Category: Health

  • Hugh Mackay. The Art of Belonging.

    We need communities to sustain us, but if those communities are to survive and prosper, we must engage with them and nurture them, writes Hugh Mackay.

    Aren’t you tired of being told that the deepest truth about human beings is that we are hopelessly selfish by nature? That even acts of apparent altruism are really just intended to make us feel better about ourselves and to look better in the eyes of others? That we are ruthlessly competitive creatures, so intent on satisfying our own needs that we are capable of aggressive and even violent behaviour towards anyone who gets in our way?

    Of course those things are true of some of us, some of the time. But there’s an even deeper truth about us: we are by nature social creatures; co-operative more than competitive. If you doubt it, look at how most of us choose to live – in cities, towns and villages – because, for all our claims to independence, we are not good at surviving in isolation.

    We need each other. We need communities to sustain us, but if those communities are to survive and prosper, we must engage with them and nurture them. That’s the beautiful symmetry of human society: to survive, we need communities and if those communities are to survive, they need us.

    So here’s the classic human quandary: we are individuals with a strong sense of our independent personal identityand we are members of families, groups and communities with an equally strong sense of social identity, fed by our desire to connect and belong. This tension between our independence and our interdependence explains why we are so often conflicted and confused: we know how best to live, but our internal war distracts us.

    It is indeed in our nature to be altruistic, because altruism nurtures the community, but our natural drive to please ourselves sometimes takes over. We know that a civil society depends on us all treating each other with kindness and respect, but sometimes we simply want our own way, regardless of its impact on others. We know the price we must pay for belonging to a community is to curb our self-interest, but our impulses and addictions sometimes get the better of us.

    If you want to see the tension between independence and interdependence in action, watch us playing team sports. Team sports are a graphic demonstration of how we must first learn to co-operate with the other members of the team before we can hope to compete successfully.

    Most of us find it hard to resolve this tension, which is why we often dream of aplace where it would be possible to live as we think we should – where we could “be ourselves” while still being part of a functioning community. This is what drives the fantasy of “village life”, even in our big cities. (Sydney’s Lord Mayor, for example, is determined to make Sydney a “city of villages” in the manner of New York.)

    That word “village” has emotional power because it conjures up the idea of a place where the tension between independence and interdependence can be resolved in a harmonious way; where we can write poetry in solitude but also be part of a caring and supportive community; where the neighbours will strike that perfect balance between friendliness and respect for each other’s privacy.

    Inside our heads, the fantasy often involves an idyllic rural setting that magically eliminates flies, snakes, drought, grasshopper plagues, and a higher rate of respiratory disease and mental illness compared with the city – to say nothing of poorer access to educational, medical, administrative and commercial services. And yet, regardless of the tough reality, the concept is appealing because the very word “village” evokes a feeling of physical safety and emotional security; a place where I could say that I belong here”.

    The good news is that you can create a village – or at least the life of a village – anywhere at all: it’s not about where you live; it’s about how you live, and the acid test is how you relate to the local neighbourhood. Mostly, our neighbours are accidental – we didn’t choose them, yet we must get along with them. They will become the people who, with or without the extra dimension of friendship, will become part of the fabric of our, and our children’s lives.

    Just like any other kind of human relationship, our relationship with a local community requires some effort on our part if it is to work.

    In modern Western societies like Australia, many pressures work against community engagement and involvement: our changing patterns of marriage and divorce demand difficult adjustments for many families and social networks; our low birthrate reduces the role children have traditionally played as a social lubricant; the rise of the two-income household means both partners are often too busy to give much time to the local neighbourhood; the mobility of the population (in Australia, like the US, we move, on average, every six years); universal car ownership reducing local footpath traffic; the IT revolution that creates the illusion of connectedness while making it easier than ever for us notto see each other.

    Communities are not self-sustaining. We need to respond to our natural “herd instinct” by joining, associating, congregating, volunteering, talking and listening – engaging. Everything from joining a book club or stopping to chat with a neighbour to greeting a stranger helps to build the social capital that makes communities strong.

    Part of the magic of communities is that, however imperceptibly, they shape us to fit them. We are the authors of each other’s stories through the influence we have on each other. Each of those stories might be unique, but the sub-text is universal: it is about finding the answer to just one question: where do I belong?

    Every community has its differences of opinion, its social divisions and its cultural tensions, which is simply to say that every community is both diverse and, inescapably, human. If you want to master the art of belonging, you’ll need to accept the imperfections, the complexities and the tensions and deal with them. And the best way of dealing with them is to overlook them. There’s a lot of tolerance – a lot of forgiveness – in the art of belonging.

    So why would you bother? Let me suggest two reasons why it’s worth the effort.

    The French Catholic existentialist Gabriel Marcel claimed that the reality of our personal existence could only be fulfilled through our engagement with communal life. He believed – and who would disagree? – that if we position ourselves (or are forced) outside a community, we tend to become obsessed with ourselves: self-absorption is the sure sign of a person not engaged with a community. After all, we never really know who we are until we know where we belong: ‘finding yourself’ makes no sense outside a social context.

    In the end, the reward for having connected with your neighbours is that you will feel physically safer and more emotionally secure in your neighbourhood. (Who wants to feel like a stranger in their own street?)

     Hugh Mackay is a social researcher and author. Hugh’s new book, The Art of Belonging, is published by Macmillan.

    This article was first published in the November edition of The Good Oil, the e-magazine of the Good Samaritan Sisters www.goodsams.org.au

     

  • Ian McAuley. Is capitalism redeemable? Part 8: Inequality’s downward economic spiral

    Let’s start with what looks like a self-evident proposition. “Countries with right-wing or neoliberal governments spend less on social security than countries with more left-inclined governments.”

    It’s a proposition university lecturers put to students of public economics, and the smarter students usually recognize that there’s a trick in it.

    Harvard economists Dani Rodrik and Alberto Alesina studied the impact of neoliberal policies such as those pursued by Britain’s Thatcher Government, and found that those policies, because they resulted in widening inequality, actually increased the demand for social security payments.

    Whatever images they may project, it’s worth remembering that governments on the right are not entirely heartless, and may even be well-intentioned. Even if it’s only because their supporters find street beggars and shanty towns indecorous, they feel constrained to spend on alleviating extreme poverty. (Lest anyone think that last suggestion is too cynical, we should contemplate our likely political reaction if the squalid conditions of Aboriginal settlements in the remote outback were more visible from the roads and railways used daily by our urban commuters.)

    Economists often argue for neoliberal policies, such as those which dilute workers’ rights, on the basis that while they will make some people worse off, they are worth pursuing because they will increase economic growth and therefore improve governments’ taxing power and capacity to make compensatory payments. Anyone with a little mathematical ability can work through the econometric equations and check the validity of this proposition.

    The main flaw in the argument is not mathematical. Rather it lies in the assumption that social security payments can compensate for some of the non-monetary costs of disruption associated with economic change. The tradeoff is rarely as stark as a choice between job and a welfare payment, but it is often in the form of compensation for a job with less pay, or with less security. It is easy, for example, for an economist in Canberra looking at a proposal which may wipe out regional economy to suggest generous re-location payments, but those calculations rarely take into account the hard-to-quantify costs of loss of a community’s social capital.

    Also, most people prefer some level of self-reliance to dependence on government benefits.

    By almost any consideration, “left” or “right”, an economy is healthier if it can provide well-paid employment for all, either in the form of jobs or self-employment in small business, without making too much call on social security benefits. There will always be enough call on the social security budget as a result of ageing, and to those with severe disabilities, without also asking it to pick up the costs of an under-performing economy.

    The general way in which governments can avoid this demand for re-distribution is to ensure the economy can support well-paid employment, through investment in human capital (education in particular), research, transport and telecommunications infrastructure, primary health care – in fact the whole set of public services that the market either cannot provide or cannot provide efficiently. Research into the determinants of economic growth show that even public investments which we may consider to be remote from the productive end of the economy, such as street lighting, have a positive effect on growth.

    But when there is an increasing demand for social security payments to compensate for poor economic performance, a nation’s public finances become caught in a destructive spiral, as demands for such payments crowd out other areas of government expenditure, particularly if a government has constrained itself with some arbitrary cap on public expenditure. As social security payments crowd out other areas of expenditure, particularly (but not only) education and infrastructure, a country’s long-term economic performance suffers, creating in turn more pressure on the social security system.  It’s a downward spiral to poverty.

    This downward spiral is far from hypothetical. It almost certainly accounts for much of Argentina’s economic decline over last century. And closer to home, the Howard Government used social security payments, such as family allowances, to compensate for our economy’s increasing inability to provide well-paid jobs. “Middle-class” welfare was, and still is, an unsustainable way to prop up material living standards.

    Hockey, Cormann and their advisors understand that social security payments and some other open-ended benefits are making a big call on the public budget, and that in material terms we are living beyond our means. Some short-term sacrifice is needed in order to put our economy and public finances back on track.

    The trouble is that they are going about rectifying this situation in completely the wrong way. Our escape from this spiral should be in the form of increased investment in public services, financed by higher taxes, rather than by cuts in expenditure, while sustaining social security provisions. In time, when those payments are no longer being called upon to compensate for our economic weaknesses, they can even be made more generous for those with enduring needs. Also, expenditure on universally-available services, particularly health and education, besides having high value in themselves, help support the living standards of those who are not so well-off, without being dependent on social security. There is a world of difference between the dignity of participating in shared services and the humiliation of applying for social security.

    Higher income taxes, and withdrawal of excessively generous superannuation benefits for the well-off, would carry a message of shared sacrifice.  One doesn’t need a PhD in economics or ethics to understand that it’s almost impossible to ask people to make sacrifices when the burden isn’t shared.

    The latest example of the Government’s stupidity in this regard has been in its support for a cut in soldiers’ pay. Any soldier, private through to colonel, knows the military tradition of shared sacrifice. The military is not a democracy – far from it – but when, in difficult conditions, sacrifice is needed, it is across the board, or is even disproportionately applied to senior NCOs and officers. Had the Government cracked down on corporate tax avoidance, made wealthy superannuants pay taxes, withdrawn privileges for family trusts, and scrapped privileges for financial commission agents, it may not be in such political strife over issues to do with military and public service pay.

    In this series of articles I have touched on some of many areas of public policy. Many of these will be covered in a book which Miriam Lyons (former Executive Director of the Centre for Policy Development) and I are writing, and which should be published around May next year.

    In the final piece I will look at some of the reasons why unjust and economically destructive public policy remains largely unchallenged. The roots of this problem lie much deeper than media bias or political apathy.

     

  • Ian McAuley. Is capitalism redeemable? Part 7: Inequality – a shameful waste

    “Australia’s program to increase world growth seems to be to cut social security benefits from the poor.”

    When Geraldine Doogue asked Malcolm Fraser to comment on Abbott’s G20 agenda, that was his summary of the present Government’s economic policy

    Unfortunately, ministers such as Hockey and Cormann may not understand the sarcasm in his comment, because there is an economic philosophy supporting their very line: redistribute income towards the rich while disciplining the poor with hardship.

    Of course that doesn’t get stated so bluntly; it’s padded in spin about a “budget emergency”, “Labor’s waste” and so on. But it shows through in the Government’s budget proposals, not only those directed at the poorest, but also in its rejection of Labor’s measures aimed at reigning in some of the undeserved privileges enjoyed by the already well-off. These reforms included changes in the tax treatment of employer-provided cars, ending the racket of hidden commissions on financial products, and modest taxes on multi-million dollar pension accounts.

    Giving breaks to the already privileged is based in part on a belief that if people are rich they must be clever, and therefore their entrepreneurial virtues should be further rewarded. It’s a belief that conveniently overlooks the role of inheritance, luck, political deals and outright corruption in contributing to many people’s financial prosperity.

    It’s also based on the slightly more respectable economic theory that those with higher incomes tend to save and invest, therefore creating jobs for others.

    As Thomas Piketty points out, the saving and investment theory holds only up to a point. Once a financially wealthy class develops it goes on accumulating more financial wealth, and there is no certainty that its financial wealth will be invested wisely. Even if that financial wealth came about in the first instance through entrepreneurship, there is no guarantee that those entrepreneurial energies will be sustained into subsequent generations, who are likely to lead an indolent lifestyle, spending their fortunes on luxuries rather than on productive investment. And that lavish consumption does little for the local economy – it is more likely to make its way to car manufacturers in Germany, watchmakers in Switzerland and vignerons in France than the more modest consumption patterns of those of more modest means.

    Also, perpetuation of privilege is often based on the well-off having first call on what economists call “positional goods”, where supply is limited – the best surgeons, the best teachers and so on. There is a strong economic case, for example, for allocating the best teachers to where they can do the most good, in endeavours such as helping kids who haven’t had the early childhood breaks enjoyed by rich kids.

    The other end of that philosophy – making it hard for the poor – is so economically dumb that it is hardly worth taking the effort to refute it. When there is no demand for labour herding people into the labour force through punitive social security conditions just doesn’t work. The business cycle is an inescapable economic reality, and in an interconnected world one’s chances of finding a job are as likely to depend on decisions of the US monetary authorities or the sentiment of Chinese investors as on local business conditions or one’s own skills and motivation.

    For those who, through a tough upbringing or educational disadvantage, lack skills, there just aren’t jobs available. Minimum wages would have to be brought down to absurdly low levels to make it worthwhile for business to employ unskilled labour, and if they did, there would be a huge waste of resources, because low wages provide no incentive for employers to use labour productively. The waste would be in that most valuable of all resources, people’s capabilities.

    Good public policy is about investing in people’s capabilities which, through circumstances beyond people’s control, have lain dormant and undeveloped, or have been devalued by life’s experiences. Far better than denying unemployment benefits to out-of-work young people would be programs to support them in gaining new skills, and, of course, programs devoting resources to children at risk – children who are otherwise going to spend their adult lives in and out or poorly paid work, in and out of the criminal justice system, and without any stake in society.

    Instead we have a suite of policies designed to sap the self-confidence and dignity from those who become unemployed, as if subjecting people to the humiliation of job rejections and having to beg from friends and charities has no negative consequences. There are consequences, however, not just for the individual but also for the community as a whole.

    Another waste resulting from punitive conditions on the unemployed is that bad management is rewarded and perpetuated. Besides collective action through unions (which is becoming more difficult), one of the few ways people can knock some sense into bad employers is having the capacity to walk out of a lousy job. A workforce of people held to employment only because the alternative is unbearable is not a productive workforce. Sullen compliance with directions, like an ongoing work-to-rule campaign, is a poor substitute for enthusiasm.

    Those are some of the reasons why high levels of inequality hobble a country’s economic performance: they inevitably involve a waste of resources. When Tim Costello spoke of the need for the G20 to bring up the standards of the poorest through “inclusive growth” he reminded us that good social morality and good economics have a great deal of common ground. That common ground seems to be unknown territory to Abbott and his ministers, hell-bent on replicating George Bush’s so-called “supply side” economics, an experiment that failed in the USA and would be even more likely to fail here because it is so alien to our tradition of the “fair go”.

    This article has focussed on the waste of unchecked inequality and the pointlessness of economic growth that benefits only those who are already well-off. The next will outline how policies which promote inequality (intentionally or otherwise), not only waste resources. They also sap governments of the capacity to prevent widening inequality from dragging down the whole economy.

     

  • John Menadue.  We pass by on the other side.

    We are one of the richest and most privileged people in the world but our recent performance on Ebola, foreign aid and refugees tells the world a quite different story.

    On Ebola, our response has been grudging and slow. We tendered one excuse after another. We moved quickly however to commit our military to combat again in Iraq and Syria. Our Medical Assistance Teams which we have deployed in humanitarian disasters like the typhoon Haiyan in the Philippines were ready to go to West Africa. They had volunteered and had vaccinations. The AMA urged us to get cracking. After a very lengthy delay the government decided to outsource our assistance. Our tardiness was in stark contrast to the response of countries such as the UK and the US. All the advice from experts was that the best way to address the Ebola outbreak was at its source. We knew that the medical and health facilities and hospitals in Liberia and other countries in the region were closing because the qualified staff were contacting Ebola and dying. Several hospitals were bereft of any staff. Healthcare in West Africa was near collapse but we delayed. Liberia has an income per head of $US454 p.a.; ours is over $US68,000. It is hard to recall a situation where our response has been so miserable.

    The UNHCR told us a few days ago that there were 13.6 million refugees displaced by the wars in Syria and Iraq. That is more than the combined populations of Sydney, Melbourne, Brisbane and Perth, our four largest cities. By our involvement in the war in Iraq we have contributed to this humanitarian disaster. But our refugee intake has remained unchanged at 13,750 p.a. Kevin Rudd had promised to increase it to 20,000 and Tony Abbott agreed before the last election. He then changed his mind and kept the quota at 13,750. If we adjusted our intake according to our population increase since the time of the Indochina refugee program, we would now be taking over 35,000 refugees p.a. which would still be quite small in relation to our migrant intake. Whilst the humanitarian tragedy in the Middle East escalates, we continue to turn our back.

