Below are John Menadue’s speaking notes, first published in Croakey, Crikey’s health blog:

Under-resourced mainstream media is not in a healthy state. It is failing significantly, with a few notable exceptions, in the health field as in most other fields. It is much more than just the shrillness of the Murdoch media. With so little news to break or analyse, it is not surprising that journalists spend such an inordinate amount of time-sharing opinions with each other.

Can online media fill the vacuum? Crikey/Croaky, Centre for Policy Development and others are in the field, but they will take time to grow. The important issue for online media to recognise is that technology is the easy part. The hard part is content both information and analysis.

In pay television for example, we have excellent new technology that has given us more channels and better pictures, but the improvement in content is marginal. We have more choices, but little increase in value. Online media is much cheaper to produce and deliver, but the continuing problem will be access to good content at reasonable cost. Bloggers give us worthwhile and diverse opinions, but are not particularly strong on the dissemination of factual information.

The Australian polity and the media are in a downward spiral, almost a death wish. Disappointment and disillusionment with politics and the media is widespread and growing.

Trivia and personalities prevailed in the media in the last election campaign. The best example of trivia that I can recall was the Australian Financial Review’s portrayal of Julia Gillard saying ‘Nauru’ instead of ‘East Timor’. As the AFR put it ‘Gillard’s Nauru gaff rocks asylum seekers’ stance’. Really? I have been getting my four children’s names confused for the last 50 years! Even Kerry O’Brien mis-speaks the ABC for the ALP.

Politicians are clearly running away from the big ticket issues – particularly climate change and the two or three track economy that the mining boom is foisting on Australia. Politicians listen closely to lobbyists on these big-ticket issues – 900 full-time of them, or 34 for every Cabinet minister. Journalists are under-resourced to examine policy issues and in many cases have become the mouthpiece of special interests with their well-funded public relations activities. The Australian Centre for Independent Journalism at UTS found in a survey of the 10 major metropolitan newspapers published in Crikey in March this year that 55% of content was PR driven, and 24% of content had little or no significant journalist input. In the specific field of health/science and medicine, the survey found that 52% of content was PR driven, with 23% of content having little or no significant journalist input.

Before I come specifically to health, let me mention the problem in the wider media context.

The Rudd Government introduced timid climate change proposals and then over-compensated the polluters. Frightened by a ‘big new tax’, the government ran away. The result of the power of special interests and the failure of the media to explain has resulted in what Ross Garnaut has described as a ‘diabolical problem’.

For a $7 m advertising campaign, the three wealthy foreign-owned miners saved themselves $7 b in taxes. There were some media commentators, Ross Gittins and Ian Verrender, who wrote cogently on the issues, but much of the media, which was the beneficiary of the miners’ advertising money, either diverted public attention from what was at stake or clambered in political support of the foreign miners. I wonder how those same journalists will react when Chinese state-owned enterprises follow BHP, Rio Tinto and Xstrata in running future political campaigns against the Australian government.  The media was missing in action on this big-ticket item.

On asylum seekers, the government and the media, and particularly the ABC, failed to frame the debate with facts. Television news and current affairs obviously worked on the assumption that if there were no pictures, there was no news. It was easy to get pictures of asylum seekers’ boats floundering in the Arafura Sea, but it is hard to get worthwhile pictures of asylum seekers’ coming by air, despite the fact that over 90% of asylum seekers come by air and not by boat. Tony Abbott said that Australia was being ‘invaded’ by asylum seekers, yet neither the government nor the media took the trouble to point out that asylum seekers represented only 1% of our migration intake.

Special interests in health, as in other areas of public policy, hold sway, with the public and the community largely excluded. The health media has gone missing on the following.

At the April COAG meeting, State governments and their health bureaucracies were left in control of hospitals. Kevin Rudd described it as the ‘greatest reform in health since Medicare’. That was nonsense. John Brumby and the states won the arguments over hospitals and got a lot more money to boot. Where were the professional and searching journalists in mainstream media? We were all overwhelmed by the spin.
Compared with many other countries, we have a much higher number of hospital beds. Australian governments have an obsession with hospitals at the expense of non-hospital care. But no journalist to my knowledge has examined this obsession we have with hospitals and hospital beds.
The media is yet to examine the gaming that goes into waiting lists. These waiting lists are more rubbery than Goodyear tyres.
The AMA resists any significance change in archaic work practices in health which if implemented could give this country enormous improvements in productivity. Health is our largest sector and our largest employer. There is serious concern about lack of national productivity improvements in recent years, but the potential for health sector productivity improvements is scarcely ever mentioned by mainstream media.
Many media economists extol competition, but the Australian Pharmacy Guild maintains its protection from competition through location rules, the cap of 5,000 on the number of community pharmacies, and the exclusion of pharmacies from supermarkets. But scarcely a peep from mainstream health journalists.
The media responds to hot button issues like a particular death in a hospital, but scarcely examines the systemic problems that cause about 10,000 avoidable deaths in our hospitals each year or 200 each week. That is the equivalent of one Bali bombing or one Victorian bushfire every week of the year.
The health insurance industry retains its corporate welfare subsidy of $5 b per annum. Yet the mainstream media spends more time publishing the views of this highly protected industry, rather than examining alternate policies to produce better public outcomes.
At the last election, pathology companies, such as Primary Healthcare Ltd, ran ads against the government’s attempt to curb burgeoning pathology costs. It was obviously affecting their profits. In the 8 years to 2008-09, pathology services, paid for by Medicare, have increased 62% and benefits paid increased by 71% – way ahead of inflation. Put another way, medical services per person from 1995-96 to 2008-09 have fallen by 5% for consultations, but risen 30% for procedures and 65% for diagnostic, including pathology. No wonder the government needs to act. Whilst Australian Financial Review journalists were talking up the problems of the pathology sector, nowhere did they frame the discussion with some facts about the enormous growth in pathology and the excessive level of referrals. Their stories seemed like public relations handouts from Primary Healthcare Ltd with minimal journalistic input.
How can the information base be improved to promote public health and a healthy media?

