Health care reform: a journey of courage


This is an edited transcript of John Dwyer's address to the launch of A Health Policy for Australia: reclaiming universal health care in Sydney on Tuesday October 10.

Thank you for giving me the honour of being here to launch a very important initiative.

We've been promised health care reform for at least the last twenty years. I have on my desk a summary of a paper that was written in 1990, after a health ministers' conference in which state and federal health ministers all put their hands over their hearts and promised faithfully that the jurisdictional inefficiencies of state and federal divisions would be addressed immediately. We all know what has happened in the following years.

The truth is that reforming our health care system is a big deal. We don't need minor changes. We don't need tinkering at the margins. We need to restructure the health care system so that it meets the contemporary needs of Australians. And to get where we want to get, to have a cost effective health care system that we can all be proud of, we're going to have to go on a journey. The encouraging thing is that when you talk to educated consumers, when you talk to health professionals, when you talk to senior policy makers and most of the bureaucrats you meet in departments of health, there is no controversy about where that journey should lead. But every journey starts with the first step, and boy has it been hard in Australia to start down that path to reform. We are currently spending too much money on a system that simply cannot deliver the outcomes that we need. No matter how much money we pour into it, the dysfunction within the system is going to gobble up those dollars without giving us what we need.

For many of us the most distressing aspect of the current situation is that our health care system is increasingly unfair. Those of us who are clinicians have watched over the last ten years and seen the deterioration in equity of access to health care services and equity of outcomes. We have moved away from that ideal which I believe most Australians very much want, the ideal of having access to a quality health care system, in a timely fashion, based on need not personal financial circumstances. Increasingly people cannot afford to see allied health professionals. Increasingly people are denied access to specialist medical care because of the costs involved and increasingly they are being seen by general practitioners who are being forced, with those people who most need quality time with them, to spend only a small amount of consultation time so that the turnstile can click through and they can earn enough money to keep things going.

The result is predictable. We have absolutely ironclad evidence that health outcomes for communities and individuals vary enormously across Australia depending on social and economic circumstances. So in the western suburbs of Sydney, people are five times more likely to die of a preventable illness than they are on Sydney's north shore. In country Australia you are eight times more likely to die if you're white and of course if you happen to be an Indigenous Australian, twenty times more likely. In a country with an 18 billion dollar surplus this inequity is surely totally unacceptable to most of us, particularly when it's not necessary. The amount of money we currently spend could extract so much more health than it does now, if we were to go down the reform pathway.

I'm afraid Australia is becoming a polarised society, in which a lot of us are ‘doing very well thank you', and yet we have increasing numbers of working poor who are not getting the help they need to stay well and to have their illnesses cared for. If I were to ask all of you ‘what is it about Australia, about our attitude to life that's different', most of us would like to think that the long-term tradition of the ‘fair go' and egalitarianism was something that characterised Australians. The way we care for each other would be something we'd like to be measured by as a contemporary humane society. And that's what we're losing at the moment.

There's a remarkable degree of unanimity about what should be done. We clearly need to solve the workforce crisis. For most of us it is distressing that despite urgings from the productivity commissioner our federal government still hasn't bitten the bullet and declared a policy of educating sufficient Australians to care for Australians. Indeed many of us feel that we should have a surplus so that we can actually be helping out in the region — rather than being increasingly dependent on 3rd world health professionals when we all know that the ethics of that are very questionable given the need for them in other parts of the world.

The workforce situation has to be solved. Primary care is perhaps the biggest reform challenge in Australia – but one which we know is achievable over the next decade because New Zealand, Canada and the UK are well down the path. We need to swing our hospital-centric system around to the win-win situation that is available with the wellness and prevention models of health. Clinical scientists are increasingly going to have genetic tools and other similar tools to predict, not only from lifestyle history but also from genetic patterns, what issues are going to be important in maintaining the health of someone throughout life. We really need to embrace this approach which has been shown in many parts of the world to be so cost effective.

To really get the community on side with the wellness model, we have to do what we have so far been unable to interest Mr Abbott in: we have to do what other countries have done and have a contemporary dialogue with Australians about what they want from their health care system, and what it means to give them what they want. Because there's no question in my mind that Australians want more help to stay well and avoid disease and get earlier diagnoses, so that we don't have this dreadful situation where, for example, half the diabetics in Australia don't even know they have it yet.

We need to educate the community and politicians that at the moment, especially with our workforce crisis, we must rationalise what our hospitals do so that all hospitals aren't all things to all people. We need to have a network of facilities available in our hospitals, creating if you like a string of pearls.

Finally, and this is not an impossible task, we need to move away from this wretched jurisdictional dysfunction between state and federal programs. Eventually we need a third party, and probably the likely outcome would be a universal insurer that has all the different pots of money at its disposal and one set of brains looking at how to manage that.

Policy is clearly not the missing ingredient at the moment. There's a lot of contemporary thinking about this that sees ideas from health professionals, consumers and economists all fusing together. What's missing is political leadership, and perhaps not even leadership but political courage. Political courage in my experience does not necessarily come from the hearts and minds of a politician. Political courage comes when we all make it perfectly clear that we won't tolerate anything but the leadership that will allow these changes to occur.

We are at a crossroads in Australia. We have an ideological divide about health care: the federal government seems to be quite content to move to a user-pays system with a safety net for the poor, so we need to tackle that ideological divide. But I have no doubt that if we all get behind and support the sort of initiative that I'm so proud to launch today, then with a Federal election coming up we can make a difference and start on this journey which we all so badly wish to take.

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