Providing better and more accessible and appropriate health and disease care can only be part of the solution. Strategies and programs that are aimed at promoting and improving wellness as well as treating illness must be given more prominence in the clinical approaches towards better Indigenous health outcomes. A crushing disappointment for clinical carers of all types who work in this field has been to see the substantial improvements in health which have occurred over recent years, much of it in children, be undermined by high-risk attitudes and behaviours in later life which result in preventable premature deaths. Examples are the serious illnesses and deaths due to tobacco smoking, physical and mental damage and deaths from alcohol abuse and other addictive drugs, vehicle accidents and other forms of violence, and the long-term consequences of overweight and obesity including diabetes and cardiovascular disease. The gains that have been made in reducing infant and young child deaths should lead to improved life expectancy but this is being thwarted by the continuing wastage of lives in adolescence and early and mid-adult life. Much of this wastage is preventable. This is where responsibility for personal, family and community-based health must become part of the equation. Indigenous acceptance of responsibility and participation must become an essential element of this process in order for real progress to occur.

    A recurring theme in the continuing debate about trying to achieve equity in health and wellbeing between Indigenous and other Australians is the need for increased participation of Indigenous people in the activities and social circumstances which affect them. Not only is there a place for enhanced Indigenous involvement in these issues, there is a real need for this to happen. Examining the way health and clinical services are currently provided to Indigenous people shows that three main sectors are involved:

    • federal and state government services
    • the specially developed and independently-run Indigenous Medical or Health Services, and
    • private or other non-government providers of clinical and related services

    If these three sectors had been working cooperatively and effectively over the past thirty or more years, Indigenous health should not be in its present sorry state. Despite past failures there is still goodwill among the wider Australian community to see that this situation is corrected. I have previously called for a fourth sector to be organised to help bring this about (Refer to earlier Gracey blog on ‘What is need to fix Aboriginal health?’ here). This new sector would be established as a community-based organisation representing ‘grass roots’ Indigenous people who are currently sidelined from the process of policy development and making decisions about running programs at the community level to suit their own needs and aspirations. Adding this new dimension would show at last that local Indigenous communities have a real contribution to make in the health improvement process. This is not being achieved by regional Indigenous Medical or Health services although they claim to be ‘community-controlled’. In fact, members of local Indigenous communities have very little or no say in the selection of such regional bodies; in effect they are voiceless. The emergence of this fourth dimension would demonstrate that local communities and their members are prepared to accept this responsibility to contribute to planning and delivering health care for their own people. Such a development should help answer the repeated calls by Indigenous leaders from different parts of Australia for their people to play a bigger role in improving health and wellbeing of the Indigenous population.

    It is time for the issues surrounding Indigenous health to be thoroughly and objectively reviewed. This would help to ensure that the mistakes of the past are not repeated and perpetuated. Australia must be able to do better. The health needs of Indigenous people are, indeed, more demanding than for other Australians. But more funds, more doctors, nurses, clinics, hospitals, and related services cannot alone provide the solution. There must be a wide-ranging approach to all of the infrastructure services and other factors which influence the determinants of wellness and illness. Education, employment, housing, hygiene, access to affordable nutritious food as well as avoidance of unhealthy lifestyles must all be part of the equation towards better health. The media often sensationalise negative factors in society that contribute to the continuing poor state of Indigenous health. While many mistakes have occurred in the past and marginalisation of Indigenous people has had serious negative impacts on their wellbeing, it is time to look to the future and take a more positive outlook. Present problems should be seen as opportunities or challenges to put things right. To focus repeatedly on racism or negative stereotyping as the root cause of this continuing dilemma could be counter-productive and tend to separate Indigenous and other Australians even further. Instead, we should try to reach a situation where Indigenous people are given better chances to accept responsibility for their own health. Encouragement and cooperation will foster trust between them and the wider society and its representatives, namely governments and their agencies and bureaucrats. But all sides must accept this will be a “two-way street” where flexibility and patience will be keys to ultimate success.

    Michael Gracey AO is a paediatrician who has worked with Indigenous children, their families and communities for more than forty years. He was Australia’s first Professor of Aboriginal Health and for many years was Principal Medical Adviser on Aboriginal Health in the Western Australian Department of Health. He is a former President of the International Paediatric Association.