    We are also ignoring our responsibilities as a wealthy country in overseas development assistance. In the last budget, the biggest cut in government spending was in overseas development assistance. We spend more on our cats and dogs than we do on ODA. At the same time that it cut funding for the poor of the world, the government kept in place a whole range of programs that advantaged the wealthy, such as superannuation concessions and subsidies to the mining industry.

    Surely we can do a lot better than this.

  • Patty Fawkner SGS. Betty has dementia.

    Grief is a constant companion when a loved one has dementia. And so, too, is grace, writes Good Samaritan Sister Patty Fawkner.

    Betty has dementia. Betty has had dementia for over eight years. Betty is my mother.

    “Mum will know when it’s time to go into care,” I would confidently say to my five siblings as Betty aged. I had utter faith in my ever-practical, no-frills, no self-pitying mother. I was wrong.

    A sober, unsentimental woman, Betty had met head-on all the challenges, joys and heartaches that come with rearing a large family with very modest means. I saw the height of her heroism and the depth of her love when Frank, the love of her life and my Dad, was diagnosed with cancer at age 57. Frank died 18 difficult months later.

    For 25 years she lived on her own and cared meticulously for the family home. But slowly, and then somewhat precipitously, Betty began to fail. She could no longer manage her money, her household, herself. She lost keys, money, her wedding and engagement rings. And she, herself, got lost.

    While her anxiety levels varied, those of her family were on constant red alert. Yes, we got the care packages and, yes, we attempted the in-house support, but Betty resisted because she “didn’t need help”. Lesson number one: Betty, as with all dementia sufferers, had lost the capacity to assess her own capacity. Logic, rational and evidenced-base arguments counted for nothing.

    I got the job of talking with her, to say it was time to go into care. For over an hour I cajoled, I reasoned, I wept. “I’m not going anywhere,” was her response. Forty minutes later, “Alright. I’ll go, but I want you all to know I’m not happy about this”. Thirty minutes later, “Alright. I’ll go and I’ll go graciously”.

    I could hardly wait to phone each of my siblings to share this impasse-breaking news.

    But two days later Betty had forgotten our heart-wrenching conversation. I began the conversation again the next week and again the next. Each time there was the same pattern of resistance, begrudging acceptance, followed by gracious acquiescence. Amazing.

    We were blessed in being able to find a place in a new state-of-the-art dementia unit in a suburb just around the corner from where Betty was born 85 years earlier.

    She was one of the first residents and was soon joined by 13 others in her wing. We sold the family home to pay for her accommodation. Overwhelming relief that Betty was safe and lovingly cared for trumped any other emotion we experienced over that time.

    Eight years on she is the only survivor from the original intake. Now 92, Betty’s dementia advances relentlessly. Physically she is frailer, though some days she looks as though she might live to 102!

    Grief is a constant companion when a loved one has dementia.

    There is grief for memories lost and for stories and secrets we can no longer share. As soon as I am out of sight Betty will not recall my visit. “It’s not that she really forgets,” a dementia specialist tells us; “it’s just that the experience is not ‘laid down’ in her brain, so there is no memory upon which to draw.”

    But even Betty’s former, pre-dementia life is no longer etched in her memory. She no longer remembers Frank or “the boys” – her five brothers – or her much loved sister. Her former life is now etched in her work-worn hands, and in her character and in her heart.

    In an inchoate way she ‘remembers’ her mother. Physical and emotional disorientation accompany the many urinary tract infections to which Betty is susceptible. At these times, she is inconsolable. “Where am I? I want to go home. Where is Mum? I want Mum.” Her yearning and distress is heart-breaking.

    Soon after Betty went into care, I was diagnosed with cancer and underwent surgery. I would have loved some comforting mothering. My mother was there, but the mother in whom I could confide was gone – another grief.

    Some weeks back Betty must have either fallen onto the floor or into a bedside table during the night. An alarm was activated as soon as she got out of bed, but some failure in the usually well-oiled system meant that no night staff came to her aid. She was found back in bed by the morning staff, hours later. Of course she had no memory of what had occurred.

    I was away and saw her a week later. Betty still had a huge lump on her forehead and half her face was bruised deeply, ugly. I cried when I saw her, more at the thought of my darling mother enduring this jarring, pain-inducing accident with no one to comfort her in the moment.

    Grief is one companion. And so, too, is grace.

    Betty was never an overly demonstrative woman, but now the dementia seems to have let the affection genie – both hers and mine – out of the bottle. I am just so grateful. I love cupping her ever-so-soft face in my hands, looking into her eyes, and saying, “I love you, my darling mother”. I joke with her that her response should be, “And I love you my darling daughter”. She used to be able to say that, but not now.

    One day I ask playfully, “Do you love me?” She responds seriously, yet with a twinkle in the eye, “I do”. I push my luck further. “How much?” “Millions,” she replies. I go away a happy woman.

    Betty seems to have rekindled a childlike delight in the simple things of life – looking at the clouds, being enchanted by a child, a flower, or a photo. Always one with a sweet tooth, we spoil her with chocolates. She savours each chocolate as though she’s stealthily partaking in some guilty, indulgent pleasure.

    There are as many laughs as there are tears. Earlier on when I could take her out for a walk, I expressed my concern that we shouldn’t walk too far. “You get tired, don’t forget,” I sensibly say. “Well you’ll just have to piggyback me back home,” she declares impishly.

    We see many signs of her playfulness and her familiar straight-shooting style. One of the residents fancies himself as a dancer and is often poised ready to do a twirl à la Fred Astaire. Betty looks at him, looks at me, rolls her eyes and says “Look at that silly old b—-r“.

    Betty was born Elizabeth Taylor, and like the movie star, appearances and grooming have always been important to her. When she sees an overweight person, she comments in a loud stage whisper, “Look at the size of that!” “Mum!” I quickly remonstrate. She smiles, hunches her shoulders and places a finger guiltily on her lips, pretending to be contrite.

    Just the other day I was sitting with Betty as my sister helped her with her lunch. She stopped eating, gazed at the woman opposite, looked conspiratorially at us and announced, “See that one, over there? She hasn’t got a clue”. “Really?” we say suppressing our laughter.

    Ronald Rolheiser reminds me that “Jesus gave his life to us through his activity; Jesus gave his death to us through his passivity”. And so with Betty.

    All her adult life she was in charge of a family and a household. She worked hard, cooking and cleaning, sewing and scrimping to make ends meet. In all this activity as wife, mother, nanna, sister and friend, Betty gave her life away. Now, she is unable to be in charge of anything – even of her most basic needs.

    Activity gives way to passivity. Staff and family perform the tasks that she once so competently mastered. In a society that equates worth and value with utility, work and activity, in a society which speaks vociferously about euthanasia, Betty’s life might be measured as having limited value.

    James Hillman in his book, The Force of Character and Lasting Life, asks the question: What is our value to others once our practical usefulness, and perhaps even our sanity, are gone? Character, he says – our own and others.

    “An old woman may be helpful simply as a figure valued for her character. Like a stone at the bottom of a riverbed, she may do nothing but stay still and hold her ground, but the river has to take her into account and alter its flow because of her.”

    Betty continues to give her life away in her diminishment and frailty. She gives to me now different gifts, at times deeper gifts, than she was able to give to me in her strength and activity.

    Betty has dementia. Betty is my mother and Betty is beautiful. She is priceless beyond all imagining.

    * Good Samaritan Sister, Patty Fawkner is an adult educator, writer and facilitator. Patty is interested in exploring what wisdom the Christian tradition has for contemporary issues. She has an abiding interest in questions of justice and spirituality. Her formal tertiary qualifications are in arts, education, theology and spirituality. This article was first published in the October edition of ‘The Good Oil’ the e-magazine of the Good Samaritan Sisters. See link below.

    http://www.goodsams.org.au/good-oil/betty-has-dementia/

  • Michael Keating. Rebalancing government in Australia. Part I.

    The Future of Federalism

    Tony Abbott recently announced that he wants ‘to create a more rational system of government for the nation that we have undoubtedly become’. As Abbott describes it, achievement of this more rational system is dependent on developing a consensus based on ‘a readiness to compromise and mutual acceptance of goodwill’.

    Understandably the initial reaction of many people was to question whether these lofty (although familiar) aspirations had really been embraced by the most negative and populist politician in living memory. But there is no doubting Abbott’s chutzpah, and perhaps the real regret is that he does not seek to bring a similar rational approach to more significant issues, such as climate change or to the many questions still to be answered regarding our re-engagement in Iraq.

    Nevertheless, we should take Abbott at his word and consider what are the options for a more rational federal system for Australia, and what difference it might make. Broadly there are two aspects to possible reforms:

    1. Clarifying and rationalising the respective roles and responsibilities of each level of government, and
    2. Resolving the mismatch between what each level of government is supposed to deliver and what they can actually afford to pay (commonly described as vertical fiscal imbalance or VFI)

    Often both these aspects of reform are linked, but it would be possible to make progress on one without changing the other – indeed the Keating Government, which established the Council of Australian Governments (COAG), made significant progress on reforms affecting roles and responsibilities, while ruling out doing anything about VFI. So I will deal with these two aspects separately, starting with roles and responsibilities in this comment, and then with taxation in a subsequent comment.

    Rationalising Roles and Responsibilities

    The arguments for ‘restoring the State’s sovereignty’ based on clearly defined separate roles and responsibilities for each level of government are that:

    • Adoption of the subsidiarity principle to maximise devolution will improve democratic accountability by bringing government closer to the people with the federal government only performing those tasks that cannot be performed more effectively at an intermediate or more local level
    • In addition democratic accountability will be further improved as this separation will eliminate the “blame game’ and the opportunities for cost shifting between levels of government
    • There will be an improvement in efficiency because the extent of overlap and duplication between different levels of government would be greatly reduced.[1]

    On the other hand, despite the intellectual attraction of these arguments in favour of separate roles and responsibilities for each sovereign government, realistically reform of our federal system also needs to consider just why our Federation has in fact evolved in favour of greater national involvement in regulatory functions and the provision of services that were originally the sole responsibilities of the States.

    In my view two key reasons for this increasing pre-eminence of the national government are first, federation was always intended by the States to lead to the creation of a national market; indeed that is why one of the first steps was to remove tariffs on interstate trade.  But now that we have a national market, and furthermore are facing global competition, businesses want common standards and licensing across a wide variety of fields; for example, everything from rail gauges, regulation of heavy road transport, company law and national competition, to food standards and the recognition of qualifications.

    Second, the responsibilities of government have grown. At the time of Federation pensions did not exist, but the Australian government now has constitutional responsibility for income support, including subsidising critical needs such as medical services, pharmaceuticals, and rental housing. Equally since World War II the Australian government has been expected to manage the macro-economy to ensure full employment and reasonable price stability.  Allied to this the Australian government also has responsibility for population policy, especially through migration, and for the growth in productivity and workforce participation which together determine the overall growth of the economy.

    These various national functions and responsibilities are, however, not self contained. Today the various functions of government are heavily inter-related in a way that was much less true one hundred years ago, when we were all much less closely connected. For example, productivity is heavily dependent on the skills of the workforce, but these skills are in turn dependent on the quality of the education and training systems of the States. It is simply not possible for the Australian Government to meet its responsibilities while being unconcerned about the effectiveness of various State government services.

    In addition, people by and large think of themselves primarily as Australians. Indeed ever since the 1920s when the Grants Commission was first established, there has been an Australian consensus that the access to basic public services should potentially be the same wherever you lived, and that you should not be disadvantaged if you holiday or move more permanently between States.

    In these circumstances the direction of reform of our federal system over the last twenty years or so has been to try and take account of both the importance of devolution in favour of greater democratic accountability, while ensuring that national responsibilities for the welfare of the Australian people and the performance of the national economy can also be met.

    In practice this has meant that in these twenty odd years there have been only one or two examples of agreement to clean-lines separation of government responsibilities. For example, the Keating Government agreed to withdraw from all forms of road funding except for designated ‘national roads’ where the national government was the sole source of funding. This should have ended the ‘blame game’ because for each and every road a designated government was solely responsible. Nevertheless, some States continued to lobby for a Commonwealth take-over of some of their major roads, and eventually this clear division of responsibilities broke down when the Howard Government re-entered road funding generally, presumably in response to political pressure, particularly from the National Party.

    More generally this approach to reform, which attempts to balance devolution with maintaining the national interest, has led to a shift in favour of national regulation of markets, with the latest major change being the enormous increase in the scope of Commonwealth regulation of workplace relations instituted by the Howard Government using the corporations power. In partial contrast, in the case of the provision of public services, there has been a much greater acceptance of shared responsibilities, but with each level of government having a separate role. At least in principle, this model assumes that Commonwealth will focus on the achievement of outputs and outcomes that have been agreed with the States, but the States should then have considerable discretion as to how those outputs and outcomes will be achieved, having regard to their own local circumstances.

    To my mind this is the sensible way for reform of our federation to proceed. Nevertheless it is not without its difficulties:

    • Progress is inevitably slow as each service needs to be considered on its particular merits involving a case-by-case process
    • There is an unresolved issue as to what sanctions if any might be appropriate where a State fails to meet the agreed outcome/output targets; and especially where this reflects under-funding by the State.

    In addition, it needs to be remembered that funding the provision of services through the States is not necessarily the best way for government to bring service delivery closer to the clients. In a number of instances the Australian Government is now directly funding non-government organisations to provide services and also private providers who can be closer to their customers than State bureaucracies. For example, the Australian Government has directly funded autonomous universities for many years, although almost all universities were originally established by the States; the providers of labour market and training programs, including TAFE, have a history of being directly funded by the Australian Government; and the proposed model for the National Disability Insurance Scheme will involve direct Commonwealth funding of providers.

    [1] This last alleged benefit from a clearer separation of Commonwealth-State powers and functions is often exaggerated. Even if we assume that the Australian public servants involved in the administration of programs involving payments to the States represented complete duplication and had zero productivity, sacking all of these people would reduce total Australian Government payments by around 1 per cent, representing a saving equivalent to only 0.3 per cent of GDP.

    Part II will be posted tomorrow.  ‘Taxation reform and vertical fiscal imbalance’

  • Adam Kamradt-Scott. Mining companies must dig deep in the fight against Ebola.

    The current outbreak of Ebola virus in West Africa shows no signs of halting. More than4,500 people have died and many thousands more are infected. Despite the creation of a new United Nations mission to tackle Ebola and commitments of thousands of western military personnel to help combat the disease, the virus is still “winning the race”.

    In September, UN Secretary-General Ban Ki-moon called on the international community to donate US$1 billion to help fight Ebola. Yet one month later, despite dire predictions that we could see 10,000 cases a week by December and 1.4 million cases by January 2015, the UN has received less than 40% of the funds needed.

    While the main focus is on what governments are or are not doing, the role the corporate sector can play in the current crisis has received very little attention.

    Is the mining sector doing enough to fight Ebola?

    With six of the world’s ten fastest growing economies in Africa and rich mineral resources that include major iron ore deposits, the region has attracted considerable foreign investment over the past decade from some of the world’s largest resources companies.

    Yet while such companies continue to promote their corporate social responsibility credentials, the response to the current Ebola crisis has been utterly inadequate.

    For example, according to the UN Financial Tracking Service, Rio Tinto, which operates two mines in Guinea and boasts that it has worked in Guinea for more than 50 years, has donated just US$100,000 to the UN Ebola Virus Outbreak – West Africa Appeal. Guinea remains one of three countries in the region most severely affected by Ebola.

    In a statement obtained for this article, a Rio Tinto spokesman said the company had donated GNF$1.5 billion (US$220,000) to date to health organisations, including donating 10,000 prevention kits containing soap and chlorine for hand-washing, constructing latrines and conducting public awareness campaigns in the Guinean “sous-prefectures” of Boola, Beyla and Kouankan.

    Another Australian resources company, BHP Billiton, which has mining operations in Guinea and Liberia, has donated a total of US$400,000.

    The London Mining Company, which owns an iron ore mine in Sierra Leone that generated US$299 million in revenue in 2013, has claimed to be assisting with the construction of a 130-bed Ebola treatment facility. This assistance, though, equates to the loan of a surveyor and fuel to help clear the land – the actual construction of the facility will be “at cost” and operated by the United States and Irish governments.

    Beyond this, in terms of financial contributions, the London Mining Company joined a consortium of businesses that collectively donated US$279,643, but independently the company has donated just US$122,100 to the UN Ebola Appeal.

