There is little disagreement about the directions public health reform should take — greater emphasis on primary and preventive care, workforce reform, community participation, improved governance and better application of information technology. It is clear that there are gaps and duplication in clinical services that reflect outdated population patterns and jealously guarded clinical territories. There is concern about the health disadvantage of certain groups, like particularly Aboriginal elder health care is the prime issue of concern. In quality of life measured by life expectancy, Australia ranks number two in the world, but in healthcare equality we rank number 17. 1
If all Australians had the same health experience as Aborigines, we would rank number 140 in the world, alongside Bangladesh .
These issues are common to many advanced healthcare systems. This is confirmed by almost any healthcare enquiry or commission. One doesn't have to be a rocket scientist to know where we need to head.
But there is considerable disappointment and disillusionment about the ability of the leaders of our health systems to lead and manage the change. And the public is right about the failure of health leadership — political, clinical and managerial. In the two inquiries I headed in New South Wales and South Australia , the cynicism I encountered was abundant and depressing. I was continually told that “your inquiry may be well and good, but nothing will really happen”.
I understand their cynicism. It is part of a larger issue of alienation, which the community feels towards all our major institutions — parliament, political parties, the media, trade unions, companies, and churches. We so often feel that they are not honest and open with us, and that they try to manage and manipulate information to protect their own interests. Major institutions have lost touch with their natural constituencies. It is true in healthcare.
I would like to identify briefly some of the major underlying problems and then suggest some possible ways forward. My comments are very much influenced by observing, at close hand, the NSW and South Australian health systems and the way they relate and react to Commonwealth health funding.
There is clearly a failure of the Commonwealth and states to cooperate in the funding and delivery of healthcare services, with resulting inefficiencies, buck-passing, cost-shifting and poor integration. It was made clear to me in NSW and SA that the public wants change here, but doesn't see any leadership through the impasse.
There is a lack of honesty by governments as to what the healthcare system, with limited funds, can reasonably provide. As a result the public has unrealistic expectations and the health workforce is under great pressure. In this situation, political mischief by Oppositions is easy. Unless governments face this issue of limited funds and rationing, and are honest with the public, they will always be under pressure and in crisis, with numerous band aids applied, but no system change.
The healthcare system is remarkably inward looking. The debate is between insiders. The community is not enfranchised or involved. If I have been able to contribute anything to the health debate, I believe it is because I am an outsider.
There is clearly the waste in the present system, with a $2.5 billion private health subsidy that produces few obvious health dividends. There is widespread overhospitalisation, over-servicing in some areas, duplication of clinical services and large central health bureaucracies.
We have a very institutionalized, medicalised and hospital-centric system, rather than a health system. The debate and resources are pre-empted by hospital interests at the expense of, for example, primary care, prevention, clinical support in the home, more appropriate facilities for the aged, and hospital avoidance programs. Hospitals should be the last resort, but, in the current system, they are often the first.
There is the problem of the quality of healthcare, and avoidable adverse events as a result of spreading our skilled clinical services too thinly.
In attempting to tackle these issues, the plea invariably is “more money please”. More money is clearly necessary in key areas, but more investment in doing the same things the same way will only delay reform. It encourages just the attitude that is at the centre of our problems — that resources are unlimited and that choices do not have to be made. It will be the same old treadmill. Governments and taxpayers rightly insist on value for money. Reform will not be successful unless we can persuade treasuries that the money will be better spent in the future. In achieving that, I believe some or all of the following elements need to be in place.
A Commonwealth/state health commission should be established in any state that agrees to cooperate with the federal government in the joint funding and operations of public healthcare services in that state. Which state will break the impasse and be the first to put its hand up? Will the Commonwealth respond? We need to move beyond Commonwealth/state pilots and demonstration projects to real system change.
I am sure that a joint service would deliver better quality and efficiency of care, even if no additional funds were provided. So let us put that joint Commonwealth/state health commission on the agenda, put the case as compellingly as we can, and hopefully within 3 to 5 years we would have started to break the wasteful impasse and buck-passing of the present divided jurisdictional system.