  • David Isaacs. Secrets and lies and bad morality: Australia’s policy on people seeking asylum

    The latest episode in the long, sorry saga of how badly we can treat people seeking asylum was played out in the High Court in February 2016. Long because the story started in 1992 when the Paul Keating Labor government introduced mandatory detention ‘as a temporary measure’ in reaction to a handful of people arriving in leaky boats from Cambodia. And I use the term ‘people seeking asylum’ advisedly, because the term ‘asylum seekers’ dehumanises the people and has been shown to cause Australians to switch off. The High Court found it is legal for the Government to send babies born in Australia and children and adults transferred to Australia for mental health and other problems back to Nauru. This decision was predictable because the Government passed retrospective legislation making it legal. As the human rights lawyer Daniel Webb put it so eloquently, the law is complex but the morality is simple. Bad Governments pass bad laws to allow them to do things that are morally wrong. I am a doctor not a lawyer, so I am not qualified to say at what point the High Court has a duty to make sure our Government does not exact really heinous legislation, but this is pretty bad. Excising Christmas Island from the mainland and sending people into detention centres on Nauru and Manus Island is our Guantanamo. These are ‘black sites’ where people can be severely mistreated under a veil of secrecy: out of sight and out of mind.

    To argue that people are now free to come and go from the detention centre on Nauru is disingenuous. They are not safe if they leave the detention centre and they are not safe in the detention centre. Their visas to stay on Nauru are restricted to 5 years, so their future is as uncertain as ever. Nauru is their prison. Mr Dutton has stated that the hospital on Nauru is comparable to Australian hospitals. I did a clinic at the Republic of Nauru (RON) Hospital in December 2015 and it is far, far worse than any Australian hospital I ever visited. Furthermore, the staffing is as important as the facilities and the RON Hospital struggles for qualified staff. Of course, Mr Dutton will argue things have changed in the last year. Verifying the truth is impossible when the only journalist allowed in for years was a single Murdoch Press Government sympathiser and doctors who speak out risk two years in prison.

    Ethics can be defined as ‘how we ought to behave’ and medical ethics as how health professionals ought to behave. I recently published a paper (available on request) in the Journal of Medical Ethics (http://jme.bmj.com/content/early/2015/12/20/medethics-2015-103066.abstract) in which I argue that prolonged immigration detention fulfils all the criteria for torture. I then argue that doctors and other health care professionals are conflicted: they have a duty to their patients to help them but they also have a duty not to condone torture. The US Central Intelligence Agency (CIA) argues to this day that water-boarding prisoners in Guantanamo and Abu Ghraib was not torture because the technique was devised by psychologists and supervised by doctors. The doctors would presumably argue that the water-boarding was going to happen anyway and they were ensuring the prisoners did not drown. Highly respected colleagues and lawyers have said to me “Nauru is not as bad as Guantanamo”. Is it not? Are we to have degrees of torture? There have been unconfirmed (probably unconfirmable) reports by a guard of water-boarding and ‘zipping’ being inflicted on people in immigration detention in Nauru (http://www.abc.net.au/news/2015-08-14/guard-tells-parliamentary-inquiry-asylum-seekers-tortured-nauru/6699162). Why would the guard lie? Mr Dutton denied it, but he would wouldn’t he.

    The harms we are inflicting on adults to punish them for having the temerity to flee persecution in their homelands are immoral. We treat innocent adults worse than we do convicted criminals. But the public are more likely to sympathise with the argument that children are innocent victims. Gillian Triggs realised this, which is why her Forgotten Children enquiry is so powerful. Alison Light, in her wonderful book “Common people”, describes how the 19th century English workhouses were intended to punish men who did not want to work, but the biggest victims were women and children. I was struck by the parallels with immigration detention centres. I am proud that increasing numbers of paediatricians and paediatric nurses have decided to speak out against what is being done to children by our Government in our name. Alanna Maycock, Hasantha Gunasekera, Karen Zwi and Josh Francis have all risked imprisonment for telling the truth.

    What should happen? The Government mantra, ‘We’ve stopped the boats’, means the immigration detention centres are redundant. Keeping people imprisoned can only be to deter other desperate people from seeking asylum. Europe, struggling with a far bigger immigrant problem, has not resorted to such vulgar deterrent policies, although extreme right wing European groups cite Australia as an example to follow. We should allow the derisory number of children to remain in Australia with their parents. We should close the detention centres on Nauru and Manus, which are not only immoral but hugely expensive (it costs over half a million dollars per year for each person kept on Nauru). Mr Turnbull committed his Government to a tough stance on border control. If that stance includes continuing to torture innocent people we should hang our heads in shame.

    Professor David Isaacs is Senior Staff Specialist, Department of Infectious Diseases and Microbiology and Clinical Professor of Paediatric Infectious Diseases at the University of Sydney. He works at the Children’s Hospital at Westmead.