The health sector is so large, complex and technical that it is difficult to understand. This is a problem for all, including journalists. It is also true for ministers, both federal and state, who are easily captured by their health bureaucrats with their mastery of detail.

The best-informed health commentary is, and I hope you will excuse me for saying it, in Crikey/Croakey and CPD. But their resources are limited and their readership falls far short of mainstream media. Hopefully such organizations will continue to grow and develop. But content is the hard and expensive part.
Health information and policy advice is biased heavily in favour of governments and their bureaucracies. They are able to dominate the debate with this monopoly of information. With the balance of power now to be held by Independents in the House of Representatives and with the Senate to be controlled by the Greens from July 1 next year, there is a unique opportunity to substantially expand the resources, both quantity and quality, available to members of parliament through parliamentary committees and the parliamentary library. The media and the community would be much better informed. (By far the best information I was able to find recently on asylum seekers came not from the Minister for Immigration and Citizenship and his department, but from the Australian parliamentary library.) The proposed parliamentary budget office will also be a considerable help, but it will be limited to budget and fiscal matters which are only one part of a much wider agenda of economic policy.
Julia Gillard was rightly criticised for her proposed citizens’ assembly on climate change. It was obviously a diversion from the main issue. But she had a point about our need in many policy areas, including health, for a better-informed community that will enable our leaders to make some tough decisions. I have been a long-term advocate of citizens’ assemblies, deliberative polling, and citizens’ juries to explore at every level, local, state and national, informed community views on hard issues in health. We need community groups who are informed by experts and not dependent on the Herald Sun or the Daily Telegraph.
The federal government has proposed a number of authorities to report on health performance, eg the National Performance Authority will report on emergency departments and elective surgery waiting times, adverse events, patient satisfaction and financial management. There will also be an Independent Pricing Authority and a permanent Australian Commission on Safety and Quality in healthcare.  All these new monitoring authorities will be helpful in providing the information-base for more informed reporting and public discussion.
This new information will not only help public policy, but also provide better information to consumers to help each of us make better decisions about our own health ‘My hospital’ similar to ‘my school’ should also be helpful.
The establishment of an Australian health commission would also facilitate better public understanding and analysis of health issues. Such a commission would implement government health programs, subject of course to the government setting out the principles and policies that should guide the commission, eg universality, equity, subsidiarity, pooled funding, etc. I foresee this commission working in the same way as the Reserve Bank in the economic field. The Reserve Bank has proved itself to be independent and largely immune from pressure from special interests. Importantly the Reserve Bank, as should an Australian health commission, facilitates and leads an informed debate on health issues and policies. That would better equip the media and us all in understanding.
Other health authorities, such as Medicare and the Australian Institute of Health and Welfare, should be instructed to facilitate public discussion on important health issues and help us get away from the current debates that are really a two-way discussion between the minister and special interests. The information they supply must be much more customer-friendly, and highlight the key issues where greater public understanding is necessary. It would make for a better-informed media. The key issue that we don’t discuss in health is that we can’t have all we want and that priorities and hard choices have to be made.
There are many ways in which public interest journalism in health can be advanced. With the failure of under-resourced mainstream journalism, the key is enhanced information and independent advice to facilitate a more informed parliament, media and community which would in turn make it easier for adaptive leaders to make the necessary but hard decisions in health.

New technology is important but the real problem is access to good content. As in all media, the key is not so much technology as content.

If you want to hear more from John Menadue on what is wrong with our media and some ideas on how we might fix it, you can listen to his conversation with Deborah Cameron on ABC’s 702 Mornings here.

In an historic decision, the High Court has struck down legislation which resulted in the early close of the electoral rolls and denied over 100,000 Australians the right to vote.

The decision is a landmark victory for representative democracy, political participation and accountable government.

The case was a constitutional challenge to the validity of changes to the Commonwealth Electoral Act 1918 made by the Electoral and Referendum Amendment (Electoral Integrity and Other Measures) Act 2006. The Amendment Act resulted in in the electoral roll being closed on the day on which the electoral writ is issued for new or re-enrolling voters, and three days after the writ is issued for voters updating enrolment details.  Previously, the electoral roll remained open for a period of seven days after the issue of the writ.

According to the AEC, historically, the calling of an election has resulted in significant numbers of persons enrolling or changing enrolment during the 7 day period, particularly young Australians.  The 7 day period enabled the AEC to advertise and promote enrolment and target particular groups with information campaigns, including Indigenous Australians and people experiencing homelessness.  At the 2004 Federal Election, approximately 423,000 people enrolled, re-enrolled or updated enrolment during the 7 day period.

It is crucial to representative democracy and accountable government that all people have the right, and the practical opportunity, to vote.   The early close of the rolls, which occurred thanks to Howard-era amendments, denied over 100,000 people the opportunity and right to vote.   The legislation disproportionately disenfranchised Indigenous Australians, young people, people experiencing homelessness and people in remote communities. In so doing, the legislation diminished our democracy.