    Yet even these extremely modest contributions compare favourably to some Canadian-based firms such as Aureus Mining Inc, which has offered equipment (on loan) but has donated just US$30,000; while IMAGOLD has donated a mere US$35,000.

    For their part, mining companies have stressed their efforts to protect employees and contractors, citing the initiation of public education campaigns and testing regimes underway at various operations.

    However, the media focus has invariably been on how the Ebola crisis is affecting business, rather than asking what larger role these companies – many of which stress their ties to local communities – may make.

    It seems clear that many of these companies see it primarily as a government role and their own as using influence to lobby. Aureus chief executive David Reading was one a number of senior resource company executives who co-signed a letter calling for a stronger global response to the crisis.

    What about the rest of the corporate sector?

    This contrasts to the efforts of other corporate donors. By any measure, the leading private sector contributor to the Ebola crisis has been the IKEA Foundation which, according to the UN, has donated over US$6.7 million to the Ebola Virus Outbreak – West Africa Appeal. This is followed by General Electric which has donated US$2 million, and Kaiser Permanente and GlaxoSmithKline, which have donated US$1 million each.

    A number of other corporations have made either in-kind or cash donations to the UN Fund. Some of the companies that have donated cash include the Bridgestone Group (US$500,000), Coca-Cola (US$248,000), DuPont (US$250,000), and Exxon Mobile (US$225,000).

    In-kind contributions have also been received from companies like the Chevron Corporation (ambulances), Ericsson (collecting donations), FedEx (shipping logistics), the McKesson Corporation (medical supplies), 3M (medical supplies), and the Shell Oil Company (petroleum and vehicles), among others.

    Certainly the UN has encouraged the corporate sector to donate resources, even publishing an Ebola Business Engagement Guide.

    Multi-billion dollar corporations – those with the financial capacity to do much more – however, have been slow to respond. And without exception, even the contributions that have been made pale into insignificance against the contribution by the founder of Facebook, Mark Zuckerberg, who personally donated US$25 million to combating Ebola.

    In the meantime, the virus continues to spread. World leaders, including former UN Secretary-General Kofi Annan, have expressed “bitter disappointment” at the international community’s lack of response. While much of the focus may appropriately be on governments, the corporate sector also has a responsibility to step up.

    In launching a fresh campaign for funds, Ban Ki-moon recently declared:

    This is not just a health crisis; it has grave humanitarian, economic and social consequences that could spread far beyond the affected countries.

    Let’s hope the message is heard.

    Dr Adam Kamradt-Scott is Senior Lecturer at University of Sydney. This article was first published in ‘The Conversation’ on 21 October 2014.

  • John Menadue. Winners in the privatisation of Medibank Pte

    Many would expect that the 3.8 million members or policy-holders of MBP who are arguably the owners of the company, would be the financial winners in the proposed privatisation.

    But not a bit of it. Some of the 3.8 million members will seemingly get some preferential issue of shares. But it will be chicken feed. The two real winners by a country mile will be the numerous advisers to the float, and the senior executives of MBP.

    The once-off winners will be the financial and legal advisers to the float. Together with the brokers, underwriters and sub-underwriters, they will make a motza. Our super profitable and large banks will also make money in the marketing of the shares. The fees and charges by all these intermediaries will run into $50 m plus.

    The long-term winners will be the senior executives of MBP. They are big fans of privatisation.

    There are numerous precedents for the escalation of executive salaries that follow from privatisation. Take the most recent privatisation, Queensland Rail.  The rail company was sold in 2010 and the salary of the chief executive increased from $1.1 million to $5.1 million p.a. His job was largely unchanged, but his salary went through the roof.

    The managing director of MBP George Savvides is already paid $1.2 million p.a.  This is double the salary of our prime minister. Corporate governance analysts estimated that Savvides’ package will increase to about $5 million p.a. MBP’s two other senior executives are now paid $1.85 million p.a. It is estimated that their packages will increase to $3.2 million p.a. each.

    The chief executive, Mark Fitzgibbon, of a much smaller private health insurance company, NIB, has a salary of $1.2 million. But MBP is about four times larger than NIB.

    In the healthcare industry, the top earner is the chief executive of Ramsay Healthcare, earning $8.3 million p.a.

    The senior executives of MBP will be major beneficiaries of privatisation. The 3.8 million policyholders/owners of MBP will get crumbs.

  • Ian Webster. Suicide prevention.

    September 10th was World Suicide Prevention Day – Suicide Prevention – One World Connected and from the 5th to the 12th October Mental Health Week ran in Australia. The week’s highlight was the ABC’s “Mental as” which ran through the whole week. Over three nights “Changing Minds – the inside story” on ABC TV involved us with the staff and patients of Liverpool Hospital’s in-patient mental health unit. It was riveting television. The program portrayed the relationships between staff and patients with disordered minds as they slowly regained their sanity. There was much humanity.

    A constant thread during Mental Health Week was the risk of suicide, but mental illness is not the only pathway to suicide.

    In September, Dr. Margaret Chan, Director-General, World Health Organisation said in launching the first WHO report on suicide prevention, “Preventing Suicide: A global imperative”:

    “The burden of suicide does not weigh solely on the health sector; it has multiple impacts on many sectors and on society as a whole. Thus, to start a successful journey towards the prevention of suicide, countries should employ a multisectoral approach that addresses suicide in a comprehensive manner, bringing together the different sectors and stakeholders most relevant to each context”.

    Suicide exacts an unacceptable toll of more than 2200 lives each year in Australia.  Three quarters are men in the prime period of their lives. From the 1990s to 2010 suicide rates declined by 17 per cent, mainly from reduced suicides in young males. But the decline has stalled and Australia must look to new approaches at national and local community levels.

    Suicide is not an act which occurs in isolation. It arises out of interactions between long-term vulnerabilities, trigger events and accumulating adverse factors in a person’s life. Disadvantaged communities are the hardest hit.

    Sadness and ‘sorry business’ pervade too many Aboriginal and Torres Strait Islander communities leading to an inexorable downward spiral in community spirit and well-being. Between 15 and 19 years of age Aboriginal and Torres Strait Islander young people die from suicide four to six times the rate of other young Australians. Urgent action is needed in these communities.

    People with continuing mental illness; those with distressing physical illnesses, disability and pain; people who identify as lesbian, gay, bisexual, transgender or intersex; armed service veterans; and those living in rural or remote areas have high risks of suicide. The Northern Territory and Tasmania have higher rates than the rest of Australia. Each community, region or group poses special challenges for actions to prevent suicide.

    Not only are families and friends devastated by suicide and left with unanswered questions and bewilderment as workplaces, schools, clubs, emergency services and whole communities can be affected.

    We know that 75% of people who take their lives will have attended a general practitioner or hospital in the three months before they died. And many of the 65,000 people who attempt suicide each year will also have been in contact with homeless shelters, schools and colleges, workplaces, Centrelink, police and courts.

    Herein lies a key piece in the jigsaw. These points of early contact are opportunities to connect a person to on-going follow-up and support to enable them to re-establish  meaningful relationships and community involvement. But this ‘chain of care’ can only be as strong as each link in the chain.

    There are hopeful signs that this is happening in different parts of Australia as communities galvanise around the issue of suicide. These local suicide prevention networks aim to build connections to prevent suicides and to support those who have been bereaved. It is a paradox that it takes such tragic events to re-kindle relationships which have been lost.

    There is no single strategy which can reduce the rates of suicide as the pathways to risk in childhood and adolescence, young adults, middle age and in later life, involve different vulnerabilities, exposures and experiences. But community connectedness and resilience are relevant at every step along these paths.

    As the WHO says this is where our efforts can be most effective. In other words governments and service providers have to understand that suicide prevention can’t be left to mental health services alone; it must involve all emergency service personnel, health and social services, local communities and especially primary health care.

    Ian W Webster, National Mental Health Commissioner, 2012-2014, Chair, Australian Suicide Prevention Advisory Council, 1998 – 2014.

  • Medibank Private and members’ equity.

    In the New Daily on 6 October, George Lekakis drew attention to a letter sent to a policy-holder in 1994 by Mary-Jo Henrisson, a customer services manager in Medibank’s NSW head office. Mary-Jo Henrisson said “We would be sorry to see you lose the equity you have built up in the fund.”

    For the full story in the New Daily see link below.

    http://thenewdaily.com.au/news/2014/10/06/exclusive-medibank-letter-government-doesnt-want-read/

  • John Menadue. Why health reform is so hard. It’s about power.

    You may be interested in this repost.  John Menadue.

     

    I have been actively involved in health policy for over twenty years. Throughout that period Medicare has been the shining light that has well and truly stood the test of time. But necessary health reforms are hard. They are deferred or avoided.  Without ministerial leadership there is an enormous lethargy in the health system.

    The major reason I suggest for reform being hard is the power of “insiders” and the way they exercise that power. At one level there are those insiders that administer health services. Health is a highly technical, large and complex field that is difficult for outsiders to come to grips with. This gives disproportionate power to health administrators on the inside. Then at another level which is ‘joined at the hip’ with these administrators are the vested interests or rent seekers who batten on the health service and dominate the public debate. It was the same type of vested interests who so selfishly led the opposition to Medicare in 1975. They are still with us today but in a different guise.

    .These vested interested who can delay or veto reform must be recognised for the power they exercise.– the AMA, the Australian Pharmacy Guild, the private health insurance funds, Medicines Australia and the state and territory health bureaucracies..

    The AMA is opposed to reform of the perverse incentives of the fee for service system of remuneration.FFS is not appropriate for chronic care; it encourages over servicing, over referrals and over prescribing. The financial incentive should be to keep people healthy through contracts and capitation in general practise and not financially reward doctors when the patient is sick.  .

    The AMA is turning a blind eye to the growing corporate takeover of general practise and the associated vertical integration into radiology and pathology. The health sector is seen as easy picking by business, if only the government would get out of the way.

    No government will lightly challenge the AMA

    The Australian Pharmacy Guild stands in the way of competition and the need for pharmacists to become more health professional and less like shopkeepers. The APG often threatens to use its power through pharmacies across the country.

    The private health insurance companies are expensive financial intermediaries who receive a $7 b annual taxpayer subsidy. PHI’s benefit the wealthy and most importantly weaken the power of Medicare to control prices. Gap insurance has underwritten an enormous increase in specialist fees. Now PHI’s want to move into general practice.  Government subsidized PHI is a major threat to health care in Australia as it has become so disastrous in the US. PHI sees governments as a relatively easy pushover.

    Medicines Australia, that represents the manufacturer and distributor of drugs charges Australians $2b per annum more pa than New Zealanders for equivalent drugs. It is a powerful lobby group.

    We have 8 state and territory health bureaucracies supported by their ministers that are very concerned to protect their own turf at the expense of an integrated national system. The federal government is reluctant to stare down the parochialism of the states

    Unless we take the health debate to ‘outsiders’ and break the power of the insiders-the  rent seekers and vested interests-, we are unlikely to see significant progress in health reform. The vested interests invariably win out over the public interest.

    There has been incremental change in response to political and budgetary pressures, but that has produces a patchwork set of arrangements that lack guiding values or principles. The debate is about ‘managing’ the health system and not about the values and principles that should drive it.

    Eight years ago, Ian McAuley and I in New Matilda suggested some key reform that we believed were necessary to ensure universality and the improvement in both the equity and efficiency of our health sector. Those suggested reforms were.

    • To focus program delivery in primary healthcare which can provide an integrated range of services?  But the debate is focussed on iconic hospitals.
    • To move to a single, universal insurer and to avoid going down the US path.
    • To organise healthcare programs around the needs of users rather than in response to providers.
    • To rationalise user payments so as to achieve equity and not distort resource allocation.
    • To retain Commonwealth responsibility for funding and standard-setting and deliver programs through joint Commonwealth/State administrations.
    • To involve citizens in healthcare to counter the strong lobbies of service providers/vested interests.
    • To focus ministerial concern on health rather than health services because many of the key services to advance the health of the population are outside the health portfolio. E.g. poverty, diet and distance.

    The public ‘debate’ on health is between the powerful rent-seekers with their well-funded public relations machines and the minister. The public is excluded from the debate and the media is ill-equipped to undertake the important examination of key policy issues. Under-resourced journalists are forced to rely increasingly on handouts by the rent-seekers.

    Commonwealth  Ministers  for Health are very dependent on the Department of Health and Ageing, particularly, as is often the case with ministers who are not across the issues and don’t have a clear policy program themselves. Unfortunately ministers who rely on the DHA will be disappointed. The Department is ill-equipped .It is structured in ways that reflects the interests of providers, e.g. doctors and pharmacists, rather than structured on the basis of community interests, such as acute care, chronic care or demography.  DHA has little economic expertise. One very senior Commonwealth official said to me, DHA does not have any strategic sense in health policy. It doesn’t effectively integrate the Commonwealth’s own expensive programs, let alone make any real progress in bridging the Commonwealth and State divide. During the difficult negotiations with the states on health reform during the Rudd Government period, the Department of Prime Minister and Cabinet effectively had to step in because DHA was not up to the job.

    The role-out of e-health by DHA is an expensive mess. DHA sees Medicare as a funding vehicle and not a policy instrument. Medicare is not even within DHA. The Department clearly sees its major role to keep the peace and keep the minister out of any public brawl or argument.  Health reform and health policy is an after-thought.

    The Ministerial/Departmental model in health has failed. It is incapable of contesting the power of the rent seekers.

    Governments are invariably captured by their own health insiders who are people of good will and professional skills but they have often spent their whole professional lives working in the health sector. Take the example of the appointment in 2008 of the National Health and Hospital Reform Commission. The Commission was overwhelmingly composed of health insiders with their limited horizons. The Chair was a senior executive of BUPA. Not surprisingly NHHRC produced very little worthwhile reform. Labour governments as well as Coalition governments like to smoodge the powerful vested interests and avoid political trouble.

    I have been urging for many years two ways to overcome the problem of the powerful insiders and vested interests.

    The first is to bring the Productivity Commission and Departments of Treasury and Finance into active involvement in health policy. The rigour and the outside view that they can bring is essential.

    Secondly, because of the failure of the ministerial/departmental model which is intensified by the poor performance of DHA I have proposed the establishment of a Commonwealth Health Commission composed of professional and independent people to take responsibility for health policy administration, subject to government policy guidelines. The Reserve Bank has shown the value of an independent and professional body that can lead public debate on important issues and implement government policies. And not get waylaid by powerful vested interests.

    Unless the governance problem in health is addressed we can forget serious reform. As part of this governance reform we need to drastically cut the power of lobbyists, both third party and in house lobbyists. Secret discussions and deals by vested interests with politicians and senior public servants must be stopped.

    Health is too important a matter to be left to the health insiders.

    What do they know of health who only health knows?

    If there was one word I would use to describe the obstacle(s) to health reform it would be ‘POWER’

     

     

  • Richard Norman, Suzanne Robinson. Health lessons from England.

     

    While Australia and England share much of their cultural heritage, the countries have answered the challenge of funding health care in quite different ways.

    The Australian Medicare system is predominantly based around private practice and fee-for-service. The English National Health System (NHS) is based on capitation, in which doctors are paid a fixed amount to manage a group of potential patients irrespective of the actual level of care.

    Neither system is perfect, but each can learn from the other; after all, they both aim to achieve efficient, equitable, high-quality health services is the same.

    Fee-for-service vs capitation

    Australia’s emphasis on fee-for-service funding reflects both a strength and weakness. Paying for each consultation or service, mainly through the Medical Benefits Schedule, incentivises doctors to do more.

    But it can also lead to over-provision of care. Most of us have anecdotes about returning to the doctor for procedural issues, such as renewing prescriptions, or receiving test results, which might be more efficiently done over the phone, or by a nurse or pharmacist.

    The English system, with its focus on capitation, may be too far in the opposite direction. Under capitation, doctors are paid an amount to manage a set of patients, this amount usually determined by estimates of need.

    If doctors are effectively paid no extra for providing additional care to a patient, then you can reasonably expect an average level of service below what is optimal.

    Both the English and Australian systems have tried various ways of blending fee-for-service and capitation, but the two systems continue to sit some distance apart.

    Pay for performance

    One possible way out of this impasse is to move towards a system in which doctors are paid for results, rather than activity.

    The English system has considerable experience in this area – good and bad – with its Quality and Outcomes Framework (QOF), which attempts to pay doctors directly for their patients’ health outcomes.

    Under this system, surgeries are awarded points for a range of outcomes including chronic disease management, practice organisation, positive patient experience, and the provision of extra services such as child health and maternity services. These points are then translated into a financial payment for the surgery.

    In England, there is mixed evidence about the appropriateness of this system. Design has proven a major challenge; in the first year, there was a cost blowout as surgeries achieved a much higher proportion of points than was expected.

    So, could such an approach be taken in Australia?

