Fairer Australia Campaign Public Meeting

Dr David A Henry

Professor, Faculty of Health, University of Newcastle

I want to start this discussion of public health with a quote. I'd like to know whether anyone knows where this quote comes from, but that's not the primary purpose of using it:

"Will Medicare be there for me when I need it? While it is perfectly clear that a majority support Medicare in its current form, it is not perfect. Some people, particularly Aboriginal people and those in rural and remote parts of the country, cannot always access medical services where and when they need them."

That quote could easily apply to Australia, but in fact it's from the Commission for the Future of Health Care in Canada, and the quote comes from Commissioner Roy Romanow QC. His Commission reviewed the entire Canadian health care system and was published in late 2002. The report is available on the web (www.hc-sc.gc.ca/english/care/romanow/) and I can recommend it to you. It is really a surprisingly readable and insightful report that covers all aspects of health care in Canada.

The preamble to the report reads: "The reality is that Canadians embrace Medicare as a public good, a national symbol, a defining aspect of their citizenship. Canadians view Medicare as a moral enterprise, not a business venture." Romanov goes on "Early in my mandate I challenged those advocating user fees, de-listing of health services, greater privatization…. Public private sector partnerships; I challenged them all to come forward with evidence that these approaches would improve and strengthen our health care system. The evidence has not been forthcoming."

This is from a QC who is not politically aligned in doing this job. The evidence was not forthcoming; in other words there is no evidence that the sorts of 'solutions' that have been widely touted in this country do anything to improve health care. "More to the point" Romanow said, "the principles on which these solutions rest cannot be reconciled with the values at the heart of Medicare".

So the review of Canadian health was about values and fairness. The Canadians have gone on to form a National Commission to oversee the structural reform of their health care system. Their process is far-reaching and coherent and it is hard to relate to in Australia, where the dialogue so far in the current federal election has concerned Medicare rebates and really nothing else. The two main parties have been talking about how the rebate will work, whether bulk-billing will work - it is all about money in your pocket, relatively small sums of money; no vision and no courage. That's what's really missing from the debate on health care in this country. The Canadians who have a similar health care system to ours have shown the way.

So the debate in this country - and it is timely to discuss this in the run-up to a federal election - does not address the problems that we know exist. These include: the inability to attract and retain health professionals in many parts of the country; threats toe basic safe care that translates the knowledge that we know as physicians can be used to help patients; a private sector that is being encouraged to develop, and is taking staff away from our public hospitals. The John Hunter and Mater Hospital in Newcastle where I work are losing staff to a new private hospital; not only staff that perform the traditional operative procedures you would expect to garner money for the companies that run these private organizations; but they are also trying to attract staff from our critical services.

I've worked in the Newcastle Mater Hospital for over 20 years, and the staff we now rely on in our emergency department are not only relatively inexperienced (which is not a criticism of them), but they are sometimes unable to communicate effectively in English in the middle of the night. This is not in any way a racist statement. It is very unfair of us to take staff from other countries, who are badly needed in these countries, and place them in positions of responsibility in our departments, to make up for deficiencies that we've created through poor funding and organisation of our own health care services. We'd love to see these people working with us so that they could train them so that they could go back and work in their own countries, and take that knowledge back. But to attract them here with higher salaries than they would get at home, and to put them into impossibly difficult positions propping up our critical services is simply not fair.

There are many problems in health care in Australia. There is a disparity between the quality of the staff that we work with and the quality of the organisations and services in which they work. The former are very good, among the best in the world. I've worked in many countries, including developed and developing countries, and the quality of the organisations and services in this country is very poor. We have a terrible mix of private and public, and federal and state - systems that just don't work well together. We need some big ideas.

This country is in a period of intense conservatism when it doesn't embrace big ideas. I came here over 20 years ago, feeling that Australia was different from the country I came from - my accent gives away where that is (Scotland). I thought that this was a country prepared to take risks. We've stopped doing that - we are in a period of being timid and very conservative. So we are condemned to repeat the mistakes that have given rise to the disjointed and elephantine structure of health care in Australia.

So are there any big ideas left in health care in this country? I've said that the political parties are fiddling around the edges, talking about rebates, bulk billing and hospital waiting lists. But are there any ideas worth considering?

I have taken some ideas from my colleagues, like Dr Arn Sprogis of the Hunter Urban Division of General Practice, and Dr John Duggan, a long term advocate for the public hospital sector. John could have made vast amounts of money as a private gastroenterologist but chose not to.

Here are ten ideas to consider:

1. We should re-assert as a community that we regard access to health care for all as a central value in our Australian culture. This is not a political slogan, it is something we should insist on.