This decision, in ordering that the rolls stay open for at least 7 days to enable people to enrol or update their enrolment, restores and promotes the fundamental human rights to vote and, in so doing, enhances democracy and promotes representative government.

The challenge to the early close of the rolls was jointly conceived and coordinated by the Human Rights Law Resource Centre and GetUp!.  The Human Rights Law Resource Centre is a leading national human rights advocacy organization which, in 2007, established constitutional protection of the right to vote in the landmark High Court case of Roach v The Commonwealth.

The matter was run pro bono by an outstanding legal team comprising Ron Merkel QC, Kristen Walker, Fiona Forsyth and Neil McAteer of Counsel, together with Mallesons Stephen Jaques.

You can read the Court’s order here.

More Than Luck is a collection of ideas for citizens who want real change edited by Mark Davis and CPD Executive Director Miriam Lyons. A to-do list for politicians looking to base public policies on the kind of future Australians really want, More Than Luck shows what’s needed to share this country’s good luck amongst all Australians – now and in the future. Click here to find out more. Like what you’ve read? Donate to help make good ideas matter.

John will address health and social service professionals on the role of the health service and strategy for health reform.

Click through the Victorian Health Association’s website to read more about the conference or download the event program.

Want to know more about John Menadue? Read his biography and recent contributions to the Centre for Policy Development.

Indigenous disadvantage
is one of several examples that the Australian Public Service Commission
identifies as a highly complex policy problem; one that is "highly resistant to
resolution" (see its recent publication Tackling
Wicked Problems). Just when you think you may have the policy solution, more
complexities are likely to appear. Complex issues, and particularly sensitive
ones such as indigenous policy and delivery issues, will require moving beyond
consultation to a more active engagement with those likely to be affected by
decisions. This is sometimes called "participatory governance" or, in the
OECD’s words, "active participation".

Fundamental
ingredients

The
literature here and overseas suggests several necessary (though perhaps not
sufficient) key ingredients for successful creation of participatory policy
mechanisms.

Three such
ingredients stand out: strong leadership, trusting relationships and the willingness
of those with power to share it. In the context of indigenous issues, strong leadership can be ticked off at
this stage, occurring from the top – from both the Prime Minister and the
Leader of the Opposition. However, this commitment will need to be maintained
for a very long time and, importantly, be imbued with a determination to see
desired changes achieved on the ground. Leaders of government teams on the
ground will need the right cultural attitude and expertise if their endeavours are
to succeed. For instance, there is much evidence from the recent government trials of whole of
government approaches in indigenous communities that attitudes at the top have
not always filtered down. Frequent turnovers of staff working with communities
have not assisted.

The second
fundamental ingredient is trusting
relationships – without this, genuine collaboration of relevant parties is
impossible. Trust has been described as both the lubricant and the glue: it facilitates
the work of a collaboration as well as holding it together. The concept of trust has only recently found currency
within the Australian Public Service – it essentially involves behaviours where
the expectations of each party are clear and there is confidence that what is
committed to will be delivered. In the context of indigenous communities, a
"trust culture" will be difficult to build up and maintain unless these
communities have a genuine opportunity to influence government decisions.

The third
fundamental and related ingredient that the literature has been identified for
participatory practices to work relates to the willingness of government to share their decision-making power. This is so much
easier said than done, especially for those officials who have been so used to
"managing" a consultation process and seeing it as a process essentially under
their control.

The report
of the 2005 Select Senate Committee on Indigenous Affairs expressed some
concern about the extent of the power inequality between negotiating parties in
the context of government-indigenous Shared Responsibility Agreements which
dealt with respective responsibilities of aboriginal communities and
governments; a concern particularly that the
provision by government of basic infrastructure facilities, such as housing
repairs or a health centre, could be
traded away.

Some implementation challenges

Even with strong leadership from the top, with a building of
trust and also effective power-sharing arrangements, other more practical challenges
remain to be overcome if effective partnering arrangements between government
and non-government players are to be
realised. Implementation challenges
explain why it is not at all surprising that there is so often a gap between the
rhetoric government now uses on participatory governance and the reality witnessed
on the ground.

There are
at least five important implementation difficulties to overcome.

The first
is reshaping respective accountabilities
of the players. Important and
increasingly complex accountability questions arise around who is accountable
to whom and for what in the process of bringing more non-government players
into the policy development and decision-making process. Can the principles of
individual and collective responsibility as well as accountability to the
taxpayer through Parliament hold when the boundaries between what governments
and communities do are more blurred? Can
there be multiple accountabilities? And how far can ambiguities in partnership
arrangements be tolerated?

As the
boundaries across sectors blur, there is an inescapable tension between vertical
accountability mechanisms traditionally inherent in the Westminster system and horizontal
accountability in terms of responsiveness to citizens. The challenge now is to reshape governance processes
and practices so that this inevitable tension is minimised and managed; and to gain
collaboration in clearly defining respective roles and responsibilities. Essential
elements needed here include that: expectations of all parties are agreed and
explicit; expectations balance respective capacities; reporting arrangements are
credible; and there are carefully designed and appropriate monitoring and
evaluation mechanisms.