    The answer is that it would be difficult. Patients are registered to surgeries in England, meaning it’s easier to link clinical outcomes with the activity of particular doctors.

    But Medicare data does show us which patients see which doctors, so linking to outcomes might be feasible in Australia.

    However, as with much of the area of international transferability of health policy, the basic policy idea would need to be adapted to reflect the existing health system architecture.

    Keeping people out of hospitals

    Over the past decade, the English health system has pursued a policy of local commissioning of services. Led by local GPs, Clinical Commissioning Groups (CCGs) are responsible for allocating their local community’s health budget on emergency care, elective hospital care, maternity services and community mental health services.

    CCGs place general practitioners at the heart of health care funding decisions, giving them a role previously undertaken by lay managers in primary care.

    The aim is to strengthen primary care and keep people out of hospitals. If you make one body responsible for purchasing primary care (such as GPs) and secondary care (predominantly hospitals), you’re likely to make better use intensive GP interventions that would reduce the use of considerably more expensive hospital care.

    In the 2012 Health and Social Care Act, the Conservative-led coalition placed £65 Billion into the hands of 211 newly-formed CCGs, 65% of a total NHS budget of £95 Billion. The English experience of commissioning is still a developing story. It appears to offer benefit, but the design of the system is crucial. Those doing the local commissioning must be supported both logistically and financially, so they have the time to dedicate to this work and it isn’t just passed on to bureaucrats.

    Australia’s fragmented system

    Our health system is funded from a mixture of state/territory and federal money. Primary care is predominantly paid for by Medicare, while much of the financial cost of providing hospital care is met by the states and territories.

    This poses a major problem for health-care reform. There is an incentive for both the states and the federal government to shift costs towards the other, which can be easily done by moving patients between primary and secondary care.

    Further, the incentive to keep people out of hospital by providing more high-quality primary care is weak, because the government level responsible for primary care (federal) does not reap any savings from this extra investment.

    Community-level organisations such as Medicare Locals are being given small pockets of funding to commission locally, and it is likely that this role will be included in the new Primary Health Networks (PHNs) when they replace Medicare Locals.

    One option is to give local commissioners more power through the PHNs and redirect some state government funding directly to the community-based organisations.

    But caution is required, as English history demonstrates high-quality commissioning requires substantial time and financial investment, as well as effective leadership and the willingness of clinicians to engage.

    Designing a better health system

    Like most other countries, Australia cannot continue to fund the increasing demand for health care, and we need to look for ways to strengthen the role of primary care and keep people out of hospital.

    In the endless debate around how to pay doctors in a way that doesn’t cause over- or under-servicing, adding payments for keeping people healthy is one possibility Australia should consider. But we need to keep in mind the possible negative consequences of such a policy.

    Similarly, Australia should consider supporting local clinicians to make decisions that benefit their community. But because our health systems are so structurally different, the design of such a system for Australia would be a challenge requiring considerable thought.

    This article was first published in The Conversation on 4 September 2014. Richard Norman is Senior Research Fellow in Health Economics at Curtin University, Suzanne Robinson is Associate Professor of Health Policy and Management at Curtin University.

     

  • Jane Tolman. I don’t want to get Dementia.

    Dementia is what many of us fear most, and the effective risk is largely related to age.   The statistics say that at 65 years of age, only 2% have dementia.  But this figure doubles with the passage of each five year period.  By 90, the risk of having dementia is about one in four.  Because of the “survivor effect” (those with the fewest risks will live to old age), the subsequent risk no longer increases at this rate.

    There is no guarantee that dementia can be avoided, whatever we do.  But what does the evidence say about what strategies can reduce the risk? Genes account for only a small percentage of those with dementia, especially among the elderly.

    There is now evidence that the risk can be reduced, and that this will lead to fewer people with dementia.  In fact, we think that if the onset of dementia could be delayed by five years, then the numbers would be halved (Dementia Risk Reduction, prepared for Alzheimer’s Australia, 2007).

    Despite much controversy in recent years about the exact cause of Alzheimer’s disease- the most common form of dementia in the western world- it turns out that the factors which protect against heart disease also protect against dementia. The UK Blackfriars consensus produced this year suggested that within two decades up to 20% of predicted new cases of dementia could be prevented with lifestyle alterations designed to reduce blood pressure, obesity, cholesterol and diabetes.

    So what can we do to minimise the risk of developing dementia?

    The brain is arguably the most important organ and should be treated with respect at all times. “Getting knocked out” sounds bad, and it is. We are now aware that episodes of concussion are bad for the brain and there are reports that head injuries contribute to dementia.  Protect your brain, and not just from toxic substances.

    It’s never too early to start with life style changes. Both physical and mental activity are critical, and the earlier they start, the better. Regular is good- say 30 minutes every day of sustained physical exercise.  Patterns established in youth are harder to break in old age.  When it comes to mental exercise, repetition of familiar tasks is not particularly useful (such as Sudoku or crosswords); there must be real stimulation and challenging to the brain. Learning a language or taking a university course in a new field is what’s needed.

    Connectivity is the new buzz word for dementia.  This relates to the structure of the brain (how nerves connect with each other) and the disruption of neuronal connectivity is emerging as a key component in the impairment of brain function. But it also relates to social connections. People don’t thrive in isolation and neither do brains. As we age, we lose social connections (people die) so it’s necessary to have a large social network when we are younger. Being with people- having relationships, joining groups, developing interests which involve human contact- these will all improve brain function and help to reduce the dementia risk.  Ideally, you should have friends who are younger than you are, but at least a mixture of ages.

    Nurturing the senses is about maximising the inputs to the brain.  Good vision and hearing are among the important predictive factors for a good memory in old age.  Fifty percent of older people have an incorrect prescription for their spectacles, and while most very elderly people have some deafness, hearing aids are often not worn. Now is the time- however young or old you are- to have a check and correct any sensory deficits as soon as possible.

    What should you eat? Moderation and balance will usually do the trick.    Having a healthy weight before old age is critical: in older age weight loss means losing muscle, and this is a sure way of triggering falls, impairing the circulation and immune function. For most older people, care needs to be taken to maintain weight, and to have protein at the centre of every meal.  Salt is bad for the brain as it contributes to hypertension which itself causes damage.  Fats are essential, but are best in balance; avoid saturated fats as these may double the risk of dementia.  Fruits and vegetables are associated with longevity, but also promote good bowel function.  Constipation in old age is the enemy of health, happiness and functioning well, each of which helps us to live the dementia journey better. Broccoli and cauliflower also contain Vitamin E which is thought to be protective against dementia. If you need more guidance, the Mediterranean diet has recognised benefits.

    Alcohol in moderation may be protective, but with excessive amounts (regular consumption in excess of two drinks a day or four in a single session) come increased risks for hypertension, cardiovascular disease and dementia.  Binge drinking may increase the risk of dementia three fold after 65.

    Smoking is a serious risk for a range of illnesses, and if you survive cancers, chronic lung diseases (especially emphysema) and vascular disease (heart attacks and strokes) then dementia is also more likely in your old age.

    Regular blood pressure checks and careful control are essential, as hypertension is the enemy of brain health. Avoiding diabetes, similarly dangerous for brains, means a healthy diet, weight control and regular screens.  See your doctor if there are any new symptoms, especially lethargy, blurred vision, increased hunger, unexplained weight loss or increased thirst.  If you have diabetes, keep the sugars under control.

    Your psyche should be as important to you as your physical health. The responsibility for your state of mind rests with you, and while stress might not be avoidable, how you deal with it is up to you.  If you need help, get it.  Whether you get dementia is not up to you.  But there are ways to reduce the risk, and to make the journey less traumatic if you are unlucky.  What is up to you, is what you know (keep up to date) and your attitude to your health (be positive).  Reducing your risks for dementia is a lifelong undertaking and will make you a happier and healthier person.

     

    Jane Tolman is Director of Aged Care, Royal Hobart Hospital.

     

     

  • David Isaacs and Ian Kerridge. Asylum seeker’s ‘brain death’ shows failure of care and of democracy.

    The news that Hamid Kehazaei, a 24-year-old Iranian asylum seeker detained on Manus Island, has been diagnosed as brain dead following his transfer to the Mater Hospital in Brisbane is a tragedy. That it is a tragedy for this young man and his family is unquestionable The news – but the extent of this tragedy may be much more pervasive than we realise.

    If the emerging details of his case are correct, Kehazaei developed septicaemia as a complication of cellulitis (skin and soft-tissue infection) arising from a cut in his foot. This, in itself, is disturbing.

    Severe infection can result in brain death – either from infection of the brain itself (meningitis, encephalitis or brain abscess), or from brain injury due to a lack of oxygen resulting from cardiac arrest (as appears to be the case here), or from reduced blood supply to the brain. Yet it is very uncommon, especially in a young, previously healthy man.

    Such a case could occur in Australia and has been described in 2012 in young Indigenous adults in Central Australia. Nevertheless, severe sepsis resulting from a foot infection is preventable. And a case like this occurring in an Australian national would raise serious questions about the appropriateness of the antibiotics used and the timeliness of care.

    Most cases of brain death result from traumatic brain injury, stroke or lack of oxygen to the brain following asphyxia, near-drowning, or prolonged cardiopulmonary resuscitation.

    What happened to Hamid Kehazaei raises concerns about the adequacy of care provided to him during initial treatment, including wound care and antibiotics, and how soon he was transferred to expert medical care, first to Port Moresby and subsequently to Brisbane.

    If this young man became ill and had his brain die while seeking asylum in Australia and while in our care, then we must examine the details of his case and ask ourselves not only whether it was preventable but whether our policies and processes actually contributed to his death.

    But how can we even begin to ask these types of questions when we know so little about the circumstances in which he became ill, and his subsequent care?

    Protestations that this is due to the necessity of respecting privacy and confidentiality, ethical principles that are core to the health professional-patient relationship, are to some extent correct. But they also obscure important features of this case.

    The government is simply wrong to claim that this issue should not be “politicised”. What is ultimately at issue here is the way in which domestic politics and border policy impose norms (rules of behaviour) that are antithetical to medicine and health care and, fundamentally, to democracy.

    Medicine, like biomedical science, requires transparency and honesty to be clinically and ethically sound. Peer review, clinical audit, root-cause analysis, family conferences, conflict-resolution strategies, case consultation, multidisciplinary team meetings, mortality and morbidity meetings, open disclosure policies: all rest on the importance of transparency and respect.

    In contrast, we know very little about the people who seek asylum in Australia. Everything is secret – their arrival, their situation, their medical need, their illnesses, and their death.

    This requirement for secrecy has largely overwhelmed efforts by many good people – legislators, human rights lawyers, refugee advocates, health workers, politicians and ordinary citizens – to shine a light on what is happening to people in detention.

    The Immigration Health Advisory Group has been disbanded, restricting the degree to which the health professions can critique the care available to asylum seekers. And even those tasked with providing medical care to asylum-seekers struggle to advocate for the people under their care.

    Policies restrict the degree to which they can care for their patients or refer them for specialist care not available in the detention centres. Contracts bind them to secrecy and many, often shocked by what they have seen, are prevented from speaking out by legal threats and intimidation long after they’ve returned to the mainland.

    The language of “border control” has been used to excuse political secrecy. But such secrecy is what we usually associate with autocratic governments and is the antithesis of democratic ideals.

    What this case illustrates, yet again, is that the asylum seekers detained on Manus and Christmas Islands and Nauru have been excised not only from the laws that determine access to Australia but from the care we should provide any vulnerable person for whom we are responsible. And from the ethical principles upon which medicine and our health system are based.

    If we care about these people, and if we truly believe in the humane values that ground medicine and the moral principles that ground democracy, then we need to do two things. The first is to hold a truly independent inquiry into the care of people in detention. And the second is to end off-shore processing.

    David Isaacs is Professor of Pediatric Infectious Diseases at University of Sydney.

    Ian Kerridge is Associate Professor in Bioethics & Director, Centre for Values and Ethics and the Law in Medicine at University of Sydney. 

    This article was first published in ‘The Conversation’. 

  • Clare Condon SGS. Sanctioned Violence: What does it do to our society and relationships?

    Some violent acts, depending on where and how they were perpetrated, are regarded as criminal. Others, however, are sanctioned by society, even applauded and cheered. Some are blatant; others are covert and subtle. Some are justified by cultural norms, by the blind eye or the deaf ear; they happen behind closed doors. Others are justified by official permission and approval, or even by public opinion.

    I wish to highlight four areas of sanctioned violence which I believe impact adversely on society and relationships. 

    Australia’s response to asylum seekers and refugees

    Currently in the Australian community, the government is justifying the use of violence to stop the smuggling of asylum seekers. This inhumane approach has bipartisan political support; it is driven by public opinion and generated by the politics of the fear of the stranger. The government’s actions are hidden from the public’s eye through secrecy and by holding people in detention in remote areas of Australia, or offshore in developing countries, such as Nauru and Manus Island, Papua New Guinea.

    The government’s often-used mantra “Stop the boats” demonises desperate people fleeing violence and persecution. By using emotive language, this policy is justified in a subtle but no less sanctioned form of violence towards humans. In letters from the government justifying this behaviour, people seeking refugee protection have been called “illegal maritime arrivals”. Their identity as humans has been expunged.

    Such demonisation sanitizes the reality for the Australian public. As a consequence, our societal and racial relationships are diminished and subtly eroded. We can begin to believe that some humans are more worthy than others, and that such actions are justified and normal, when in fact the government of the nation is engaged in sanctioned violence.

    Children are being held in detention centres. ..These children are exposed to brutal, negative and neglectful modelling. The consequences of such detention are likely to breed a dissociative reality for these children, leading to a spiral of hatred and evil within their own life experiences.

    As citizens we must ask: what behaviour do we propose for the future human development and relationships for these innocent children? Is society encouraged to be vindictive, self-serving, aggressive in all its relationships with anyone who is identified as a stranger, rather than a society which is welcoming, other-centred, and compassionate, respecting the dignity of the other in those relationships? One response from the government stated it would not be involved in “misguided compassion”. True compassion is a strong virtue. It is the antithesis of violence. There is nothing weak and soft about a well-guided compassionate response. 

    Sanctioned violence in sport

    Sport is a feature of a nation’s life and culture, especially in Australia. It has an essential role to play in a healthy society. Violence on the playing field and amongst spectators not only sets a bad example to impressionable young people, it is destructive of basic civil relationships. It can instil fear and anxiety, especially in children. . There are significant vested interests to subvert any attempt to study the area in a serious manner.

    It seems that violence in contact sports has increased. I suspect that the introduction of high monetary stakes, as well as sports betting, has influenced this increase. Do the normal expectations of civil behaviour cease once players step onto the field? Does the constant replay of violence and thuggery seek to justify this behaviour?

    One is not a ‘real man’ unless he is like these highly paid, macho stars. Is it not time for some extensive research on the facts and some community discussion on the type of role modelling that sport ought to be portraying to young people, and what kind of relationships society might expect to support and sustain in an advanced civil democratic society? 

    Domestic violence – the hidden nightmare for many women and children

    You might think it odd that I have placed violence in sport before one of the most hidden and often sanctioned – violence of the household or domestic violence – which impacts mostly on women and children. It is often hidden, excused and justified from a male perspective. The macho image often promoted by sport can become the macho image for some men in their daily behaviour. Are they connected?

    Australian research[1] indicates that: 17% of women aged 18 and over have experienced sexual assault since the age of 15; 87% have a relationship with the perpetrator; only 1 in 7 who experienced violence from an intimate partner had reported the most recent incident to police; women with an intellectual disability are 90% more likely to be subjected to a sexual assault than women in the general population.[2] Between 2010-11 and 2012-13, there was a 29% increase in the number of children who were subjects of substantiations of sexual abuse, thereby reversing previous downward trends.[3] Most of these are from the lowest socio-economic areas.

    These statistics are chilling. Domestic violence often leads to homelessness, further abuse of children, significant health issues for the woman and her children, ongoing economic hardship, unemployment, and social, psychological and family isolation. Thus, the capacity for building strong, healthy and mutual relationships in the future is undermined and damaged severely.

    Does media violence have an impact on human behaviour?

    There would be some who would say the jury is still out. Conflict is what makes a good story! Violence has always been part of the movie world, but now violence in movies, TV shows and electronic games has become the norm. They are louder, bloodier and more vicious. Some US research suggests that by the time a child is 18, he or she has watched some 200,000[4] acts of violence.

    There have been hundreds of reports with diverse views on the impact of media violence, particularly on children. However, there is reasonable consensus that long exposure of children to violence portrayed in the mass media leads to long-term aggressive behaviour.[5]

    My concern is the impact sanctioned violence has on society and our relationships. Some of the consequences can be corrosive and long-term. Where violence is sanctioned and regarded as acceptable and routine, then societal norms are being established for the future. Such acts become embedded in the cultural fabric of society.

