Health is once again
shaping up to be a major election issue. However the major parties are not as divided
on health policy as they appear. If there were no major choices to be made on the
future of health and health care in Australia, such agreement would not
matter. Perhaps the two main parties have simply decided to seek the centre
ground because that is where the voters are. But are they? How can political
parties work out what the citizens of Australia really want from their health services?
The answer lies not in
opinion polling or superficial ‘consultation’, but in citizens’ juries. This
particular form of ‘participatory democracy’ involves bringing together a random sample of the relevant population; asking them to put
their citizens’ hats on; giving them good information on the issues for debate;
encouraging them to question experts to clarify that information or seek more
information; and then giving them time to reflect and to make recommendations.
This approach formed the basis of the five juries which I have helped facilitate;
four in WA and one in South Australia.
The Canadians and the British have also embraced citizen juries in their health
care reform processes.
Other forms of ‘participatory democracy’ exist,
but citizens’ juries have several advantages over most other methods:
fact that participants are selected randomly reduces the
over-representation of special interests and axe-grinders to which other
methods are vulnerable,
fact that participants are given comprehensive information and time to
reflect on it avoids the media-driven knee-jerk responses sometimes found
by opinion polls and plebiscites,
asking them to put on their ‘citizens hats’, citizens juries encourage
participants to make recommendations that serve the widest possible
number, rather than just focusing on competing sectional interests.
So, if political parties really want to find
out what most Australians want from health policy, they simply need to set up
say 20 citizens’ juries across the country and ask them what they want from
their health services. It is not difficult and in my experience people love to
be involved in this way.
Importantly, these are not ‘decision-making’
bodies. Their task is purely to recommend
the principles that the citizens believe should underpin their health
services. It remains for ministers (and others) to accept or reject the
recommendations and to decide how to implement them.
For example,a citizens’ jury in
WA in 2005 identified the principles of greater transparency in decision
making, greater equity, more prevention and increased resources for mental
health as top priorities. To achieve this, they were willing to give up some
small inefficient hospitals and Emergency Departments. The responsibility for
decision making that followed the juries’ recommendations, however, remained where
it had always been; with politicians and policy makers.
In each of the citizens’ juries
I have facilitated, greater equity has been identified as a priority. The
citizens consistently want a better deal for the disadvantaged, especially
Aboriginal people. They also have some lesser concerns for other disadvantaged
groups and want to shift the focus of health investment towards prevention and
away from cure.
They also appear to want what
might best be described as the ‘moral responsibility’ for setting principles. I
have witnessed jury participants puffing out their moral citizens’ chests when
reporting on their recommendations. They respond positively to the idea of being
asked to act responsibly on behalf of their community.
Equity as a health care
principle is especially interesting. There is a vacuum in equity policy in Australia. Who is
currently responsible – morally responsible – for equity policy in health care?
Who is responsible for its formulation, its deemed importance (relative for
example to efficiency, with which it may sometimes conflict) and for putting it
into practice whether nationally or at a state level or in a hospital or a
general practice? Oddly, at none of these levels is the answer clear. One
answer – the citizens’ answer – is that it should be citizens!
The other key topics of debate by
juries – on the overall objectives of the health care system (is it just
improving health?), the need for transparency in decision making, etc. – can be
looked at in similar terms. These issues may not carry the same weight as
equity in terms of moral responsibility, but some sense of responsibility is
still likely to be present in the community.
There is no impasse here; no
threat to our parliamentary democracy from these citizens’ juries. Having
‘citizen ownership’ comes with political advantages, as the community is better
informed and more aware of the problems of running a health service within a
constrained budget. Citizens at the first jury with which I was involved in
2000 remarked on how, after being on the jury, they better understood the
system and were more sympathetic to those who had to decide how to spend the
In primary care, the ALP has
suggested GP Super Clinics. Nicola Roxon1 has argued that these
be ‘designed to ensure more Australian families have access to doctors, nurses,
specialists and allied health professionals … all in one centre, in their local
community where they need them.’ The questions remain however as to what these
clinics will actually do to allow this better access, what their priorities will
be and where the main access gaps are from the point of view of those who might
use these clinics.
The GP Super Clinics appear
to be based on the GP Plus2
Clinics currently being established in South
Australia. I recently facilitated a citizens’ jury established
to consider one of these clinics.
Issues of access loomed
large for participants. One of the main requirements identified for improving
access to services was information. The jury recommended increased
efforts to ensure that knowledge was available to the local community about the
clinic and the services it provides. It also identified other access issues
related to affordability; breaking down language and cultural barriers; and providing
cultural safety/security, especially for Aboriginal people.
There is not much to choose between
the two main parties on their current health policies. Both talk about radical
change but are not committed to it. Both are concerned only with the mechanics
– for example who will run the hospitals rather than according to what principles
and to what end. Neither seems to have an overall strategy based on coherent
principles (such as equity for example). Neither is addressing the big issue of
the balance of care between hospitals and the community. Would it not be better
if at least one party were prepared to go to the voters acknowledging that they
are unsure how best to proceed and want some guidance on principles from the
citizens? Health politicians should recognise that it is the citizens’ health
service. They should allow citizens to say what values they want to drive it,
and then design a system that gives the people what they want.
1. Nicola Roxon, Speech to Catholic
Health Australia’s Annual
29 August 2007.
2. South Australia’s Health Care Plan