Second, is
the need to pay attention to an alignment
of organisational structures. Too often when governments set out to put
participatory governance mechanisms in place,
they are observed to be operating in the context of traditional structures and
processes (for instance referral back by government officials on the ground to
head office). Yet these practices may not align with the purpose of participatory governance (for instance, where more
autonomy in decision-making is needed by officials working with communities on
complex and/or sensitive issues). A key implementation issue, therefore, is to
redesign public sector institutions and practices to align more with the new
participatory and interactive framework.

When
governments engage with indigenous communities, there is an additional issue: it can be anticipated that there will be a
deep divide between the types of structures and processes governments use to
obtain results and ensure accountability, on the one hand, and traditional
indigenous governance arrangements on the other. If these are not understood by
all parties, and addressed early on with some collaborative alignment
attempted, then all the commitment that can be brought to bear on the task at
hand will not be enough to ensure implementation success.

Again, it
is not easy to turn this rhetoric into reality. There are many Australian
examples of where there was good intent and there was genuine engagement at the
initial stages of the project, only for there to be a switch back to old
patterns and relationships in the later stages of implementation when
government resumed the role of a more dominant player – a situation at odds
with genuine participatory arrangements.

Third and related, there is the really difficult issue, in
the shorter term at least, of gaining and maintaining the appropriate cultural environment. This was found to
be particularly relevant in the case studies analysed in the Connecting Government report (MAC 2004) especially so in
evaluations of the COAG Indigenous Trials. A growing academic literature on indigenous
governance, in Australia
and elsewhere points to the importance of gaining a ‘cultural match’ in
ensuring successful policy implementation.

Jim Cavaye, an expert on community engagement mechanisms
observed a few years ago approaches which amount to: "we are from the
government and we are going to engage you" rather than there being an
understanding of the value of investing in relationships from building up a
partnering approach. (2004:94)

Fourth, the extent to which the public service has the relevant skills and capacity to engage
with non-government players in the policy process is a real issue and was
recently acknowledged by the Australian Public Service Commissioner in her
2005-06 State of the Service Report.

…the APS needs to
build its capacity to effectively and successfully engage the Australian
community. This will include recruiting for and developing strong relationship
management skills, the willingness and ability to listen to the views of
others, and conflict resolution and management skills (2006:248).

In more
specific terms, a government commissioned evaluation of the COAG Indigenous
Trials raised a series of relationship issues in building partnerships,
including indigenous partners identifying a basic set of required skills for
government officers. These included: good listening; acting in good faith; high
levels of good will; willingness to share power; recognising and acknowledging
intra-community and familial relationships and how these impact on leaders;
understanding the pressures on communities; being honest and open; and being
human (Morgan et al 2006). These are the skills that can be expected to
be ones all public servants involved in participatory activities will need to
acquire.

Alongside
the building of internal government capacity is the equally important task of
ensuring that those whom governments engage, also have the necessary resources
and capacity to participate fully.
Non-government bodies also need to assure government that they have the
capacity to be responsive to broad consumer and community needs.

An
interesting, if radical, question arises here in terms of the boundaries around
the participatory activities of public officials. For example, would there be
occasions when officials could be expected to be supporters, if not actual initiators
of citizen or community empowerment?

Finally,
there is much scope to ensure appropriate evaluation
of policy initiatives and their implementation. The OECD indicates that to
date there has been little evidence of countries making progress in developing
appropriate evaluation frameworks. There are many possible reasons for this, one
being that active citizen participation is most required on complex and sensitive
policy issues which, so far, have not been coped with by standard program
evaluation methodologies. But it is likely also to be because of a lack of
clarity with respect to the purpose of citizen participation.

Professor Brian Head, in the context of
participatory initiatives, has recently asked some relevant questions: is the
purpose to be about outcomes only or is it to also be about processes and how
well relationships are developed? Is the
purpose to learn and/or to generalise from a
particular instance? Is it about
auditing and compliance, or to provide some encouragement to participants? Or is it some combination of these? (2006). One
could also ask: from whose perspective is the evaluation to occur? Only the government’s or also that of
non-government players? If also the
latter, is the purpose of their participation and their respective roles,
responsibilities and accountabilities understood and agreed? To what extent would non-government players have
a say about the place, method and timing of the participatory processes?

Concluding
Observations

It is
important to note that an active participatory approach is not normally to be
expected in most policy and delivery government processes. But it is now
generally agreed that this approach becomes necessary for dealing with complex
and sensitive issues, such as those surrounding indigenous matters. Hopefully
this will be taken as a given when the newly established and bi-partisan
Commission considers its next moves.

Whatever the
actual level and mechanisms of involvement of non-government players in policy
processes that governments decide upon, it is of paramount importance that
expectations on both sides be well understood and aligned. If, for example, the government wishes to consult
only now and then but not actively to engage throughout the whole policy
process, that needs to be stated and understood at the outset. If the government has already made a decision
which is irrevocable but then wants to engage the community within that
context, that also needs to be clearly stated and understood before communities
participate in discussions on any next steps.

Relatedly,
clarity of language and intent and avoidance of rhetoric is essential. Incorrect
and inappropriate use of terminology such as ‘collaboration’, ‘partnership’, ‘engagement’,
apart from causing inefficiencies in process, may result in negative outcomes,
reduction of trust and/ or reduced community engagement potential.