    If it is acceptable for a government to treat strangers in a cruel and demeaning manner, then it becomes acceptable for the citizen to treat the stranger in a similar manner. If it is acceptable to use excessive violence on a sports field, then why not off the field in school yards? If it is acceptable to exercise violence in the private space of home, then why not on the streets? If it is acceptable to spend hours watching real or virtual violence on a screen, why not activate the same violence in ordinary relationships?

    My congregation of religious women follows the fifth-century rule of St Benedict, a way of life which helped to civilise Europe after generations of wars. Benedict’s dictum for his followers was that all should be structured so “that the strong have something to strive for and that the weak have nothing to run from”.[6]

    In those areas of our society where violence is sanctioned, we citizens need to actively participate in social engagement and collective action. We need to say no more, we can do much better. “Compassion is the very final possibility for saving the human person in his or her naked existence in the face of the direct negation of this existence”.[7]

    This is an edited version of an address delivered by Sister Clare Condon SGS at the Australian Human Right Commission https://www.humanrights.gov.au on August 13, 2014.

    Sister Clare Condon is the Congregational Leader of the Sisters of the Good Samaritan of the Order of St Benedict, Australia’s first ‘home-grown’ congregation of Catholic Religious women www.goodsams.org.au


    [1] Cindy Tarczon and Antonia Quadara, The Nature and Extent of Sexual Assault and Abuse in Australia, December 2012, The Australian Centre for the Study of Sexual Assault www.aifs.gov.au/acssa/statistics.html

    [2] CASA Forum 2014 Victorian Centres Against Sexual Assault

    [3] The Child Protection Australia Report 2012-13 of the Australian Institute of Health and Welfare

    [4] American Academy of Paediatrics, Media Violence, 19 October 2009 http://pediatrics.aappublications.org/content/124/5/1495.full

    [5] The Australian Psychological Society in 2013 updated its report: Media Representations and Responsibilities: Psychological Perspectives

    [6] Rule of Benedict, Chapter 64:19

    [7] Walter Kasper, Mercy, Paulist Press, New Jersey, 2013, p.29

     

     

  • John Menadue. Who owns Medibank Private (continued)

    In my blog of August 14 I examined the question of who owns Medibank Private (MBP) particularly in light of the Abbott Government proposal to privatise the business. This is not an idle question or an academic issue only. MBP has 3.5 million members and the government has estimated its sale value at $4 billion.

    The Government has now announced that MBP will be sold by Christmas

    It is clear that for many years it was assumed that the policy-holders/members owned MBP. That is clear from an examination of the accounts and the comments of a former chairman of MBP. John Deeble who was an architect of Medibank/Medicare and who was a director of the Health Insurance Commission which operated MBP put the issue as follows ‘The question of ownership in 1976 (when MBP was established) wasn’t raised because it was never considered that the government owned MBP.’

    The Commonwealth Government put $10 million as seed capital into MBP. This amount was repaid. The operating capital of MBP over the years was then contributed by the members through accumulated profits… No further capital contribution by the Commonwealth Government was made until 2005 when the Howard Government injected $85 million into the business. This amount has remained unchanged for nine years.  Last year MBP paid a dividend of $450m to the government. In one year the government received in a dividend more than five times what it had contributed in equity.

    In addition to the policy issues, it is also important to consider the legal advice which has been offered to the Commonwealth Government.

    In 1981 the Fraser Government considered selling MBP. According to Cabinet documents that have been released, the issue of selling MBP was considered by the Fraser Government’s Expenditure Review Committee – ‘the razor gang’. Members of this committee were Phillip Lynch, Margaret Guilfoyle and John Howard.

    The government’s legal adviser was the Attorney General’s Department which together with the Government Actuary and the Department of Health advised the ‘razor gang’ that the Commonwealth government did not own the assets of the Health Insurance Commission. We know from publically released Cabinet documents that on 19 March 1981 the Expenditure Review Committee decided that ‘the Commonwealth does not in any legal sense have equity in the Health Insurance Commission or its assets’.

    Three days later the Committee recommended to Cabinet that the proposed sale of MBP be abandoned. And it was abandoned.

    In 1988 the Hawke Government was contemplating the sale of MBP. The chairman of the Health Insurance Commission set out clearly in the authority’s annual report at that time that the Commonwealth had no beneficial rights in the fund’s assets.

    It is hard to see that anything has materially changed since 1981 when the clear view of the Fraser Government, based on legal advice was that MBP was owned by its members and not the Commonwealth government.

    The 3.5 million members of MBP have a major interest in this business which the Commonwealth Government now values at $4 billion.

    According to Peter Martin in the SMH today, policy holders are petitioning the government for ‘free shares’. This would seem essential but will it be fair? We know that there are a lot of hanger’s on clipping the ticket- co-lead managers, co-managers, brokers, advisers, lawyers and MBP executives. They will all be making a motza. But as for the members!!

    I am indebted to George Lekakis and The New Daily for the work they have undertaken on the ownership of MBP.

  • John Dwyer. The structural reform of Medicare rather than its funding is the real challenge.

    Part 2: Attracting the future work force needed to provide Primary Care.

    There is another imperative for introducing Integrated Primary care (IPC),the new model of primary care described in part one of this review; the recruitment of the next generation of GPs.

    Recent surveys of the career intentions of medical graduates show only 13% are interested in a primary care career and only 13% of them have any interest in working in rural Australia. They see that 70% of GPs do not want to be tax collectors for the government and note that the Medicare rebate for a standard occasion of service has been reduced to $31.60. GPs are specialists aren’t they? This is not attractive remuneration especially when socio-economic circumstances leave 80% of GPs with little option but to bulk bill their patients. This in turn leads to “turnstile medicine: unsatisfactory to both practitioner and patient, and the well documented poorer health outcomes associated with this form of practice. Many GPs want to move away from the “fee for service” model and try to do so by joining the “corporate” GP world. There many are dissatisfied with the model of care imposed on them.

    On the other hand young doctors considering a career in primary care are attracted to the IPC model; after all they have seen team medicine as a normal activity in our hospitals.  In New Zealand 85% of GPs have voluntarily abandoned fee for service payment in favour of salaried or contractual payments.  The same is true for 65% of US GPs. Currently about 65% of GP practices in Australia feature three or fewer doctors. However good the care on offer these are not strong economic units. IPC practices, established as companies with community representation on their boards, offer great flexibility and the chance for the clinicians working in the clinic to develop equity in the business. This is important as our GP specialist on average earn far less that many of their colleagues.

    IPC Clinics also facilitate the introduction of other urgent reforms. Pre-agreed per capita funding for patients with defined chronic conditions, if established competently by peer review, offers opportunities for better outcomes to be rewarded. There is an excellent opportunity for the planned replacement of “Medicare Locals” with “Primary Care Networks” to facilitate the introduction of IPC into Australia. Current discussions suggest that there are to be 21 PHNs established across the country. There mission statements are yet to be clearly defined but the better integration of patient care will be a major focus. By sponsoring geographically local sub-units (Lets call them Primary Health Care “hubs”) within defined Local Hospital Districts, affiliated IPC clinics in the area could be provided with the centralised assistance needed to better operate their care model.  IT expertise, bulk purchasing, continuing education resources, in house review of new drugs, meeting with local hospital clinicians re patients frequently readmitted to hospital and many other initiatives could be available. Although the review commissioned by the government recommended that PHNs not engage in clinical work, a number of primary care hubs in New Zealand offer acute care services and even run observation wards where patients can be treated for many hours while a decision re the need for hospital admission is made.

    So can we afford to introduce these structural reforms? The reality is that we cannot afford not to. Hospital expenditure dwarfs Medicare expenditure and increases more rapidly. The future of affordable quality hospital care is inextricably linked to better primary care reducing the demand for hospital services.

    IPC would provide us with many more healthy Australians whom we are predicting will need to work longer .A 40% reduction in avoidable hospital admissions would save us at least $12.5 billion a year and reduce much personal suffering. It can be estimated that these results would require an additional $5-7.5 billion a year being spent on Primary Care by the time the changes are fully introduced nation wide. Diverting the dollars spent on subsidising private health insurance would almost supply the money needed but there are many other savings that would follow structural reforms. Increasing the level of health knowledge among Australians would see them stop looking for health out of a bottle and provide the almost $3 billion they spend on unnecessary supplements, vitamins and “good bacteria’ for better primary care help. Better attention of many doctors to the need for an evidence base for the care they give could save $20 billion spent on low value or no value procedures. Nine departments of health for 23 million Australians comes with duplication costs of at least $3 billion.

    The reality at this time of course is that the Abbott government has shown no interest in structural reform for our health system. The peak advisory body on Prevention has been discontinued. However we must continue to engage the community in a discussion of what they want from their health system and alert Australians to the benefits of IPC. Adequate penetration of the new IPC model with all the structural and cultural changes required would take at least a decade.  We can all live with this journey providing the destination remains clear. The journey needs public support and bottom up implementation from within the health professions themselves. Politicians need not fear the slowness of progress within the election cycle. These reforms are achievable as we can note from numerous successful implementations elsewhere. The community will applaud the political leadership that commits us to the journey and supplies the infrastructure to drive the initiative. Ideally a transition authority would be established to guide us on the journey. The challenge now is to find that political understanding and leadership that will help us take that “first step” that must start all journeys.

    John Dwyer is Emeritus Professor of Medicine UNSW

     

     

     

     

  • John Dwyer. The structural reform of Medicare rather than its funding is the real challenge.

    Part 1; The model of primary care we need for contemporary Australia.

    For months the federal government has been telling us that a mandatory co-payment for a visit to our GP was essential to afford the $19 billion we currently spend on Medicare each year and projected increases. There would be an added benefit in that the payment would send a price signal to remind Australians that such visits can no longer be free. Too many of us are visiting our doctors too often! Additional revenue would be generated by a seven-dollar co-payment for prescriptions, pathology and imaging. Given the above propositions it is confusing to say the least that our government now plans to put every penny raised by these co-payments into a medical research fund that should eventually be the largest such fund in the world. Perhaps Medicare spending is not so unsustainable after all. International evidence tells us that we should be spending more on Medicare funded services to reduce total health expenditure. How would this work?

    Medicare needs to evolve from a universal insurance entity that pays doctors bills to one that funds clinicians who will provide a specific model of care. An uncapped payment of doctors “fees for service” not tied to any health outcome measures is not a satisfactory way to use taxpayers health dollars. World wide the move is to achieve better health outcomes more cost effectively by focusing on delivering  “Integrated Primary Care” (IPC) available from a person’s “Medical Home”.

    In our doctor centric health system, Australians visit their GP when they have a problem. They do this, on average, seven times a year. Many should go far more often to improve their health and many who need care the most visit their doctor infrequently. The burden associated with chronic and complex and often-incurable disease, compromises the quality of life for too many Australians, dominates the care requirements of many GP practices and cost us all a fortune. Given that so much of this suffering is preventable why is their so little emphasis on prevention and the provision of the health infrastructure to facilitate prevention? Only 2% of the annual $180 billion health spend in Australia involves prevention.

    At the other end of the care spectrum our Primary Care system lacks the infrastructure to care for many in the community and thus avoid the need for hospital care. We have more inpatient “overnight” beds per capita than any other OECD country and yet at the moment we need more. We hear almost daily about access problems for patients stuck in Emergency Departments because there is “no room in the Inn”. What our government does not seem to appreciate is that annually some 600,000 of these admissions (cost $ 30 billion) could be avoided with an effective community intervention in the three weeks before eventual hospital admission. The University of Melbourne studied this matter and found that each year seven million bed days are consumed by avoidable hospital admissions. We spend more than $140 billion on public hospital care each year, seven times more than we spend on Medicare. If we had one level of government funding health care instead of our destructive jurisdictional division of government responsibilities (States for hospitals; Canberra for Primary Care) we would readily spend more on Primary Care models that would reduce the need for so many hospital beds.

    The preferred model of IPC involves establishing a practice (Medical Home) populated my clinical teams, (doctors, nurses, allied health professionals a dentist etc) in which patients enrol with the understanding that they and the team share the responsibility for keeping them well and providing the best possible care when they are ill. The psychology of enrolment is all-important as is the principle that the most suitable members of the team will care for one’s current specific needs. Health maintenance is regarded as an active endeavour. This is evidence-based personalised care. Health literacy and lifestyle analysis, and support for needed changes, might be facilitated by specialised nurses and nutrition experts. Continuity of care improves the chance of early diagnosis and treatment of problems that could become chronic (early signs of adolescent mental health issues for example).

    Team management of chronic conditions with a team based case manager and care for fragile members of the practice in the community by appropriate clinicians to reduce the incidence of hospitalisation are also important initiatives. There is one medical record and rapid access to team members is facilitated by IT connectivity.  Well-established IPC units in other countries have reported up to a 42% reduction in the need for hospital care. Such a model makes best use of the unique skill set different health professionals possess, so different from our current “silo” mentality that makes the integration of an individual’s care so difficult. So successful is this model that already universities around the world are concentrating on moving to inter-professional learning curricula, “Team learning to prepare for team practice”.

    This is “Managed Care”, a term that conjures up in the mind discredited model of care available in the US. There are three players making decisions in much of the US system, the patient, the care team and the patient’s insurer. The latter, famously documented in Michael Moore’s documentary on the issue, all too often interfere with care plans even vetoing them on grounds of affordability. We need to think carefully about the wisdom or otherwise of allowing our private health insurance industry (PHI) to cover members primary care expenses. I would be less worried about interference in care plans here than in the likely creation of a “two tiered” primary care system in which those who can afford PHI would enjoy much better primary care than those who could not. The resulting furtherance in the inequity palpable in our current system would not only be un-Australian but expensive.

    Part 2 of this series will be posted tomorrow. It covers the necessary changes in the health workforce. 

    John Dwyer is the Emeritus Professor of Medicine at UNSW.

     

  • Elizabeth Elliott. Compassion goes missing on Christmas Island

    When it comes to children in need, most Australians feel compassion.

    Most will applaud today’s announcement that ‘Boat Kids’ will be released into the community. However this decision does not go far enough. It includes only kids aged less than 10 years (excluding many vulnerable teens); only those detained on the Australian mainland (excluding kids on Nauru, Manus and Christmas Islands); and only kids who arrived before July 19th 2013. Furthermore, the number to be released includes kids already living in community detention housing.  

    Christmas Island is a remote tropical ‘paradise’ in the Indian Ocean, over 2600 km from Perth or Darwin. When I visited with the Australian Human Rights Commission in July 2014, as part of their Inquiry into Children in Detention, it was ‘home’ to 174 children, including 26 unaccompanied minors – all boys aged between 14 and 17 years.  Australia continues to detain kids, despite the United Nations Guidelines on the Detention of Refugees that ‘Children should not be placed in detention’ and that ‘Minors who are asylum-seekers should not be detained’.

    Compassion, it seems, has gone missing on Christmas Island.

    ‘Home’ for families in these immigration detention centres consists of a small metal cabin, some 3 x 3 metres squared in one of two rows of similar cabins separated by a wooden walkway. Add a bunk bed and a cot to the rooms and there remains little space for a child to learn to crawl or walk, or for exploratory play. According to the father of a 2 year old boy “the housing is dirty, sub-standard, hard to be there. The child keeps hitting his head on items in the room – the bed, the shelf – because of the lack of space.”

    Cramped conditions, a punishing climate and overcrowded living in close proximity to scores of families make for little privacy and dire health consequences. Childhood infections spread quickly. When we were there many children had a respiratory virus and there had been outbreaks of gastroenteritis. We repeatedly heard the refrain “my kids are always sick.”

    The air-conditioned environment exacerbates symptoms in the many children with asthma. Others have medical conditions requiring assessment, medical or surgical treatment on the mainland – and for some the long wait for transfer had been intolerable.  A two and a half year old with no speech, a 6 year old with deafness requiring grommets for glue ear, a child with a facial abscess needing surgical drainage, a boy with an undescended testes, a child with rotten teeth, a girl with sleep apnoea….

    Of greater concern than signs of physical ill-health, however, are the psychological symptoms we heard of from many children.

    They reflect past and ongoing trauma, including the depression and self-harm many have witnessed in their own mothers. Stress in young children was manifest by onset, in detention, of bed-wetting, nightmares and defiant behaviour. In older children we heard of refusal to eat, separation anxiety, regression of speech, development of stutter, mutism and social withdrawal. Some expressed their stress through their art. A 10 year drew his ‘family home in jail’ and a six year old drew herself behind bars, with the caption ‘I want go out’ . Crying was ubiquitous in these images.

    Conversations with teenagers, who could articulate their predicament, were particularly poignant.

