This initiative A Health Policy for Australia is most welcome. We desperately need debate in health. This note is intended to further that debate.
While I would endorse much of what is being said, there are areas that I feel could do with more emphasis and elaboration and some that I think have been left out which I see as important.
Values and Transparency
Inequity and inefficiency need yet more emphasis than the authors have given them. Major indicators of inequity in Australian health care are the health of Aboriginal people; the size of the private sector and its inaccessibility by the poor; the metropolitan focus of Medicare; and the relative neglect of the health of Australians in the bush. Greater equity is what citizens want (see below).
We need more explicit policies on technical efficiency and especially more incentives to do things as well but more cheaply. The cry is too often ‘more money!’ In comparison to most other developed countries, little use is made of economic analysis to promote efficiency (with the exception of the Pharmaceutical Benefits Advisory Committee), and few of our top managers have training in economics.
More worrying still are allocative inefficiencies (unfortunately conceived wrongly in A Health Policy for Australia as being about fairness) which arise when resources are going to lower rather than higher valued interventions. This form of efficiency is about priority setting, for example between prevention and cure, between cancer and heart disease. Yet amazingly we do not have a system of explicit rational priority setting in Australian health care.
When, as is now the case, decision making on resource allocation lacks transparency, the underlying values are brought out too infrequently. Many of the problems of inequity and allocative inefficiency stem from lack of transparency. Leaving resource deployment largely to the discretion of individual clinicians, how can we expect that in aggregation this will add up to a coherent allocation of health care resources? It is not the doctors’ health service; it is ours, the citizens of Australia.
Managing health services is difficult. I would like to have seen A Health Policy for Australia give this more attention. There is a paucity of good managers. Those there are need to be given their head and awarded higher incomes. When they do not perform, they need to be removed.
Morale is low throughout the system. There is a lack of leadership and of faith in the system and a distinct air of crisis management. Very conservative attitudes dominate which do not encourage solutions to be thought through but instead foster a ‘keep-the-head-down’ mentality.
Health services need tough managers. In an exercise in which I was involved, we were asked by the WA Health Department to look at which one of the (too many) cardiac surgery units in Perth should be recommended for closure. We came up with a recommendation. At the highest level an about turn resulted in no unit being closed, almost certainly as a result of ‘leaning’ by doctors. It is spineless decisions like these that see more and more money going to the tertiary sector and not enough to public health and Aboriginal health where the public want it spent (see below).
The Community Voice
Chosen at random from the electoral roll to look at some key issues in health care policy, citizens’ juries in my experience can work well . Treat citizens with dignity, give them good information, make resource constraints explicit and ask them to think rationally and responsibly, they do. They tend to be more altruistic than is reflected in current health care. They do not push for shiny, high-tech items but rather prevention and equity. They recognise Aboriginal health as the greatest inequity. These juries are a way to allow the voice of the Australian community to be heard.
A Health Policy for Australia does give weight to the voice of citizens. However it is the paper’s authors who have set the principles. The first principle that citizens have come up with in juries is that it is the citizens who should set the principles!
It is one of the fascinations of the current health system that the media and public policy are almost wholly about mechanisms. The community voice can provide a vision, the principles upon which citizens want the health services built.
This is surely the top priority in Australian health care. It remains appalling. To increase spending on Aboriginal health care by 50% would require a cut of only 1% for the rest of Australians . Various small surveys suggest the Australian people would support positive discrimination for Aboriginal people .
There is also a need to pursue "cultural security" for Aboriginal people ‘ensuring that the delivery of health services is such that no one person is afforded a less favourable outcome simply because they hold a different cultural outlook’ . Further, institutional racism in Australian health services  must cease.
Financial Problems of the Teaching Hospitals
The teaching hospitals have an unfortunate record of gobbling up more and more spending. Yet here in the West, 80% of patients in tertiary beds don’t need to be there . The reasons this happens are three: first, too many tertiary beds; second the self-interest of the medical profession; and third little is done to address the inefficiency of these cathedrals. The policy is spend! spend! spend!
Increases in the numbers of doctors in this sector over the last few years have not been matched by increases in output. The gap between increases in the medical salary bill and rises in productivity is yet greater.
The real problem for the health service here lies in the extent to which senior managers and politicians listen to the AMA and the doctors generally and let them set the agenda. The failure to take a tough decision in cardiac surgery as recounted above is symptomatic of the problems in getting recognition of the need for efficiency in our tertiary hospitals.
1. Mooney G Let the people decide! Citizens’ juries in health. /node/&CategoryID=7. Accessed 14 October 2006
2. Mooney, G, Jan S and Wiseman V (1998) How much should we be spending on
health services for Aboriginal and Torres Strait Islander people? Editorial.
Medical Journal of Australia, 169, 508-509.
3. Mooney G, Jan S, Ryan M, Bruggemann K and Alexander K (1999) What the
community prefers, what it values, what health care it wants. A survey of South
Australians, SPHERe Report, SPHERe, Department of Public Health and
Community Medicine, University of Sydney, Sydney.
4. Houston S (2001) Aboriginal Cultural Security, Health Department of Western
5. Henry B, Houston S and Mooney G (2004) Institutional racism in Australian healthcare, Medical Journal of Australia, 180, 517-520.
6. A Healthy Future for Western Australians (2004). Report of the Health Reform Committee (The Reid Review). Western Australia Department of Health, Perth.