At its heart,
successful engagement requires the management a few basic tensions for
governments: there is the tension of
balancing the vertical accountabilities of the Westminster system with the horizontal
responsibilities of government out toward communities. But there is also a
tension between attempting to pursue the most immediately efficient practices
on the one hand and, on the other, spending the required resources to gain
trust and collaboration over what can be lengthy periods of time with the aim
of achieving more effective and long-term outcomes.

Moving in
the direction of a more participatory governance framework will require careful
management – governments will have to build new structures and ways of working.
They will need to develop new skills, new capacities with new and different
types of relationships and interactions. Into the future, at least in the case of
indigenous issues, we can expect participatory governance and partnering
relationships to become mainstream activities for governments and their officials,
no longer something to be dabbled in on the side.

This article is an edited version of an Issues Paper on Participatory Governance for the University of Canberra’s
ARC Project on Corporate Governance in
the Public Sector: an Evaluation of
its Tensions, Gaps and Potential. The author is alone responsible for any
views or errors in this paper.

REFERENCES

Australian
Public Service Commission (2007), Tacking
Wicked Problems: a Public Policy Perspective, Commonwealth Government

Cavaye Jim
(2004) "Governance and Community Engagement: The Australian Experience", in
Lovan, RW, Murray, M and Shaffer, R (eds), Participatory Governance, Ashgate,England.

Head Brian
(2006) "Network-Based Governance – How
Effective?". Paper delivered at Governments and Communities Conference, Centre
for Public Policy, University
of Melbourne, September.

Management
Advisory Committee (MAC) (2004) Connecting
Government: Whole of Government Responses to Australian Priority Challenges,
Commonwealth
of Australia

Morgan
Disney Associates (2006) Synopsis Review
of the COAG Trial Evaluations, Report to the Office of Indigenous Policy
Coordination (OIPC), November.

One of the most important dimensions of the workshops, however, was to encourage participants to believe that they could achieve change. While generally well-received, at one point an attendee working within the gay community politely pulled me aside and said, ‘No offence, but while it maybe ok for a white, middle-class, university-educated, NGO worker from the eastern suburbs to believe this, why would anyone care about a fag from the western suburbs?’

Unfortunately this attitude dominates a large part of our community. While some believe that they can change the political environment, others cannot imagine that they have such influence. This makes the relationship between citizens and civic organisations a highly uneven one. If we wish to promote greater community engagement, we must therefore take into account the nature and causes of this disparity. Unfortunately much of the existing research on citizenship has taken an overly homogenous view, detracting from its potential value as a basis for citizen engagement activities.

The complex citizen

The Centre for Cultural Research is currently conducting a research project on the complex, heterogeneous and constantly changing nature of citizenship. [1] The initial findings of this research are outlined below.

Citizenship often reflects of the environment in which citizens find themselves. Within Sydney, for example, we have a postcard harbour surrounded by places of controversy and poverty. Residents of very different backgrounds live in close proximity – often harmoniously, and sometimes less so. According to recent research by Griffith University’s Urban Research Program, the city is becoming increasingly polarised, with the wealthiest sections enjoying high levels of access to amenities, while other sections are experiencing increasing deprivation. The changing physical, demographic and relational structure of the city has meant that there has also been a change in the way that different groups interact with, and perceive, civic bodies.

These disparities not only present challenges for policy makers generally, they also have important implications for citizens’ relationships with each other, as well as with the civic institutions that are meant to represent them. This is particularly the case if civic institutions are seen to either neglect or favour certain groups, and in part, this has given rise to what can be described as a ‘citizenship surplus’ as well as a ‘citizenship deficit’.

A citizenship deficit emerges when groups sense or believe that they do not have access to political avenues to be heard, represented and demand change. In this context people feel unable to be engaged or are frustrated in their attempts to represent themselves or demand action from government and services on their behalf. This leads to disconnection from political processes.

Contrary to common perception, citizenship deficits don’t only affect the disadvantaged. As the traditional responsibilities and activities of government are outsourced and privatised, there is a parallel privatisation of decision making which removes opportunities for meaningful civic engagement from rich and poor citizens alike.

The idea of a citizenship deficit is a fairly familiar one. Less often considered is the possibility that citizenship can be in ‘surplus’ – in contexts in which citizens’ capacity and opportunity to engage exceeds their willingness to do so.

Because citizenship – and citizenship deficits – are fluid and heterogeneous phenomena, they can be categorised in a number of different ways. One possible categorisation is portrayed in in the diagram below.

1. Marginalisation and
citizenship deficits

The first category of citizenship deficit is brought on by a sense of marginalisation. This is driven by a belief that interaction with civic institutions is pointless as opinions and demands will be ignored, which means that there is no connection between the population and the civic institutions surrounding them.People feel that any effort to be involved will not be rewarded with results, and consequently a sense of disengagement and disempowerment prevails.

2. Privatisation and
citizenship deficits

This citizenship deficit applies to much wealthier populations and results from a lack of access to civic institutions because of privatisation and neglect by government authorities. This in turn leads to the privatisation of decision-making and withdrawal from the public arena as well as from democratic processes. Consequently, the residents in the pockets of wealth may find their relationships with civic institutions more like that of consumers than citizens.

This group has often been described as the ‘aspirationals’ and are most often found in the growth corridors of Sydney. There is no reason to believe that the disengagement of this group is result of choice – instead it may be driven by the failure of government authorities to service their needs.

