Australian governments would be unwise to assume that their multi-billion dollar health funding package will solve the problems in health care.
The COAG package seems to be more about spending more money than the sort of serious reform that’s needed. It’s very largely going to mean more money to train people to work the same way as they’ve done for 150 years.
I see no agenda or strategy as yet to address the design and structural problems of what we loosely call our health “system”.
The major design problems that are yet to be addressed include:
An archaic workforce where demarcations and restrictive work practices abound. The health sector is the largest and fastest growing sector in the Australian economy, yet its work practices have been virtually unchanged since the 19th Century.
If there is not a 40% productivity improvement to be achieved over 10 years by breaking down professional barriers and in upskilling and multiskilling the health workforce, I would be very surprised.
We have about 300 nurse practitioners in Australia when we should have thousands. Ten per cent of normal births are delivered by midwives in Australia. In New Zealand it is 90%. The medical colleges place barriers on entry. The exemption of retail pharmacies from competition policy, results inevitably in high prices and restricted hours of service.
Quality and safety problems abound but are not addressed in a systematic and concerted manner. Each week we have about 200 avoidable deaths in our hospitals, and I estimate that the cost of avoidable mistakes in our hospitals is over $6billion pa.
The Federal Government provides a $6billion annual subsidy to the private health insurance industry when it would be much more efficient and equitable for the money to be paid by a single payer directly to hospitals both public and private, and to not-for-profits. The private health insurance industry has misled us that subsidising financial intermediaries is necessary to ensure private health delivery. Medicare and particularly Veterans’ Affairs have shown that it is more equitable and efficient to pay money directly to private providers rather than channel it through high-cost financial intermediaries.
A highly medicalised and sickness model of care. Medical services attract about 95% of government funding at the expense of prevention and public health. Payment on the basis of fee-for-service provides quite perverse incentives. More income is to be made out of treating sickness rather than keeping people well.
Inexplicable variations in clinical practice. Patients with the same condition will be treated very differently, depending on which hospitals or health care provider they seek. In the reviews that I chaired in NSW and SA, very large practice variations were very obvious and across a wide field with no discernible difference in health outcomes. Birth by Caesarean sections is probably the best-known example with some areas notorious for interventions well above the average rate. Medicare has enormous data about clinical practice patterns which it should disclose in the interests of both equity and efficiency.
The introduction of e-health has been glacial despite the potential benefits in patient satisfaction, reduced costs and fewer mistakes with modern information technology This is not a political or philosophical issue. It is an operational and administrative matter for which government officials must bear the chief responsibility.
There is not only fragmentation between commonwealth and state health programs, but within governments. What real analysis is made of the health benefits of say, spending another $1billion in Pharmaceutical Benefits Scheme rather than $1billion in Medical Benefits Schedule? I am not aware of any attempt to integrate these two very large programs to maximise health outcomes at lower cost, particularly in other parts of health care.
The numerous health programs are not focused on patient needs and health outcomes, but on historic producer inputs. In theory, governments have generally abandoned input based funding but not in health. A more integrated system would have programs not based on inputs (PBS, MBS, hospitals) but around classifications of users, e.g. by age, type of service (chronic/acute/occasional) or by region. None of these output classifications will be perfect, but they would be much better than our input-based focus.
Provider-based programs also give great power to the providers — doctors, drug companies, hospitals and the private health insurance industries to dominate the public discussion and the allocation of resources. The community and patients are largely excluded in major decisions affecting their health and the allocation of scarce health dollars. Those with lobbying power, the media-savvy, and the powerful skew resources in their interests.
A countervailing power of informed community members and patients is essential to break the power of vested interests who will concede incremental change but not structural change in the delivery of health services.
We have very hospital-centric services at the expense of primary care. According to the OECD figures of 2005, the number of acute hospital beds per 1000 of population was 3.5 in Australia, 3.1 in the UK, 2.9 in Canada and 2.2 in Sweden. The public pressure is always for more hospital beds, when we need programs to reduce the pressure on hospitals and treat people in the community or in their homes. At CPD we envisage a rollout of 200 primary health care clinics across Australia with each having an average 100,000 population catchment.
The centres would be as large as possible to provide wide professional multi-disciplinary coverage. These clinics are not only necessary in themselves, but they also offer the best way to address some of the major design problems I have referred to before, eg workforce, prevention and fragmentation. It is hard to reform existing institutions and practices, particularly in hospitals. It is hard to teach old dogs new tricks. A new architecture of primary care provides an opportunity to address long-standing and entrenched design and structural faults.
In short, there should be no more extra money for health without reform.
John Menadue AO is a board director of the Centre for Policy Development. He headed the Department of Prime Minister and Cabinet from 1974 to 1976, working for Prime Ministers Gough Whitlam and Malcolm Fraser. He has recently chaired major health reviews in NSW and SA.
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…double dipping, sorry…..the surgeon refuses to see me. My experience is one of the better outcomes I am aware of . I don’t want to jump on the fellow, we are all human and make mistakes, but one expects simple honesty in these situations.
