The Greens oppose the CPRS not because it is too weak, but because it will point Australia in the wrong direction with little prospect of turning it around in the timeframe within which emissions must peak, says Senator Christine Milne.
Time to take on Australia’s toughest closed shop: specialist medicine
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Is anyone else dumbfounded by the current dispute between the Federal Department of Health and the ophthalmologists? Personally, I can’t decide who is being sillier. In this specific case the ophthalmologists have threatened to withdraw their services from the public system, and particularly from those rural and remote areas with the lowest levels of existing services unless the government backs off from its proposed cut to their Medicare rebate for performing cataract surgery. Since the same professional groups also control the number of eye surgeons available in Australia, and just like all the other doctors training groups they create very high barriers for entry of overseas-trained doctors, the government (and the public) has no real choice. If they walk out of the public system, your grandmother won’t be having essential eye surgery any time soon. Sadly, this grubby industrial tactic has a long history in Australian medicine (remember the surgeons walking out of public hospitals in the mid-1980s). Let’s just consider that there are three critical perspectives in play. The first is that of the Rudd government. It keeps telling us that it is serious about health reform, but keeps letting the department come up with these minor issues instead (see the recent public relations disaster that surrounded proposed changes to the reimbursement of IVF services). The second is that of Australian specialist doctors, particularly those who perform financially rewarding procedures under the lucrative fee-for-service system. Presumably, all Australian procedural specialists see this kind of threat to cut rebates as the “thin edge of the wedge”. Consequently, they are likely to resist collectively any substantive change. The third is that of the Australian public. Of course, their real health needs are quickly put aside in the middle of such a fundamental stand-off between government and doctors. As we all know (because we see it regularly on the TV news) the Rudd government is in the middle of its rather hospital-centric consultation on national health reform. During this sensitive period, you would think that the minister would be avoiding any unnecessary skirmish with a specialist doctors group until she was ready for the main game. (Of course, we are all assuming that there really is a main game to be played out sometime between 2010 and 2013.) Perhaps, however, if this were the season for real health reform, then the government might think that this was a great time for a big dispute with a group of procedural specialists, particularly when they are clearly holding us all to ransom. It has certainly caused me to wonder whether there is there anyone old enough in the PM’s or the health minister’s office to recall the pilots’ strike of 1989? Remember when that old unionist, Bob Hawke, decided to take on the closed shop of Australian pilots (remember when only Australian pilots could make you safe in Australian skies?). If we now had a government committed to real health reform, then now would be a great time for a workplace reform minister (e.g. Julia Gillard) or someone with real union credibility (e.g. Greg Combet) to take on the toughest closed shop in Australian industry (i.e. the procedural specialists). Interestingly, while the Hawke government did go on to break the stranglehold the pilots had over Australian skies, it never did break up the monopoly Australian doctors exercise over health services in this country (In 2009, it is still the case that only Australian-recognised doctors can provide safe health care.). This fundamental and persisting failure in economic reform underpins much of the dysfunction in our health system today. As long as there is a gross under-supply of specialists, no real competition between the existing providers, big financial rewards for those who perform procedures and an unwillingness to think about big changes to the way governments reimburse doctors services, the general public will remain the big losers (i.e. you pay more for the services you do get, you have less access to the services you need, particularly if you can’t afford private health insurance and nobody develops the really serious health programs for chronic diseases that the system doesn’t provide). Any real alternative (i.e. Medicare Select or competitive national social insurance schemes) has fast disappeared from the agenda. The government likes to talk tough about health reform, but as previous governments (and some private companies) have found, if you have no real strategy for breaking up the control that specialist doctors have over the supply of services, and no alternative funding mechanisms to fee-for-service on the table, then its chances of real success are slight. Ian Hickie is a psychiatrist and executive director of the Brain and Mind Research Institute at the University of Sydney |
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10 Comments
I think it also apposite to point out that the Drs group that the Rudd government has decided to take on, the Opthalmologists, is headed by the former President of the AMA and scion of the National Party in Queensland, Dr Bill Glasson. If ever there was a perfect synthesis of latter-day Wooldridgean political Doctor’s representative, then Glasson is it.
You’re right, the government should have developed a water-tight strategy for coping with the likes of Glasson before they took him and the other emotional string pullers on.
Professor Hickie,
Name me one other profession where the Government gets involved in setting the fees that the professional can charge? I just heard a lawyer on ABC radio saying that he would charge “$40,000 plus GST” for 1 weeks work at a Coronial inquiry!
Why doesn’t the Govt start setting caps for what lawyers can charge, accountants, plumbers etc. In fact, i think it is down right ridiculous that a restaurant here in Perth can charge me $45 for a seafood meal, perhaps the Govt can step in and legislate that restaurant can only charge $30?