3. Citizenship surplus
- empowered not engaged

In the third category citizenship is in ‘surplus’ even if there is limited or no political engagement. This group appears to have quite a lot in common with the ‘aspirationals’ but may come from areas that are highly serviced by civic institutions: the choice not to engage is therefore voluntary. There is a strong push for self sufficiency – a belief that their social capital, wealth and status means that they do not not require the services of civic institutions (including government bodies). While not antagonistic towards such institutions, the belief is that the services provided by the private sector are ultimately superior to public ones. Members of this group may overcome their disengagement if there is a threat to their quality of life (such as a proposed development) or a threat to their value system (such as a support for an apology of discomfort with the Howard government’s mandatory detention of refugee children). Their engagement is accompanied by a belief that political influence is possible and supported by the mobilisation of some impressive resources.

4. Insurgent
Citizenship – empowered and engaged

The final category of citizenship identified is the insurgent citizen (see Holston 2007): that is, the citizen who is both engaged and empowered. This group may not have access to a great deal of financial resources, but has high social capital and both a willingness and ability to make time to be engaged in the political process. Consequently, they feel empowered through their social background and are engaged with civic institutions and political processes.

This group can have either progressive or conservative characteristics. On the one hand we see ‘activists’ promoting social justice issues (including students, academics, unionists and so on), and on the other hand we see the emergence of groups that take an anti-immigration stance (such as ‘anti-immigration’ political parties).

These different categories represent broad groupings which include include a great deal of internal variation. Further, the composition of these groups are not static as populations and individuals may move quickly between the groups as situations and experiences change.

There is little doubt there is a relationship between attitudes to citizenship and the health of a democracy. In Australia, democracy is robust in some ways, but many feel disempowered or disengaged and some feel both. Often civic institutions seem remote and disinterested which has in part driven a decline in the public’s interest in political parties (Jaensch et al 2004). To stop this, we must confront and challenge our citizenship deficit.

[1] The research project is also supported by
Oxfam Australia’s Young Engagement Program. I would also like to acknowledge the
efforts of Kylie McKenna in obtaining much of this research data.

References

Gill, J. and Howard, S. (2001). “It’s like We’re a Normal Way and Everyone Else is Different”: Australian children’s constructions of citizenship and national identity.

Educational Studies, 27(1), 87-103. Holston, J. (2007) Insurgent Citizenship: Disjunctions of Democracy and Modernity in Brazil, Cloth., California.

Jaensch, D., Brent, P. and Bowden, B. (2004) Australian Political Parties in the Spotlight, Democratic Audit of Australia, Science Program Social Sciences, National University, Report No. 4.

Pusey, M. (2003) The experience of middle Australia: the dark side of economic reform, Cambridge University Press, Cambridge.

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:

• The
  fact that participants are selected randomly reduces the
  over-representation of special interests and axe-grinders to which other
  methods are vulnerable,
• The
  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,
• By
  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
health dollar.

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.

Endnotes

1. Nicola Roxon, Speech to Catholic
Health Australia’s Annual
Conference, Sydney,
29 August 2007.

2. South Australia’s Health Care Plan

https://www.library.health.sa.gov.au/Portals/0/south-australias-health-care-plan-2007-2016.pdf

CPD and Sydney University’s Australian Health Policy Institute presented a joint seminar on the use of citizen juries to improve outcomes in health policy decisions on Thursday 18 October at the Eastern Avenue Auditorium, University of Sydney.

Dr Dan Fox, President of the Milbank Fund, and Dr Lyn Carson
of the United States Studies Centre spoke on citizen engagement in health policy reform in the US, Australia and internationally. A panel of policy experts, including CPD Bord Director John Menadue, then joined the speakers to debate the topic and take questions from the audience.

CPD members are invited to join us for this free event.

Date: Thursday, 18th October

Time: 5.30 – 7.30 pm (refreshments from 5 pm and at conclusion)

Venue: Eastern Avenue Auditorium, Eastern Avenue, University of Sydney. (Map reference k19)

RSVP: By Monday, 15th October to Diana Freeman (02) 9351 2818.

Further information available at AHPI website.

Consumer and community voices need to be centrally involved in both discussing and influencing government decision making. As well-meaning as the professions, health services, and government bureaucracies are, they are inevitably driven by their own professional, governmental or commercial paradigms and, in some cases, self-interest.

Yet an effective system should operate primarily for the benefit of the users of the system: health consumers, their families and communities. It is time in 2007 that our health system was not only sustainable, but also a national system, underpinned by nationally agreed (but locally implemented) values and principles. This doesn’t seem so much to ask in a country of only 20 million people.

What crisis?

Why do I and many others say there is a crisis looming?

Firstly, there are obvious strong and potentially unsustainable pressures on – and gaps within – the current system. These have been well canvassed elsewhere, including in Health care reform: a journey of courage [1] (and in the Centre for Policy Development’s A health policy for Australia: reclaiming universal health care)[2], and on the website of the Australian Health Care Reform Alliance (AHCRA).[3] The problems include an ageing population, increasing use of (often expensive) technologies and consistently higher than inflation cost-rises, a very fragmented primary health care system, dire workforce shortages, and a very complicated public-private mix (have you ever tried to explain our system to anyone overseas and noticed how their eyes bulge?).

However, apart from rare collaboration (e.g. the recent joint action on the mental health system), the various tell-tale signs (even alarm bells in some case such as dental services) do not seem to have galvanised Australian governments into significant united action (For example, there is no committee of senior officials from the various state, territory and federal governments that meets around primary health care – the very core of the health system – despite the sector’s reliance on their various funding streams).