Mr Menadue has accurately identified many of the problems in our health system. Howard and Woolridge gutting doctor training numbers was the first act of absolute negligence in the management of our health system under Howard…the first of many. Why was that done?
Doctors, as in the 19th century, are still a law unto themselves. Yes, many people have unrealistic expectations(watch too much bad american tv), but the facts speak for themselves.
A well known Briz surgeon removed the wrong limb from a patient. He was allowed to continue operating and then removed the wrong brain region in another patient leading to their death. 2 for 2, a needless double amputee and manslaughter. This fellow was so well connected, he remained operating. I believe a wrong leg then amputated was the straw that broke the camel’s back. This chap has escaped sanction and naming, and still works as a consultant.
Iatragenic deaths in Oz last year…….can’t tell you where I got this info, but a quality industry estmate of 50,000 a year in Oz is pretty close to the mark.
Good on you Crikey, and thank you Mr Menadue for at least attempting to keep the bastards honest..
I don’t like your chances of demanding accountability from a profession who are a law unto themselves and,. who, labour under often unrealistic outcome expectations from patients.
I can tell as many good medical stories as bad, but without transparency and sensible accountability the system will, as it has for some years, continue to deteriorate.
cheers.greg.
September 2003, diagnosed with a critical collapse of lumbar spine + complications, 2 years of double sided sciatica and occassional paralysis and loss of all feeling and function, led my GP(a fabulous bloke and doctor) to have me admitted to Royal Brisbane Hospital.
I arrived with all my clinical notes, x-rays etc, and an admission request letter. After 7 hours on a trolley in various corridors, I was processed through the Emergency Department. At 2am I was told by a 1st year intern( to be fair, under enormous pressure due to the arrival of numerous victims of a major MVA), that, and I quote, “you are a fucking malingerer and if you do not leave now we will call the police”.
Stunned and with no money (pensioner) as I expected to be admitted, I was left to walk and crawl 4 miles to my home….that took 9 hours. Appealing to a specialist friend, the next day an MRI was done and I was admitted at another hospital, RPA, where I spent the bulk of the next 4 months and had 6 inches of my Lumbar spine removed. An active infection (to this day unidentified and prior to surgery misdiagnosed by the surgeon but not by my chiropractor), meant a 4 hour operation became 9.5 …. I woke up on the table due to the misdiagnosis and the dangers of continued anaesthesia.
The next morning a member of the surgical team I had developed a friendship with, came to my bedside and , again I quote, told me, ” We fucked it up greg. The diagnosis was wrong, your mate was right, the infection was live and the work that has been done is a hodge podge which will mean you face some pretty serious ongoing problems”. That gentleman was a foreign surgeon about to return to his own country and unconcerned by potential consequences of his honesty.
To this day I am on morphine for pain, have massively compromised mobility and lifestyle/quality, and cannot find a surgeon who will work on me. Everybody tells me I must go back to the man who fucked it up so badly in the first place.
no letters left……
I graduated in Medicine 49 years ago and spent a lot of that time in Public Health and Community Medicine. I think that experience, and the status of Emeritus Professor (albeit like all old epidemiogists broken down by age and sex) qualifies me to give my total support to John Menadue and IMHO he is right on the money. Bitter experience however tells me that the opposition is such as to win every battle – as it ever has and, possibly, ever shall do.
I am a reasonably well-paid professional with private health insurance that will almost certainly be using the public system when I give birth next year. Why? I would much rather be in a large hospital surrounded by specialists in case something goes wrong during or shortly after the birth than some place masquerading as a hotel that doesn’t have specialised neo-natal facilities. Two, while I would love continuity of care, I cannot justify the $3000+ I would be out of pocket for having my own doctor – who might be replaced by another doctor anyway if I should inconveniently go into labour on the weekend or a public holiday. And Three, despite all the horror stories one hears, I have in the past experienced far more professional personal medical care by doctors and nurses in the public system than in the money-making private sector. And for me, that is far more important than aesthetically pleasing surroundings.
Actually, as I have the private health insurance, the public hospital will probably have me sign a document so it can squeeze some much needed additional funds out of my insurance company so I will technically be a private patient – but not one footing an additional $3000 bill.
A friend of mine was until recently working as a nurse specialising in cardiology.
He quit after 4 years, having become entirely disillusioned with the job because Cardiologists (doctors) would convince patients they needed surgery in their last months of life, to extend their life, in many cases by very small amounts.
My friend would hear from the patient and/or their family that they wanted to die at home. What would happen is that the doctor would talk them into surgery and they would end up having to die in hospital, many in great pain because of complications, all to get a few day, weeks or maybe a month or two of extra life, connected to machines. All when this was not what the patient and their families wanted in the first place.
Of course, the Doctors made lots of money out of the surgery, which would also then cost the public system hundreds of thousands of dollars in extra, mostly unwanted and unjustified support services.
Left alone, many of theses people would have died maybe a little earlier, but happily and peacefully at home with their families.
A debate on the desperate need to extend life at all costs is a debate we need to have in Australia. I personally do not want my life extended if the quality of life is to be markedly less.