2. We should accept as a community that the best way of funding health care is through taxation, and communicate this to politicians so that they lose their fear of talking about taxes. At the moment, they can only talk about taxes when they are going to cut them, they can't talk about them in any other context. We as a community can tell them that we accept that no other form of funding of health care works.

3. We should follow the Canadian example and move health care away from state and federal politics. That is the purpose of the National Commission on Health Care in Canada. This means that the decisions are not made primarily to please the Minister or to make him or her look good, whether at a state or federal level. Clearly politicians have to decide how the money is raised, and how much is raised, but I don't think they should decide how the money should be spent.

4. I believe, and a number of people have said this, that we should move toward regionalisation of all health care funding (by pooling state and federal funds). Our region includes the Hunter, New England and Port Stephens areas and has over 900,000 people - the equal of Tasmania, the Northern Territory and the Australian Capital Territory put together. The populations in those two Territories and one State have three governments looking after them; we have a single administrator for our health care. This is not to be critical of the current administrator, but the region deserves more in the way of infrastructure. I'd say that our total budget for health in this expanded Region should be roughly $1.5 - 2 billion, based on a fair share on a population basis. That's the annual recurrent funding of services (including drugs), not capital expenditure. If we as a region were allowed to decide how to commit that funding across our GPs, community health services and public hospitals - imagine what we could do. We have a large number of talented and creative people in our region- many of them have worked with the World Bank, the World Health Organisation, and in important national and regional positions. Think of the contribution they could make to a truly integrated healthcare system that would meet the needs of the community rather than politicians.

5. We should move away progressively from the experiment in privatisation and private sector involvement in health care provision. This is not a political ideology - the reason for moving away from it is that it just doesn't work. Deciding about where you should be treated by whether you have a single room, or the quality of the food, is missing the point. If you need health care, you need good quality health care, provided by people who know what they are doing, and this is best organized through public funding. The World Bank (not exactly a left wing think tank) agrees. It talks about 'large risk pools' -spreading financing across large sectors, and that can only be done in the public domain. What can the private sector do well? It can organize procedural work. Why shouldn't it do it under contract to the public sector? The British government has engaged the private sector to provide hip and keen joint replacement operations and cataract surgery on a contractual basis. Why can't we use the private sector in that way rather than as some sort of alternative health care system?

6. We need a good balance of preventive, curative and palliative services. We don't have that balance at the moment. We must not see them in competition or as alternatives; they are actually complementary to each other. It can be done, we have the knowledge to do it but we are prevented from doing it at the moment because our health care services are in different silos.

7. We should stop hiding behind the ageing of the population as an excuse for our inability to face the real problems in providing health care. Really, the ageing population is not the reason that we are facing problems with health. We should stop pretending. We've known this for a long time. We know what kind of services the elderly need and it is a matter of finding a way of doing it efficiently.

8. We should move the funds for training of health professionals away from the Department of Education Science and Training into the Department of Health and Ageing. Surprisingly, Iran has done this well. They put the funding for training of health professionals - doctors, nurses, allied health, pharmacists into the Department of Health. The Department then goes to the educational institutions and says "we need this many doctors, nurses, pharmacists etc. Can you do this for us and at what price can you do it?" Through that contractual arrangement they have a reasonable means of matching the training to the community's needs. We should move the control of post-graduate training of health professionals (including general practitioners and specialists) away from their professional colleges. The colleges are important; as a Fellow of the Royal College of Physicians of Edinburgh, which is an ancient, prestigious organization, I recognise its value. But Colleges should not decide how many physicians, and the mix of specialties, there are in Scotland or in Australia. That decision should be based on need. We should set the professional standards through the colleges, but the numbers who are trained to meet those professional standards should be decided by someone else.

9. We should remove the boundaries between the health professions. We know that nurses pharmacists and allied health staff can provide excellent services that have traditionally been provided by doctors. We shouldn't be hanging on to these historical boundaries There are many things that nurse practitioners and pharmacists can do, particularly in rural and remote areas. You don't need a doctor to do them. They need training; they need legitimacy; they need to work with doctors. But we don't always need physicians to provide these services. In many places a physician working with a number of other health professionals can provide better services than several doctors whom we are struggling to find, and struggling to pay. The creation of health care teams with professional flexibility, and a re-definition of these professional boundaries can make a difference.

10. Finally health is not just for the health professionals, it is for all of us, for the city planners, for the economists and most of all at this particular time, it is for the politicians. We would like to move the decisions away from them but they have to take the first step.

Thanks very much.