    They became distressed, describing flashbacks of trauma experienced at home, during harrowing boat trips to Australia, and during their time on Manus, where some were sent as a result of incorrect age determination. According to one boy who went to Manus, ‘I saw with my own eyes one boy hung himself in a cupboard – they were taken to hospital.’ They talked of their fear of being returned to Manus when they turned 18. 

    All spoke of feelings of hopelessness, sadness and lack of a future. They talked of frequent crying, families missed, lost expectations, lack of education and feelings of guilt because they had not fulfilled their family’s hopes after more than a year in ‘Australia.’  One boy summed this up as ‘a horrible situation. I feel depressed, preoccupied with my misfortune. I have not smiled or laughed the last few months. There is nothing to make me happy or to tell my family to make them happy.’  Some talked of self-harm and some spoke of death. In the words of one 12 year old girl ’My life is really deth. I don’t know why I’m in the jail realy. I don’t kill any body.’

    Detention of children for lengthy periods is in contravention to the UN Convention of the Rights of the Child. This states that ‘The arrest, detention or imprisonment of a child shall be in conformity with the law and used only as a measure of last resort and for the shortest appropriate period of time.’ The UN Human Rights Committee reiterates this: ‘Asylum seekers who unlawfully enter a State party’s territory may only be detained for a brief initial period in order to document their entry, record their claims, and determine their identity.’  Most people have now been detained on Christmas Island for over a year and the anniversary of their arrival came as a bitter blow for many.  One man asked ‘Is it the Australian government’s aim to make us all go mad?’

    As victims of a policy that dictates that any arrival by boat after July 19th 2013 will never be settled in Australia, many have accepted their fate of settlement offshore. But their arbitrary detention without assessment for refugee status has left them in an intolerable limbo. One father said ‘If they won’t have us in Australia, find somewhere else for us to go. We can’t go home.’ A mother expressed her anguish, ‘The criminals, at least they know their sentence – we don’t.’ Many felt guilty for placing their children in such a predicament. As one mother said, ‘Even if I did something wrong, coming here, why ruin the life of our kids?’

    As a reflection of their increasing despair and frustration about the adverse conditions for their children, a group of young mothers with young infants resorted to self-harm.

    When we visited 10 such women – deemed at future risk – were under 24-hour surveillance by guards, not nurses. Despite this mental health crisis the centre has no resident psychiatrist. ‘I swear the physical health is not so much a problem. It is the stress and the psychological impact of the detention that is getting to us,’ said one mother of two.

    It is outrageous to keep asylum seekers in the limbo of uncertainty. It is unacceptable to keep children in detention on Christmas Island, and it is unjust to deny children optimal health care and education.  One mother said ‘one of the most important concerns for my baby is he has not received his BCG vaccine – when everyone in the world should receive it. They say ‘we don’t have it’ or ‘later’ – the story changes.’ In the words of one child, ‘I not want to sit in jail? I want to go school….in here no have school everyday. Please help me?’

    Australians might well ask ‘Where is the compassion on Christmas Island?’

    If we are to retain our international standing as a civilised society, we cannot continue to persecute children seeking asylum as a deterrent to others.

    Elizabeth Elliott AM, is the Professor of Paediatrics and Child Health, Sydney Medical School and Consultant Paediatrician at the Children’s Hospital at Westmead.

     

     

     

     

     

  • John Menadue. Who owns Medibank Private?

     The government has announced that it hopes to raise $4 billion from the sale of Medibank Private. But like many of its budget ‘savings’ it might find that it has to rely in this case  on the High Court rather than the Senate to decide if the $4 billion ‘saving’ can be realised.

    The case has been made by many people that the government is not the owner and certainly not the sole owner of Medibank Private. A view is strongly held that Medibank Private is owned by members/policy holders of Medibank Private. There are 3.8 million members. There is not much doubt that Medibank Private’s equity including accumulated reserves has come overwhelmingly from members’ contributions. At 30 June 2013 issued capital was $85m. Retained earnings were $1.3b. The market value of Medibank Private is estimated to be $4b by the government’s financial advisers.         .

    Medibank Private was first launched in 1976 with operations placed in the hands of the Health Insurance Commission (HIC).

    An examination of Medibank Private’s accounts by The New Daily (George Lekakis) reveals that before 1997

    • In 1988 the Chairman of Medibank Private, Fred Miller, wrote to Health Minister Neal Blewett that ‘Medibank Private is a non-profit organisation based solely on its contributors’ funds. The government has no financial interest in Medibank Private’s assets and reserves. Medibank Private’s assets and resources are the property of its contributors.’ This view by the Chairman was spelt out many times in statements and financial disclosures.
    • Members were officially recognised as ‘equity holders’ in the business from 1993 to 1996.
    • The balance sheets of Medibank Private before 1997 clearly show that the members owned the net assets of the company and not the government.

    The accounting treatment of Medibank Private was changed in 1997 by the Howard Government. This established government control and ownership of the fund.

    • In 1997 the term ‘members’ equity’ was removed from the balance sheet and replaced with a new concept of ‘fund equity’.
    • The Howard Government then directed the Health Insurance Commission to transfer equity of the fund to a new government-owned company known as Medibank Private.

    It would seem that the actions of the Howard Government and later the Rudd Government were designed to extinguish the rights of the members/contributors.

    The Australian Government can acquire the private assets of citizens under Section 51 of the Constitution but the acquisition must be on ‘just terms’. It is arguable that extinguishing completely the rights of contributors – the early ‘equity holders’ – can hardly be said to be on ‘just terms’.

    I must confess that I have a personal interest.  I have been a contributor/’equity-holder’ since 1976. I have contributed tens of thousands of dollars in premiums. Most of it has been a waste of money, but I suppose it gave me something called ‘peace of mind’ but not much more.

    Who owns Medibank Private? The High Court may be called upon to tell us.

     

    In my blog of March 26, 2014 ‘Privatising Medibank Private, who cares’ I argued the all health insurance, whether public or private is parasitical. Warren Buffett described PHI as the tapeworm that is destroying the US health system.

  • Peter Sivey. Health budget: GP care isn’t the problem, costly specialist care is.

    The opening of eight new medical schools in Australia in the past decade has seen a massive increase in the number of new doctors entering the workforce. The number of new junior doctors graduating in Australia doubled between 2004 and 2011. But while fears of an overall shortage of doctors seem assuaged, we don’t have the right mix of doctors.

    A recent trend is the increasing specialisation of the medical workforce. In 1999, 45% of Australian doctors were general practitioners (GPs) but this proportion had fallen to 38% by 2009. Similar trends can be observed in the United States and United Kingdom.

    This trend is concerning because primary care, provided by general practitioners, is the most efficient and equitable type of health care, particularly preventive care and the management of chronic disease. These components of GP-provided care have the potential to improve health outcomes, lower costs and reduce the need for future more costly interventions.

    In contrast, specialists tend to be reactive and expensive, seeing patients only when a health condition has taken a turn for the worse, when surgery, expensive pharmaceuticals, or other intensive treatments are required.

    Of course, a modern health-care system needs a high-quality specialist sector; specialists are the doctors patients rely on when they’re sickest. But workforce planners should strike the right balance between primary care and specialist physicians.

    So what is causing the growing imbalance towards specialism in medical career decision making?

    Our recent study asked junior doctors in Australia about their job preferences. We did this using a discrete-choice experiment, where respondents made hypothetical but realistic choices about their future career. By analysing their responses statistically, we could tell what factors drove their choices.

    Our results show a range of factors affect choice of speciality. Opportunity to practice procedural work and academic opportunities are some of the factors that drive junior doctors to specialise rather than choose general practice. But the elephant in the room is money.

    Specialists in Australia earn almost twice as much as GPs. Survey data shows average earnings in 2012 of $194,000 for GPs and $360,000 for specialists. Even when adjusted for the longer hours that they work, specialists’ hourly wages are still 60% higher than GPs.

    We found expected earnings have a large effect on choice of speciality. But lowering the income gap could redress the situation. Our modelling shows that increasing GPs’ earnings by A$50,000 per year (a 28% increase from 2008 levels) would increase the number of junior doctors choosing general practice by 11%, or 247 more trainee GPs per year.

    So, how can policymakers increase GPs earnings relative to specialists?

    The main policy tool available is Medicare. Medicare influences GPs’ earnings via rebates for the consultations they provide. Increasing Medicare rebates for GP services would therefore be a simple way of increasing their earnings. Of course, this is entirely the opposite of current government policies to introduce co-payments for bulk-billed consultations and reduce rebates.

    Innovative payment mechanisms may provide a more cost-effective way of increasing GPs’ relative earnings. Introducing additional funding sources using capitation (where doctors are paid for looking after enrolled patients for a whole year, not just per consultation) and pay-for-performance would allow earnings increases to be linked to higher quality of care, rather than just the number of consultations provided.

    Increased earnings for GPs needn’t blow a hole in the budget either. Offsetting savings could come from targeted reductions to Medicare rebates for specialist services, which would reduce the earning power of specialists, especially those working in private hospitals on privately-insured patients.

    In 2012/13, the government spent $3.9bn subsidising private specialist consultations. A proportion of these Medicare subsidies could be redirected to GP consultations.

    Together, these measures could reduce the relative earnings advantages of specialists over GPs, encouraging more junior doctors into general practice.

    Peter Sivey is Senior Lecturer, School of Economics at La Trobe University. This article was first published in The Conversation on 7 August 2014.

     

  • How does Australia’s health system compare.

    The Treasurer, the Minister for Health and the Commission of Audit have warned us in one way or another that the Australian health service is unsustainable, particularly with an ageing population. The Treasurer tells us that the age of entitlement has to end in health as elsewhere.

    We need to keep modernising Medicare but by almost any international comparison we have one of the best and most sustainable health services in the world. We need to keep our problems in perspective.

    The Commonwealth Fund publishes a regular research report on health systems in major countries. The Commonwealth Fund is a highly regarded private US foundation that compares major systems around the world to stimulate innovative policies and practices in the US and elsewhere.

    In its 2014 report ‘Mirror, mirror on the wall’ it compares the performance of healthcare systems in eleven major countries. The comparisons cover quality of care, access, efficiency, equity,‘healthy lives’ and health expenditures per capita.

    Its overall health ratings for these eleven countries were as follows:

    1. UK
    2. Switzerland
    3. Sweden
    4. Australia
    5. Germany and Netherlands (equal)
    6. .
    7. New Zealand and Norway
    8. .
    9. France
    10. Canada
    11. US

    On almost all the measures the UK with its National Health Service is a stand-out performer. It has well and truly stood the test of time. The single payer nature of the UK health service is its strength. The regular laggard in almost all these rankings is the US. It tells us a great deal about the failure of a health service based on multiple private insurance payers. (Our private health insurance lobby is trying to take us down this disastrous US path.)

    When one looks at the break-down of these rankings, the UK ranks at the top in quality of care, access, efficiency and equity. US ranks last in access, efficiency and equity. What is more, the UK system is the cheapest at $US3,405 per capita in 2011 compared with the US, the most expensive at $US8,508 per capita in that same year.

    As indicated above, Australia stands at number four in overall rankings amongst the eleven countries. In particular areas we ranked as follows

    • In quality of care we ranked number 2.
    • In access, we are well down the list at number 8. This reflects in part our high level of co-payments or out of pocket costs. The proposed $7 co-payment will add to our problem of access.
    • In efficiency, we rank number 4.
    • In equity we rank number 5, which reflects in part our failures in mental health, indigenous health and in remote healthcare.
    • In ‘healthy lives’ we rank number 4.
    • In health expenditure per capita in 2011 at $US3,800 we were the third lowest amongst the 11 countries.

    Another measure of our success of course is our high life expectancy.

    It is quite clear that by world standards we rank quite well. We are behind the UK, but far ahead of the US. The single payer Medicare has also stood the test of time.

    But there are ways that we could improve our health services.

    • Mental health, indigenous health and remote healthcare are major shortcomings.
    • Our co-payments are confused and inequitable.
    • Subsidised private health insurance makes it harder for Medicare to control costs. (I find it hard to put up with the gall of the private health insurance funds that will never publicly debate their cause, privately lobby ministers in order to achieve results that will take us down the disastrous US path.)

    There are many ways in which the efficiency of our system could be improved and costs better managed.

    • The split of commonwealth and state responsibilities adds to costs and hinders integration of hospital and non hospital care.
    • The remuneration of doctors through fee-for-service is a perverse incentive which encourages over-servicing and over-prescribing. It also hinders the treatment of long-term chronic sufferers.
    • The government subsidy to private health insurance adds $5 billion plus per annum to government costs, benefits the wealthy and weakens Medicare.
    • Australian drugs cost substantially more than in NZ..at least $2b. pa.. because of the clout of Medicines Australia in negotiating prices with the Australian government.
    • With its lobbying power, the Australian Pharmacy Guild protects pharmacists from competition.

    There is a lot we can do to improve healthcare in Australia and better manage costs. But overall, we have a very good and sustainable health service which ranks well against comparable countries. We need to keep a sense of proportion.

    For further information on the Commonwealth Fund Report, including the overall rankings, google The Commonwealth Fund and search Mirror, Mirror on the Wall 2014 Update.

  • Turning the federation clock back to 1901.

    The Commission of Audit has made many unhelpful suggestions about budgetary and economic issues. It seems to have been driven more by ideology than fact.  See my blog of May 1 2014 “The Commission of Audit and facing the wrong way”.

    One of its most unhelpful suggestions is that Australia returns to the 1901 intentions of the federation fathers and with clear lines of responsibility drawn between the commonwealth and the states as set out in Section 51 of the Constitution. The Abbott Government’s terms of reference for its White Paper on Federalism also suggest that his government would like us to go back to the arguments about sovereignty. We are being urged to look back to 1901 rather than focus on the way our constitution has evolved to date and will need to evolve in the decades ahead.

    This sterile debate about states’ rights comes and goes, but the issue is never resolved. Malcolm Fraser attempted to do what Tony Abbott now suggests – defining sovereignty clearly between the commonwealth and the states. But Malcolm Fraser’s plans went nowhere. The same will happen over the present intentions of the government.

    In his blog on the Federation on May 23, 2014, Michael Keating set out very persuasively I thought why the national government has become pre-eminent and why that trend is likely to continue.

    • We now have a national market and face strong global competitors in a way that our founding fathers would never have dreamt of.
    • The powers of the commonwealth government have grown remarkably eg pensions, health services, managing the national economy and migration.  The exercise of these powers by the commonwealth government has been necessary and beneficial.
    • The commonwealth government dominates the taxation field and that will continue. The states could impose state income taxes but have chosen not to. High Court decisions over the long term have been consistently against the states in key areas.

    With three levels of government, commonwealth, states and local government, we are over-governed. With the territories we have nine departments of health, nine departments of education, nine departments of transport, and so on. There is great waste and duplication.

    The best solution would be to abolish the states as Jeff Kennett and others have suggested and replace them with fewer local government bodies that have substantially increased powers and coverage. That would best serve Australia’s interests but unfortunately the abolition of the states is not going to occur.  The states remain poor and proud.

    But there are possible ways that we could reduce duplication, waste and the blame-game between the commonwealth and the states.

    The two biggest areas of overlap, confusion and expenditure by the states and the commonwealth are in education and health. In 2010-11, education spending by the states and territories was $48.1 billion or 24.3% of total state spending. In that year, spending by the states and territories on health was $49.9 billion or 25.1% of total state spending. Health funding by the states is likely to remain the fastest area of expenditure growth.

    Together education and health are responsible for over one half of state budgets. Reducing overlap, confusion and spending in these two areas would make a substantial contribution to our federation and particularly the delivery of improved education and health services at lower cost.

    For years I have argued that in the health field the best solution to end the blame-game and confusion, and to integrate health services and improve the quality of care, would be to establish a small joint commonwealth-states health commission in any states where political agreement could be achieved. See my blog of June 3 ‘The blame-game in health’. A small planning commission would cost very little compared with large likely cost savings. Further the cost could be reduced by scaling back commonwealth and state government health department costs.

    A joint agreement on governance in health, the pooling of all commonwealth and states health funds in that states, and the implementation and monitoring of an agreed health plan in that state would be a major improvement in health services. Those services would continue to be delivered by the existing suppliers – commonwealth, states, local or private. An obvious example of the benefits of such a joint health commission is a reduction in hospital admissions. It is estimated that about 750,000 admissions to public hospitals each year in Australia could be significantly reduced if the commonwealth government improved the services available in primary care in the critical weeks before hospital admission. The problem is that the commonwealth largely funds primary care and the states largely fund public hospitals with poor integration between the two.

    Implementation of such a joint arrangement would be relatively easy. The real obstacle is securing a political agreement.

    We should also keep in mind that when Kevin Rudd proposed a takeover of states hospitals as a last resort, there was strong public support for this action as shown in opinion polls. Unfortunately he backed down and the health confusion continues.  The public would be open to a major reform in health.