Ian Hickie is right. There are none in the Federal Health Minister’s office who have a historical perspective whether it was Labour & Bob Hawke (& don’t forget the unforgettable Sir Peter Abeles) with airline pilots or the likes of Bruce Shepherd, Woollard, Glasson (how long will he last at Cancer Australia?) and more recently Capolingua who tried so hard to be as tough as the men but failed so miserably.Over the years who tried the hardest and who knew exactly what the problems were? Take a bow Dr Blewitt (who was ritually insulted by Bruce Shepherd), Carmen Lawrence and in the latter part of his tenure Alan Fels. None of them received sufficient political support to take on the Colleges and Alan Fels was ultimately dragged away from using the Trade Practices Act as a convenient weapon to open up and throw some light on the dark, in-house processes of selecting those who might ultimately become qualified consultants. And as for using the threat of specialists removing their labour from the public system - it is used regularly in so-called negotiations and sometimes occurs until the relevant state or territory health authority gives in. Here we are in 2009 and a ‘Closed Shop’ process is still allowed to flourish with all the resulting problems described by Ian Hickie. This systemic issue lies at the heart of health reform but no-one has the courage to deal with it.
(In 2009, it is still the case that only Australian-recognised doctors can provide safe health care.).
And as long as the general public remember the problems at Bundaberg Hospital they will; believe this.
“perhaps the Govt can step in and legislate that restaurant can only charge $30?” - If the government was picking up part of the tab for your sea food meal Sean Cornell they would indeed and so they should!
Strange to read the comment “only Australian-recognised doctors….” as if it is excessive and unnecessary to require overseas trained doctors to be assessed in Australia - and that from a doctor. A builder / an architect / a dental hygienist all have to have their training (if done overseas) assessed to be allowed to provide services, if your driving licence was issued overseas you have to be examined - and people presenting as having a degree from an overseas university where the standard might or might not be satisfactory, should be allowed to practise freely! Extraordinary. Does Dr. Patel ring bells?
About 10 years ago I worked in the Health Services branch of the Dept of Vet Affairs. I recall my boss there telling me once that the whole health care system in Australia was controlled by the medical specialists and I now know how true that is. Remember a few years back when every man and his bank were building private hospitals, hopefully a licence to print money. The problem was/is that if a hospital can’t get specialists to operate/consult there, they might as well shut the doors which happened to many. When Specialists do deign to engage with a private hospital, the hospital is required to provide, free of charge, offices, staff, computers, parking, coffee machines etc etc. If we only had a government with the guts to enforce the trade practices act, things could change. Alex
Sean Cornell, of course all those trades and professions you mention don’t actually have caps on the number of people who can be trained in them by industry bodies. So they are actually more market based. Doctors on the other hand have fought tooth and nail against new university medical faculties (ANU anyone) for decades and then strictly limit the number of specialists trained each year.
There is no doubt the system is flawed but to blame the Specialists is an easy avenue for blame.
To train as a specialist you need to get into a training programme, which yes is capped.
Why? Well you could let another 100 orthopaedic surgeons into the scheme each year, for example. The problem is they won’t get hands on experience as you need as close to 1:1 access to a senior colleague to get real experience and training. They will be fighting for operating and the poor patient will have more faces than a footy team looking at them.
I would love more trainees to teach. The States won’t pay for positions in public hospitals.
Stop worrying about the specialists they are such a small cog in the system. Look at the administrators who waste your tax money cost cutting the small stuff and allowing the enormous waste to proliferate. The big picture is so obvious when you work in the system.
And Bakerboy, can I have the names of the private hospitals who provide free of charge the computers and free rooms etc not in my area! They charge fees in my neck of the woods.
And I can’t leave without a comment on OTD’s. Some are good and some are unbelievably bad. I once watched a specialist anaesthetist from the sub continent intubate a patient. She handled the laryngoscope like the kiosk lady-ie she had never used one before. She was considered to be competent from her CV. Beware what you wish for.
An excellent analysis of the problem. The basis for the problem however is not a shortage of specialists but the fee for service remuneration which sets the scene for specialists to stay in the private system and charge what they feel they deserve. In private hospitals in major cities there is seldom any evidence of a shortage of specialists. In the public hospital next door and in more remote settings there is a shortage. Combining a fee for service remuneration system with publicly funded private hospitals (through the PHI rebate), and continued underfunding of the public system at a Federal level, means there is little attraction for specialists in public hospitals so they make their lives in the private system and will naturally defend their position.
The alternative not even considered by either major political party is to fund public hospitals properly to make them more attractive for specialist to work in, stop funding private hospitals (gradually), and employ more specialists in the public system at a salary which many would accept. Whilst some specialists will never be satisfied with a salary, many who work in the private system would be keen to work in the public system if it and they were adequately funded. It would still be cheaper for taxpayers than getting the work done privately where mutliple taxpayer subsidies make the cost to government of a procedure is at least as much as in the public system. This would tap into the professionalism of many doctors who drift to the private system because that’s where they can get things done and be rewarded.
tim woodruff
doctors reform society