The second indicator is the explicit acknowledgement by so many inside the system that a crisis is looming. In fact AHCRA itself was formed because 46 significant national and state health organisations (representing health professionals, health services and consumers) agreed that the current system was too fragmented and would be unsustainable without some radical action.

There are parallels with the water crisis, where governments have been reluctant to label the accumulating plethora of telltale symptoms as a major national problem, until faced with the bleeding obvious (and now it may be too late to solve it fully). In the health system, we have a similar looming crisis with far-reaching implications, but one similarly immune to short-term simplistic patch-ups. Further, like water, it is a crisis that needs a national solution, not nine different solutions. Kevin Rudd’s recognition that Federal-State duplication is a major issue needing urgent action is encouraging.

It is clearly time for a national health system, not fragmented by myopic funding systems, lacking a shared vision and values. So the Health Issues Centre and AHCRA strongly believe that a meaningful (and we use that term carefully) national dialogue with citizens and consumers is needed to help build the first national vision and framework for health care. This does not necessarily mean that only one government would end up running health care. But it does mean that all governments in Australia would use this vision as the basis of their health planning. No such common goals or principles (in which citizens and consumers have had any say) currently exist.

Why is it time for a citizen and consumer engagement?

We have called the required approach an ‘engagement’ rather than just ‘consultation’ for one main reason. We are seeking deliberative thoughtful conversations with Australians over this critical issue. This may sound like jargon to some, but it implies a stronger involvement than just a search for instant answers. We think this is an important distinction.

The case for such engagement can be made from a few perspectives. The obvious corollary from the case for a national system is that for such a significant policy move, citizens/consumers have a right to influence national frameworks that will shape health care for decades ahead. It is commonly argued that significant citizen and consumer engagement is needed when public policy is at a key turning point.[4] This usually occurs when a society is reassessing its options, setting priorities, or mapping the boundaries of major change. The current debate about the future of health care has now reached this point.

A more basic case is that citizen engagement in policy reform is part of a democratic approach to governance in Australia. This is already happening in a range of sectors at lower levels. Indeed, active involvement by consumers, carers and community members is gradually spreading throughout the health system. Certainly at the health coalface, consumers increasingly want better information and more input into decision making on their own (and their family’s) treatment and ongoing care.

Consumer participation is becoming an accepted part of the modern health care approach, now cemented into hospital and community care accreditation standards[5]^,[6], quality and safety guidelines[7] and some governments’ policies[8]. There are now many hundreds of examples around Australia of consumers’ input and involvement at the service level (e.g. feedback, input into new developments); and at the organisational level (e.g. advisory committees, or consumers on quality committees)[9]. Although there is yet relatively little formal evaluation of the impacts of this trend, there is much anecdotal evidence of its value.

So involvement in higher level decisions about the future of the health care system flows naturally from this participative movement, and is increasingly expected by Australians. Such counsel about the bigger questions or about broad directions for change is currently rarely sought, but it could easily be so. As Macfarlane has written: “it is their (citizens’) health and their money”[10].

Lastly, the other strong case for citizen/consumer involvement at such a crucial point is that change needs to reflect the community’s values. When major reform was being considered in Canada, a country-wide consultation was undertaken. The head of the reform commission, Romanow, noted:

“the values we hold play a central role in defining how we view the critical issues facing the future of health care. They play a central role in deciding which problems should have the highest priority, which options are acceptable, and in shaping the solutions we choose to adopt”.[11]

Citizen and consumer engagement can help to clarify how deeply held values are evolving with changing circumstances, as is happening now in our society and health care system (e.g. rapidly changing technologies, rising community expectations, ageing population).

John Menadue has similarly argued that “unless the Commonwealth and State governments involve the community in setting priorities in health spending, we will not make real progress in systemic reform…. Unless the community is locked in through appropriate structures and processes, health reform will not happen. The public must be connected”.[12]

So what type of national consultation do we need?

The federal and state governments should jointly run a national engagement process with citizens and consumers, aimed at eliciting some consensus on the main values, principles and priorities for the future of the Australian health system. This process would be based on a set of principles, described below, so that it was legitimate and credible, transparent, meaningful, information-rich and deliberative (i.e. seeking thoughtful, not merely instant, responses) for participants.

What would such an exercise produce?

Importantly the results should be the critical set of inputs for the development of a national vision and framework for an ‘Australian Health System’. Either the Council of Australian Governments (COAG) or a newly formed Health Reform Council, reporting to COAG, should oversee this. These results would comprise a set of key principles and values that participants (as citizens and consumers or carers) believe should shape the health system in the future. They might act as a sort of ‘design brief’ or set of criteria against which system change should be judged.

What might such an approach look like?

There are several alternative ways of conducting this engagement exercise, depending on the resources available. We have sketched an ideal approach (and we believe the future of the health system deserves a comprehensive approach) as well as a proposal for a more limited (and less costly) consultation with lower, but still valuable impact.

An ideal approach

Community engagement can be as long as a piece of string, but we are proposing a complementary set of methods to both inform all Australians of the need to consider the future of the system (to alert people to the issues and to stimulate national debate) and seek in parallel specific views from a smaller but reasonably representative sample of citizens/residents. Thus it will involve both broad marketing techniques and targeted consultation.

The first set of methods, aimed at the whole population, might include communication via TV, radio and print media to prompt public thought and debate. Some national, broadly accessible, good quality, easy-to-read information should also be made available (via the web, hard copy, translated versions), with a variety of opportunities for people to offer feedback (eg via workbooks, websites, postcards).

