To a man with a hammer, everything looks like a nail. And so John Menadue, Director of the Centre for Policy Development, who has undeniably hit a few nails on the head in his time, continues to bang on for 30 years. I do not want to disagree with everything he wrote in Crikey recently — some comments are quite fair — and I certainly have a vested interest in this debate, but some comments just get my goat.

“Work practices that are virtually unchanged from the 19th century”? He cannot be referring to clinical practice, so I assume he was referring to role demarcations and organisational structures. That is, after all, the filter through which bureaucrats see health. Perhaps my job as an intensive care specialist tints my own view of just how much has changed since it became law that doctors actually had a degree, or since the same happened for nurses 80 years later.

Another tiresome misrepresentation is that “Medical colleges place barriers on entry”. Medical colleges have no control of how many medical graduates are trained, how many training jobs are funded by states, how provider numbers are allocated, or who becomes registered as a specialist. If medical colleges exert any influence at all, it can only be because governments choose to follow their advice. State health departments have in recent years registered medical specialists without consultation. Sadly, there have been some well-publicised mistakes.

Although there are many talented and committed doctors who choose to work in rural Australia, there are not enough. Unsurprisingly, the set of doctors willing to take up a relatively poorly paid job in rural Australia includes the set of doctors who were drummed out of better paid jobs overseas. In this context, “poorly paid” should be measured based on what a doctor might earn in the gulf states. Whether the standards required by the various colleges are too high or not depends on whether you are paying for health care, or receiving it. Medical specialists are not some monolithic cabal. If anybody honestly believes that our mechanisms of selection are so biased by self interest, then they can put together their own.

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Mr Menadue wants more nurse practitioners. I will not attack the concept, but readers might pause to reflect on what the current international market rate of pay is. There is a (very) small set of nurses practitioners who return to Australia for personal reasons, but work predominantly in the USA. These people would be happy to work in Australia, for a reasonable rate. Those rates of pay are invariably higher than that paid to the resident doctors who staff our hospitals.

It could be argued that a fully trained nurse practitioner should not be compared to a trainee medical specialist. But that is precisely who they would displace, since these are the people who actually do most of the “medical” work in public hospitals. More nurse practitioners might (or might not) improve the quality of care, but would certainly increase the staff cost. Perhaps you might envisage trainee nurse practitioners loose in hospitals? I have seen this. It gives the worst of both worlds.

Similar comparisons can be made when asserting that more midwife deliveries would improve obstetric care. Midwives are (per hour) much cheaper than obstetricians. Usual midwifery practice is asserted to provide a high degree of satisfaction to the mother. Midwives achieve this, in part, by spending more time with the mother. Increasing bias towards midwifery and against medical obstetrics was a political decision in NZ. It was asserted at the time that this would decrease cost, but that did not occur. The most recent review of acute services in NSW has reiterated that midwife-led low risk obstetric services should occur only in environments where higher acuity backup is available. This will not save money, other than by closing units which fail the test.

One recurring theme internationally, is that increasing supply of medical services increases utilisation. In oversupplied markets (like New York City) both the consumption and the cost per episode are extraordinarily high. A redistribution of health services would improve health in currently undersupplied parts of Australia. An absolute increase in supply across Australia would result in an absolute increase in consumption, but it is controversial whether that would lead to an overall improvement in health. However achieved, an increase in consumption would certainly increase total costs. Many in the Labor Party yearn for a highly controlled health system staffed only by employees. Such a small proportion of the health budget is actually paid to doctors that this change would be irrelevant.

Politics is the art of looking one way and going the other. If John Menadue wants somebody to blame for this failure to take the high road, he might ask whether state treasuries and politicians are willing to pay the price. On the other hand, the reflex of blaming doctors for all health policy problems served the Whitlam government well, so Mr Menadue may find it easier to just keep banging that nail forever.