    I am confident that joint arrangements in health that I have suggested would be the best way to end the confusion between commonwealth and state responsibilities. It would be more in keeping with our current needs and aspirations than going back to the federalism of 1901.

    It was a great achievement for Australians to come together in the federation of 1901. It was a real break-through at the time but the split of commonwealth and state responsibilities in 1901 is not particularly helpful for us in this century or the next.

    The key features of such an arrangement in health could be applied in the education field.

    Although with some rancour, our federation has evolved since 1901. We should look forward to the sort of society and economy that we should become in the future rather than nostalgically looking back to 1901.

  • Rod Tiffen. ‘The Australian’ and tobacco consumption.

    As the Australian approaches its 50th anniversary amid much self-congratulation, an insight into its editorial standards and how it conducts itself in controversies is provided by its recent reporting of competing claims over tobacco consumption.

    Tobacco is still the largest preventable source of premature death in the world.

    Despite the scale of its damage the Australian’s owner Rupert Murdoch has always had a curious attachment to the tobacco industry.  He was on the Philip Morris Board for a decade, and members of that company have often been on the News Corp Board.  Internal Philip Morris documents in the US described him as sympathetic to their position and his newspapers as ‘our natural allies’ and noted that his papers rarely publish anti-smoking articles.

    The fight to reduce the problems caused by tobacco has been a great policy success in Australia.  While around 37 per cent of the adult population (15+) smoked cigarettes daily in 1970, only around 16 per cent do now, and the decreases in per capita tobacco consumption have been even more dramatic, now around one third of their 1970 levels.

    There have been three strands to achieving this reduction.  The first has been public education….  The second has been raising the price of cigarettes…  The third has been legislation restricting areas where people can smoke, and importantly the ability of the industry to advertise its product, to give smoking a ‘cool’ image.  This was gradually extended from advertising on radio and television to print advertising to event sponsorship.

    The latest such measure came when under the Labor Government, led by Health Minister Nicola Roxon, Australia became the first country in the world to mandate that cigarettes could only be sold in uniform plain paper packaging, a move aimed at making young people less likely to take up smoking.

    It is interesting to note that before the enactment there were several scare campaigns by the tobacco lobby.  Tim Wilson, of the Institute of Public Affairs, which is reported to receive funding from the industry, said that the legislation could cost Australian taxpayers $3 billion in lawsuits over the intellectual property surrounding cigarette packaging.  The sum at the moment is closer to zero.

    On June 6, in a front page ‘exclusive’ by Christian Kerr was headlined ‘Evidence “World’s Toughest Anti-Smoking Laws” not working’/Labor’s Plain Packaging Fails as cigarette sales rise’.  It began ‘Labor’s nanny state push to kill off the country’s addiction to cigarettes with plain packaging has backfired, with new sales figures showing tobacco consumption growing during the first full year of the new laws.’  A supporting editorial began ‘Suck it up nanny, plain cigarette packs have not cut smoking.’  Columnist Judith Sloan followed up ‘The nannies are panicking’, and referred to ‘Head Nanny, Nicola Roxon’.  Henry Ergas similarly began ‘Not every nanny encourages her charges to take up alcohol and tobacco, but then again not every health minister is like Nicola Roxon.’

    The one piece of hard evidence in the original article is an industry survey commissioned by the tobacco industry to be used in lobbying against the introduction of similar laws in Britain.  More problematic than the provenance of the data is that the company was only prepared to release selective snippets, which makes it difficult to evaluate its overall worth and meaning.  The industry claim that smoking sales had increased was fleshed out with anecdotal evidence.  Except for a one paragraph ritual denial from the Labor shadow minister all the examples went in the one direction, that the policy was having no effect.  The owner of a convenience store, for example, was cited, but no public health experts.  A later story quoted a ‘proud’ Brisbane smoker saying the policy had had no effect on her.

    It is especially notable that the newspaper did not cross-check its industry data with any official data sources.  Others soon filled the gap.  The blog by leading economic analyst, Stephen Koukoulas, ‘the Kouk’, challenged the story by using Australian Bureau of Statistics National Accounts figures which indicated a decline in smoking over the calendar year 2013.

    A much bigger reaction followed Paul Barry’s dissection on the ABC TV’s Media Watch on June 16.  Skewered yet again by its arch-enemy, the Australian reacted vigorously.  It ran five stories on the topic the following Wednesday.  In the subsequent week or so, there were two editorials, a couple of references in ‘Cut and Paste’, and several news stories and commentary columns. Such huge attention was clearly more due to bruised editorial egos than to audience interest.  The coverage offers an instructive guide to how the Australian conducts controversies about itself.

    In this tobacco controversy legal affairs editor Chris Merritt criticised Media Watch for not disclosing that Stephen Koukoulas had worked on Julia Gillard’s staff for 10 months, and using Professor Mike Daube who had been a member of the government panel that recommended plain packaging laws.  Daube is an eminent authority on public health, while Koukoulas was a senior member of the Treasury for many years, and is a leading economist.  But red trumps expert in the eyes of the Australian.  Conversely the paper did not indicate that two of its staff working on the story – Christian Kerr and Adam Creighton – had worked for the Liberal Party, while one of its experts, Sinclair Davidson, had links to the Institute for Public Affairs, which is supported by the tobacco industry.

    The newspaper then wheeled out its three favourite academics – Judith Sloan, Henry Ergas and Sinclair Davidson – in its defence.  All three got the basic facts wrong.  Davidson asserted that ‘I have no doubt that the consumption of cigarettes has risen since plain packaging was introduced; we just can’t be sure whether it is by existing smokers or new smokers’.  Sloan repeated this claim.  Ergas claims that Australian Bureau of Statistics data shows tobacco consumption increased by 2.5 per cent in volume terms in the year immediately after the introduction of plain packaging.

    In fact, the statistical evidence is fairly clear, and in the other direction.  According to Media Watch the industry admits that the number of smokers fell in 2013 by 1.4%, and also that the number of cigarettes smoked per person fell by 1.4%.  Alan Austin gives the quarterly figures on household expenditure on tobacco consumption for nine quarters from March 2012 to March 2014.  Each quarter in 2013 was below its 2012 equivalent except for the December quarter.  Then there was a sharp fall in the March 2014 quarter.  Later Treasury data was released, and it advised that ‘tobacco clearances’ fell by 3.4 per cent in 2013 compared with 2012.  Clearances are an indicator of tobacco volumes in the Australian market.’

    The one exception to this consistent picture of declining consumption – and the one that the newspaper’s commentators have seized on without giving its context – is a spike in the last quarter of 2012.  This was almost certainly due to the anticipation by retailers and some customers of the large customs rise which was scheduled to occur in December.  Predictably this momentary increase was followed by a large decrease in the next quarter.

    The other figure used in several reports is a trend towards increased sales at the cheap end of the market.  But this is not inconsistent with a decline in aggregate sales.  Cheaper cigarettes now command a larger share of a shrinking market.  Their growth has been more than cancelled out by the decline in the more premium brands, no doubt to the chagrin of the tobacco companies.

    All three of the Australian’s columnists based their commentary on a false reading of the data.

    The paper’s economics correspondent, Adam Creighton (19-6-2014) argued that the data ‘do not discredit the Australian’s claim the policy might have contributed to rising sales of cigarettes.’  Actually, there was no ‘might’ in headlines such as ‘Plain fact: more people smoking’.  He also still believed that ‘as of now there is no evidence to refute the industry’s claims of a rise in the number of cigarettes being smoked …’

    What would a reader relying solely on the Australian know after all this coverage?  They would not have a clear idea of what the paper’s critics had been saying, or why they were saying it. They would not know that the AMA and Cancer Council had criticised the paper’s coverage as misleading.  They would probably think that tobacco consumption had increased rather than decreased.  They would not have had a clear and unvarnished account of the official statistics, or where the weight of the evidence lies.

    One cannot help thinking that the Australian in 1964 would have covered the tobacco story more competently than did the Australian in 2014.

    Rod Tiffen is the Emeritus Professor, Government and International Relations, University of Sydney. The above are extracts from a paper which will shortly be published by Inside Story.

  • Woolworths and Pharmacies.

    The response of the Australian Pharmacy Guild (APG) to Woolworth’s proposal for free health checks was entirely predictable. It was about protecting the territory of pharmacists.

    But the APG did have a point. Are the leviathan department stores who sell large amounts of alcohol and tobacco really serious about our health? I don’t think so?

    But if the challenge of Woolworths would help curb the anti-social behaviour of the APG that would be a real public service.

    Pharmacists are the most over-qualified and under-utilised of health professionals. In the national interest and in their professional interest, pharmacists must participate in the transformation of our health sector. The 5,000 or so pharmacies on high street are a highly accessible and high profile resource, more so than GPs’ surgeries. Pharmacy attracts HSC students with high academic scores. Standing at the boundary of self-care pharmacists provide a range of services to customers – advice on medications, advice to see the GP, aches and pains, colds and flu, burns, rashes and abrasions. I cannot see why pharmacists for example shouldn’t almost immediately undertake blood tests, as well as flu injections and managing repeat prescriptions.  Their more active involvement in preventive health programs and primary care in general is essential.

    But the APG sees pharmacists primarily as shop keepers rather than health professionals

    Professor Sansom, described as Australia’s ‘pre-eminent pharmacist’, a former Chair of the PBAC, and the Australian Pharmacy Examining Council, put it bluntly a few years ago. ‘The profession would miss out on inclusion in future healthcare models unless it changed its current structure.’  He added ‘the current structure which is heavily structured on drug distribution…All of those things together and independently restrict the innovation and development in pharmacy practice which will promote this profession as a legitimate partner in new primary healthcare delivery models rather than being seen simply as a distributor.’

    Andrew Gilbert, Professor and Director of the Quality Use of Medicines and Pharmacy Research Centre at the University of South Australia, also described the problem very graphically a few years ago…

    ‘I know from the many telephone calls I get from disgruntled young pharmacists who are expected to dispense over 300 prescription items a day. They say that they are instructed that their primary duty is to supply the product, correctly labelled to the right person and that this type of professional performance measure limits any attempt to work with patients, to use Consumer Medicines Information Sheets as part of the patient consultation process and to provide a primary healthcare service. … These [supply] requirements leave no time for patient-centred healthcare, primary healthcare services, patient education and training, professional development through mentoring by experienced pharmacists and discussions with other health professionals regarding the care of complex patients. Professional services … [are] viewed as optional extras by many community pharmacists; services that may be provided if they are not too busy with the core business – supply. … Why is one of the most valuable professional services a pharmacist can offer, a pharmaceutical care focussed review in collaboration with the patient and their doctor only offered as an add on service in some pharmacies that chose to participate.’

    In addition to resisting the enhanced professional role of pharmacists the APG is in the front line in resisting competition. For example pharmacies must generally, in urban areas, be 1.5 km from each other? One consequence of this restriction of competition agreed to by the PGA and  Australian governments is that the number of community pharmacies has remained substantially unchanged at 5,000 since 1993.(At 30 June 2012  there were 5298 community pharmacies)  There are Pharmacy Location Rules which effectively put a cap on pharmacy numbers, This capping of pharmacy numbers is despite  population increase of almost 30 % since 19993 and an increase in PBS services, including Repatriation Pharmaceutical Services of over 80% since 1993.  In 1993, the average number of PBS prescriptions per pharmacy was 21,200. Last year it was close to 40,000.

    The consumer organization, Choice, in 2005 commissioned a study by the Allen Consulting Group on these location rules. Choice commented that ‘the location rules provide little consumer benefit and only advantage existing pharmacy operators’. (Choice, August 2009, p65)

    Last week the Productivity Commission said ‘There has been a failure to act on recommendations of a national independent review of pharmacies to relax ownership and other competitive restrictions”

    Our pharmacy sector needs a major shakeup. It needs to encourage pharmacists and particularly young pharmacist to be in the front line of primary care including employing nurse practitoners. In short they need to be less like shopkeepers and more the professionals they were trained to be. Further we need more competition but not from types like Woolworths

    I outlined the above case to the 2009 Pharmacy Australia Congress. It was well received well by many pharmacists but not by all. It was particularly welcomed by younger pharmacists who felt their professional skills were not being effectively used. Subsequently I accepted an invitation to speak to the Australian College of Pharmacy Dinner in Brisbane. It was described as a “must not miss event”. But the invitation was withdrawn. It was the first time in my public life that this had occurred. Perhaps I did not have the pulling power I thought! But the real reason for the withdrawal I am certain was that the APG leaned on the Brisbane College. This is typically the way the APG works–don’t engage in public debate but like all vested interests covertly lobby ministers, members of parliament and senior officials. That lobbying would now be going on with the present five year Pharmacy Agreement to expire in June next year. The present agreement is worth over $10b or $2m each year for the 5000 or so community pharmacies in Australia

    The APG like other powerful vested interests in the health field, the AMA, Medicines Australia and the Private Health Insurance Industry stand in the way of necessary reform. The public pays in higher prices and higher taxes.

  • Out-of-Pocket Costs in Australian Healthcare and the $7 Co-payment.

    In my blog of  May 12 on health co-payments I set out my objections to the proposal including that we already have a very high level of co-payments, that they are a “dogs breakfast” and that the proposal on its own would be unfair. The debate has moved on since then which raises further concerns about a proposal which covers not only GP consultations but pathology and radiology tests and pharmaceutical prescriptions as well.

    My first concern relates to process and where this co-payment issue might be headed. Minister Dutton has repeatedly said that he wants ‘to start a national conversation’ about health. I agree. But the minister doesn’t do what he has promised. He has barged in with a ‘solution’ to the “unsustainability of Australian healthcare”, without any ‘conversation’. In practice what he is proposing in the budget is a mechanism to kill bulk billing and clear the ground for Private Health Insurance to fill the gap. Minister Dutton has said repeatedly that the government has an interest in greater involvement of PHI in primary healthcare. He said ‘we will be… looking over the next few years at new and innovative ways in which we might fund and deliver primary healthcare, including through partnerships with private insurers’. He has expressed interest in trials of PHI in primary care in Queensland.

    In terms of equity and efficiency it is remarkable that the government proposes a $7 co-payment, but maintains the $5 billion p.a. subsidy for PHI. That is real corporate welfare at the expense of low income earners and our health service in general.

    The intrusion of PHI into primary healthcare should be strenuously resisted. The experience with PHI around the world is clear, particularly in the US. It pushes up costs dramatically and does not improve health outcomes. There is no benefit to the Australian community if the government saves $1 in official taxes, only to turn round and for the community to pay  a lot more  in ‘taxes’ to BUPA, Medibank Pte or NIB, for the same or an inferior service. Because of its intrinsic inefficiency PHI will always be more expensive than Medicare. Since 1999 average PHI premiums have increased 130% whilst the CPI has increased by only 50%. PHI administrative costs are about three times higher than Medicare’s.

    I have written extensively about the damage that PHI does wherever it gets a foothold. The encroachment of PHI into primary healthcare as suggested by the minister is a much more serious threat to our universal system of healthcare than the co-payment in itself.

    Warren Buffet has described PHI as ‘the tapeworm in the US health sector’. It is also true in Australia. Its expansion here should be resisted. Minister Dutton is quoted as saying that he ‘will never go down the path of a US style healthcare system’. But allowing PHI into primary healthcare would take us down the American path.  Private doctors and private hospitals have enormous power to set prices unless there is some effective counter. Multiple private insurers have little power to control these prices as the US shows. Only a single payer, usually a public payer has the power to control prices

    My second concern is that co-payments could discourage disadvantaged patients from seeing their GP. The COAG Reform Council has just reported that 5.8% of Australians delayed or did not see a GP because of cost and 8.9% delayed or did not fill a prescription from their GP because of cost. A co-payment will make that worse. It will force some patients to use more expensive and less appropriate emergency department services in public hospitals which are already under great pressure.

    Third, the proposed co-payment will undermine preventive health services and continuity of care for people with chronic conditions. The best place to focus on prevention and at an early stage is in primary care. Any discouragement of access to GPs because of the co-payment would be detrimental to preventive healthcare. The decision by the government to abolish the National Preventative Health Agency is an indication of the government’s lack of concern on health prevention. The tobacco, alcohol and the junk food industries will be pleased with that abolition decision. A strong primary health care sector is the key to an equitable and efficient health care system anywhere in the world.

    Fourthly, the best way to reduce costs and pressures in primary care is not through a co-payment but to move away from fee-for-service remuneration. This type of remuneration promotes ‘turnstile medicine’. FFS may be appropriate for occasional and episodic care but it is not appropriate for long-term and chronic care. We need a major review of remuneration practices in primary care with more emphasis on capitation and bulk-charges for chronic care to keep people well at minimum cost. The British single payer system has many advantages. One advantage is as the Economist of May 31 2014 put it, “doctors are paid to keep people well, not for every extra thing they do so they don’t make money performing unnecessary tasks and tests.” Addressing this remuneration question is far more important than a co-payment.

    Fifthly, there will probably be unintended consequences for the $7 co-payment. If the co-payment takes effect, it is likely to result in an increase in doctor’s fees. The attraction of bulk billing for the doctor is that it removes the cost of handling and accounting for transactions. An invoice is sent directly to Medicare. Once the doctor is obliged to handle the $7 co-payment, another transaction occurs, either by cash or probably credit card. This inevitable patient/doctor money transaction will provide the doctor with an opportunity to charge above the bulk billing rate. As soon as doctors stop bulk billing, we can expect a rapid rise in doctors’ fees on top of the $7 co-payment.

    Sixthly there are numerous other ways to reduce health costs and by billions of dollars e.g. the duplication and gaps in health care between the Commonwealth and the States, the out of date list of medical services funded under the MBS,, adverse events, archaic workforce structures and high drug costs resulting in us paying more than $2b pa than our New Zealand friends for equivalent drugs. But real savings in these areas means tackling vested interests like the AMA. The Pharmaceutical Guild, Medicines Australia, State health departments and the PHI sector. It is politically easier to attack the less powerful by a co payment.

    Far from having a sensible and informed public discussion about health, Minister Dutton has embarked on an ill-considered and ideologically driven course.

     

  • Jane Tolman. Dementia: how did we get it so wrong?

    In the past few weeks I have had the privilege of participating in the second running of the Massive Open Online Course (MOOC) on Understanding Dementia run by the Wicking Dementia Research and Education Centre at the University of Tasmania. This has provided a forum for learning and discussion about dementia for 15,000 carers, health professionals and interested persons from all around the world.  More than that, the participants are able to seek answers to their questions, and to tell us their concerns about their “journey” and about their expectations.

    I think there is much room for improvement in the way health professionals have dealt with dementia.

    We handle the diagnosis of dementia very badly. Families complain that doctors are unwilling to make the diagnosis, defer the diagnosis, or deny the diagnosis (just getting old). Statistics tell us that only about 40% of people with dementia ever get a diagnosis. There are established sets of criteria for diagnosis; but many of us still use a cut-off score on a basic cognitive test to make a diagnosis, maintain that a diagnosis can only be made post mortem with a biopsy, or tell our patients that it is a diagnosis “of exclusion”. While evidence suggests that the personal story (history in doctors’ language) offers considerably more weight to a diagnosis than any examination finding or test, families still find it hard to put their case, present their information and are sometimes dismissed due to privacy issues.

    Notoriously, people with dementia develop a lack of understanding of their situation.  Doctors call this “lack of insight”. People with dementia also lack skills required to make good decisions, to reason and to solve problems. These features of dementia are poorly recognised by many health professionals.  And yet they can expose the person with dementia to extreme danger.  Assessing cognitive capacity for decision-making can be challenging. Many clinicians are hesitant about providing an assessment, and many who do so, provide an inadequate assessment. It is essential that doctors embrace this role, and develop their competence in such assessments.

    What families most want to know about dementia is what will happen as the condition progresses. When we do make a diagnosis, we rarely address this.  Current staging systems of dementia tend to focus on what people can do rather than what their needs are, are often designed for research, and rarely address the real need: how to provide dignity to very vulnerable people.  At the time of diagnosis, or soon after, loved ones (and the person with dementia where relevant) should be given information about the stages ahead and what they mean.  There should be a “road map” to help people navigate the path.

    Dementia is often described as a memory problem and clinics for its diagnosis and management are still sometimes labelled as Memory Clinics. It’s time that we acknowledged that dementia is about a range of domains, including Cognitive (memory, language, insight, judgement, planning, reasoning), Function (inability to perform household and other tasks and ultimately personal care) , Psychiatric (commonly delusions, hallucinations and depression), Behavioural (aggression, screaming, following, calling out) and Physical (swallowing, continence, mobility and eating). Families and carers have the right to know the facts.  When these symptoms of dementia arise, families should not be surprised and need to be able to recognise these as manifestations of the disease.

    Dementia is a relentlessly progressive terminal illness. As a profession we have failed to identify dementia as a disease which has much more in common with cancer than with forgetfulness. At the time of diagnosis of other neurodegenerative conditions such as Motor Neuron Disease, a palliative approach is often instituted from the start, and early decisions are made about future feeding and assisted breathing. But in the case of dementia, we often offer families few choices, because we have failed to recognise that quality of life will be compromised, or to identify the role quality of life plays in decisions about management.

    The behavioural and psychological symptoms of dementia are common, and yet they are poorly understood by many of us.  Many clinicians offer treatments which have little (or sometimes no) demonstrated usefulness and which have well documented adverse effects.  We continue to offer medications which sometimes only work by virtue of their sedating effects, and we fail to communicate the facts to families. The best evidence from international data is that at best 20% of those with dementia who receive antipsychotic medication for the treatment of behavioural and psychological symptoms derive benefit. Despite this evidence, up to 80% of the residents of aged care facilities who have dementia are regularly taking antipsychotic medication.

    Despite the rhetoric, we rarely practise holistic, person-centred medicine when it comes to dementia.  This would mean the following: acknowledging that every person with dementia is a unique case; providing the knowledge which is essential in making wise decisions about management, and being aware of the evidence; ensuring that there is a decision-maker who can make informed decisions (in collaboration with the clinician); offering choices, and perhaps above all ensuring that this, of all conditions, requires a very clear focus on dignity for the person with dementia, and careful consideration of best way of providing it.  Management of dementia should always be a collaboration between the person with dementia, the loved ones, the medical team and paid carers.

    The MOOC has taught me that we need to listen more to those who live with dementia; that is to the carers, both loved ones and professionals. We can provide good care for those with dementia. But in many ways, we need to go back to the basics.  And we need to make sure that we listen to carers, engage them in management and acknowledge the critical role of education.

    Dr Jane Tolman is Director of Aged Care, Royal Hobart Hospital.

  • Mary Chiarella. Nurses – debt and job satisfaction.

    In the AFR Laura Tingle rightly points out that nurses do not tend to fit the mould as one of those groups of fortunate students who may reap significant income returns for the cost of their university education. She goes on to point out that “modelling released by Universities Australia this week suggest nurses’ uni debts will rise from $19,398 to as much as $37,390 under the budget proposals. This is for a job paying a starting income of $48,729”. She calculates that a nursing graduate who works 6 years full time on graduation, followed by six years part-time before returning to full time work, would have a debt of $66, 195 that would take 22 years to repay.

    So this brave new world of market forces is pretty bad news for nursing recruitment. That is even if you consider that caring ought to be commodified in the first place or whether there are some things that are so important the market should protect them rather than hang them out to dry. Remarkably people often feel quite differently about these matters when they are in need of intensive or palliative care.

    But wait, there are more spanners to throw into the works. It’s also ipso facto bad news for nursing retention. This comes not long after Health Workforce Australia’s report Health Workforce 2025 (HWA, March, 2012) modelled future requirements for registered nurses and identified that, with no changes to the status quo, there would be a shortfall in registered nurses of 109,000 or 27%. As it turns out the government also decided to get rid of HWA in the last budget, so these data won’t bother them for much longer.

    Note this is a report on registered nurses. This distinction matters for safety and quality in health care.  We have an abundance of information about the impact of baccalaureate prepared RN staffing on reduction of adverse events. If the cumulative evidence from these studies were a pill, they would have stopped the trials and given the pill to everybody. Duffield et al’s work (2007) in NSW looked at the relationship between skill mix and adverse events, and governments and their advisory bureaucracies should ignore it at their peril. It is the biggest study ever undertaken examining the relationship between these two issues at unit level and she has received international acclaim as a result of it. For every 10% increase in RNs there is a 27% decrease in failure-to-rescue –we have wards way below that level today.

    But HWA’s report points out that we wouldn’t need that many nurses if we only retained 1 in 5 (ONE IN FIVE!!)  of the ones we currently lose. A 20% improvement in retention would ameliorate the predicted RN shortage –so we really only need to understand why they are leaving and do something about it. Elementary.

    A synthesis of serial investigations and reports demonstrates that the two primary reasons why nurses leave the profession are a sense that they are not valued and a belief that they are not able to deliver high-quality care. Job satisfaction is therefore connected with both skill mix and shortages. The work environment plays an important role in job satisfaction and patient safety as well, as Aiken and colleagues’ multi-country studies indicate (2010). In a number of their studies, hospitals providing “supportive” environments, in terms of staffing levels and organisational factors, were more likely to have better patient outcomes compared to less “supportive” hospitals. These findings are consistent with other surveys indicating the central role of the work environment in job satisfaction and patient safety. So a simple question, will increasing the HECs debts and anxiety improve the work satisfaction of our RN workforce Mr Abbott?

    Mary Chiarella is Professor of Nursing, University of  Sydney.

  • John Menadue. Have we too many doctors?

    There are no international comparisons that I can find that show that we have a shortage of doctors in Australia. In fact, we may be moving into a situation of having a surplus of doctors.  In its “Health at a glance” the OECD found that we are above the average in our supply of doctors. The OECD provided details of “practising doctors per 1000 of population in 2011” for over 40 major countries. The OECD average was 3.2 practising doctors per1000 of population. Australia was slightly above the average with3.3 practising doctor’s per1000 of population. For the Netherlands it was 3.0, for the UK 2.8, for NZ 2.6 and Canada 2.4. The top four countries with over 4 practising doctors per 1000 were Greece, Russia, Austria and Italy. The OECD is quite explicit about trends in Australia It says “in several countries (e.g. Australia, Canada, Denmark, the Netherlands and the UK) the number of medical graduates has risen strongly since 2000 reflecting past decisions to expand training capacity…In Australia the number of medical graduates has increased two and a half times between 1990 and 2010 with most of the growth occurring since 2000”

    In 2004 when Tony Abbott was Minister for Health he decided against advice that we had a shortage of doctors. As a result the number of domestic students graduating from medical schools in Australia increased dramatically from 1,287 in 2004 to 2,507 in 2011. It has been described as a “tsunami” of medical graduates. The OECD found that in 2011 with 12.1 medical graduates per 10,000 of population we were well above the OECD average of 10.6. We know that this increase in numbers is making it very difficult to find training places for the increased number of medical graduates.

    We also know that with bulk billing and with patient dependence on the advice of their doctor about future appointments, tests and referrals, doctors have an ability to generate work for themselves and other professionals. Doctors can and do drive the demand for their services through fee for service.  That has serious cost implications.
    Apart from the total numbers the other important issue is the distribution of doctors across Australia.  All the data shows serious shortages of doctors and other health professionals in rural and remote Australia. These shortages are occurring despite the fact that we now have about 3,000 International Medical Graduates (IMGs) who are tied to areas of need. These IMGs have performed a useful role in rural areas although there has been some concern over language and sometimes professional skills. However it seems logical and legally defensible (“civil conscription”) that if we can determine where IMGs can work, why can’t we do the same for Australian medical graduates and insist that new provider numbers only be issued according to need in Australia. We don’t need more provider numbers and doctors in Belleview Hill and Toorak, but we do need them in rural and remote Australia.  Through governments, taxpayers subsidise medical education and about 80% of the remuneration of doctors comes from government. There is a legitimate interest in new doctors working in areas of need, at least in the early stages of their career. Hopefully they will find professional and personal satisfaction in country areas and decide to stay.

    Another option to overcome shortages of doctors in rural Australia would be to auction provider numbers by postcode but that would probably be too radical for many professional people who don’t like open markets.

    In short we are moving to a surplus in the total number of practising doctors but serious shortages still exist in rural and remote Australia which could be addressed, at least in part by limiting new provider numbers to areas of need.

    Why can we send teachers to areas of need but not doctors?

     

  • John Menadue. The Blame Game in health

    Attempts to resolve the Commonwealth/State blame game have been unsuccessful and expensive. Time and time again federal governments try and buy off state criticism by spending more taxpayer’s money without any real improvements in the delivery of health services.

    This futile blame game is not surprising in a federation where there are nine departments of health for a population of 23 million.

    Over many years there has been confusion about the role of the Commonwealth in hospitals. In 2007 John Howard offered to underwrite community organisations prepared to take over State hospitals. (The issue at the time was the Mercy Hospital in Launceston.) In 2009 in his book Battlelines, Tony Abbott said that a Commonwealth withdrawal from hospitals would be a ‘cop out’. It would be “anachronistic and inefficient”.  Kevin Rudd threatened to take over State hospitals if a satisfactory arrangement could not be made with the States but backed down even though opinion polling showed strong support for a Commonwealth takeover of State Hospitals.

    The Abbott Government now seems intent on winding back the commonwealth’s role in health. It is proposing a reduction of $80 billion in school and hospital funding over the decade to 2024-25.As a result the states are into the blame game again

    The budget announcement is a major breach of faith between the Commonwealth and the States.

    • The Commonwealth has unilaterally cut $1 billion from State budgets from 2017.
    • The Commonwealth will no longer honour an agreement to fund some growth in State hospital costs. The Commonwealth had pledged to partly fund this growth in State hospital costs, provided those costs were based on efficient costs determined by The Independent Hospital Pricing Authority. (We know that there are major differences in costs not only between hospitals but also within hospitals.) This increase in funding based on improved performance by State hospitals has now been abandoned.
    • Furthermore, by sharing the costs of hospital growth for the first time, the Commonwealth had a direct interest in containing hospital costs by making primary care work better and reduce hospital admissions.

    Following this threatened withdrawal of $80 million to the states, the Prime Minister went on the front foot in describing the federation as ‘dysfunctional’. He said that we needed to ‘fix the federation’ and to ensure that ‘the states are sovereign in their own sphere’.

    I can understand his frustration with the federation, but his proposal would take us backwards in a quite dangerous way. His comments on federalism are quite contrary to what he was saying several years ago and now derive more from ideology about ‘state rights’ than common sense and a modern view of our economy and society.

    As Michael Keating in his five part series on this blog, pointed out, there are good reasons for the pre-eminence of the national government in many fields.

    • Unlike the 1890s before federation we now have a national market in almost all key aspects .That national market has to respond to growing global pressures and competition.
    • Responsibilities of the federation have grown enormously since federation. In the 1900s for example pensions did not exist.
    • The national government’s dominance of taxation is clear-cut and will not be reversed. That domination is essential for good economic management.

     

    But that still leaves us with the fact that many commonwealth and state functions are inter-related. Those inter-relationships must be sensibly managed.

    Personally, I would favour a Commonwealth takeover of all state health functions and particularly hospitals. We need national leadership and clear responsibility. In an optimal situation I would like to see the states abolished altogether and replaced by a smaller number of consolidated local governments.

    But that is not going to happen, short of a major crisis. That is why I have proposed what I have called a ‘Coalition of the willing’. In such an arrangement the Commonwealth should offer to set up a Joint Commonwealth/State Health Commission in any state that will agree.  That Commission would be jointly funded by the Commonwealth and the State. There would be one pool of money. This joint commission would plan the delivery of health services in the State and so provide more cohesive hospital and non-hospital health services. It would be a small planning and funding commission with little or no net increase in bureaucratic overheads. In any event any small increase in these costs would be minimal compared with the enormous present costs of commonwealth and state systems duplication and the costs arising from lack of integration between commonwealth and state services. For example the Productivity Commission estimated that 750,000 state hospital admissions could be avoided annually if there were effective interventions in the three weeks before hospitalisation. Those interventions are in the hands of the commonwealth that funds general practise

    In such a joint funding and planning arrangement the delivery of health services would continue through existing health agencies, Commonwealth, State and local government. The new Commission would be jointly appointed by the two governments and with agreed and transparent dispute resolution arrangements. In the event of a disagreement, the Commonwealth position should prevail as it would be the chief funder.

    Tasmania and SA should be obvious starters for such a joint commission given their size and difficult financial position. Hopefully success in one State would then encourage other states to swallow their pride and improve their health services by cooperating with the Commonwealth in a joint commonwealth/state health commission.

    In March 2007, I set out this proposal in more detail .

    I still believe that this is the most sensible and practical way to solve the commonwealth/state impasse and blame game in health. This proposal could also be applied in the education field to resolve the disputes and the blame game in education between the commonwealth and the states.

    I think most Australians are sick of the blame game in health. The problem can be resolved but, in the first instance it requires a political agreement between the commonwealth government and any state that wants to cooperate. With such political agreements implementation would be relatively easy. Politics is the hard part.

    A more modest start would be for the Commonwealth and a State to establish joint arrangements on a regional basis.Commonwealth and State funds would be pooled in that region and agreement negotiated for a health plan for the delivery of all health services in that region.

    We need to coordinate Commonwealth and State health services.