The information provided to stimulate discussion would ideally be agreed by all stakeholders in advance, so it was (relatively) non-political, unbiased and factual. In reality that is a near impossibility, but an accepted level of consensus will need to be reached. Ironically, in an exercise to consult the community, getting the professional and political stakeholders to agree on the base information to distribute may be hardest part of the process (but indicative of what often happens and why consumers must have a say!).

This set of ‘whole of population strategies’ would open up access to all, but the input garnered would need to be interpreted cautiously. The responses received from such an exercise always run the risk of being biased towards the louder, more organised, better resourced or the more ideologically driven. That is why the second part of the exercise has been proposed.

Participants for the latter consultation should be drawn from three main groups:

• citizens selected at random – this would form the bulk of participants – a sample of as little as 1000 people may be statistically sufficient;
• high users of care who depend heavily on an effective system, and who have considerable experience of how the system meets or fails their needs (e.g. those who are chronically ill) – sufficient individual consumers and carers need to be involved that their different views are captured; and
• high needs or traditionally hard to reach population groups, including those with special vulnerabilities (i.e. the homeless, people with disabilities) who have special prevention and care needs that are not necessarily met, or who may under-use the system.

There is a wide range of newer potential engagement methods available. Unlike the more traditional mechanisms (seeking written submissions, consultation/town hall type meetings) these methods provide the opportunity for people to engage in representative, well informed, deliberative processes that lead both to recommendations on specific issues as well as a strong sense of people’s underlying values and principles. That is, participants get good quality information to help them see the bigger picture, and the processes allow time for people to really explore the information and come to conclusions from a broader community perspective, not just their own (This contrasts with normal telephone polling, for example, which provides no extra information and seeks instant opinions, not thoughtful responses.)

A variety of methods should be used, none perfect by themselves, but which in combination should provide a fuller picture with less bias than any individual method. Methods might include citizen’s juries, deliberative councils, websites, televoting, round tables, citizens’ assemblies, and ChoiceWork Dialogue among others.[13]

For example, citizens’ juries (CJs) are one of the more widely practised of the new techniques worldwide and have been used in Australia and extensively overseas. A CJ brings together a group that is representative of the profile of a local community or the population as a whole (ideally chosen at random). Participants are asked to consider an issue of local or national importance, usually involving a matter of policy or planning. Although participants are called ‘jurors,’ they also serve as lawyer and judge during the process. Information is presented in a quasi-courtroom, formal setting, and jurors are asked to reach consensus on the issue as representatives of a collective public voice, and not out of self-interest.

The CJ process is designed to allow decision-makers to hear directly from citizens, to learn about their values, concerns and ideas regarding an issue of public importance. The great advantage of the CJ is that it yields citizen input from a group that is both informed and (relatively) more representative of the public at large than typical methods. Its disadvantage is that decisions can potentially be shaped by the provision of unbalanced information, its presentation, and the general lack of understanding by average citizens of the very sick, chronically ill or highly disadvantaged.

ChoiceWork Dialogues (used by the Romanow Commission in Canada) engage representative groups of ordinary “unorganised” people to tackle a complex problem (what balance of services do we need in this community?) and make value-based choices. Participants are given the opportunity to “work through” conflicting values and difficult choices in order to reach judgments on an important issue. ChoiceWork provides an opportunity for people with differing views to find common ground and move forward together. Again, not only is the decision reached of interest, but so are the values voiced in making such choices.

Televoting is a less participative process and allows citizens to cast ballots on specific issues, but differs from conventional polling in a number of significant ways. Televoting provides a randomly selected, statistically significant sample of respondents with balanced, factual background material on an issue before they are polled. The Televote allows easy access to more detailed information, and time to consider the information and issue/s before making a decision. It is a useful follow-up when more in-depth methods (such as above) have identified some key values or principles and confirmation or prioritisation is needed from a larger group of citizens or consumers.

The involvement of a sample of citizens will give a sense of the views and priorities of ordinary Australians. However, this sample of general citizens may not appreciate the special needs of those forced to use a lot of health services because of their chronic conditions. Similarly, the needs of minorities may not be sufficiently understood by all citizens, especially as experience shows that such groups are often under-represented in mainstream exercises. Specific involvement of these three groups will therefore provide a more balanced set of outcomes.

Numbers consulted do not need to be large if random sampling methods are used and the findings from the various methods are triangulated. However, they do need to be enough to be defendable and legitimate or the exercise may be considered futile.

Internationally such large scale consultations or engagements are not new, and broad community exercises have been undertaken in the UK, Sweden, New Zealand, France and especially Canada, as noted above.

More modest versions

More modest versions of the above could be undertaken. For example, the broader marketing of the consultation to the public could be left out, and the focus could be on the specific consultations. Further, some overlap with other already planned consultations could enable some processes to provide local answers and views, as well as underlying values and principles useful to the national exercise.

General principles

However it is undertaken, the community engagement process clearly needs to be seen as legitimate by the community, along with key health interests and politicians. If lacking, it will be perceived as a waste of time. There are several ingredients to legitimacy. The process should:

• be non-partisan
• be transparent, and run by an independent organisation

• be information-rich for participants, that is they receive good quality, readable, full information on which to base their responses
• be deliberative, i.e. people will get the chance to listen, question and discuss before giving their final views
• use a variety of methods (to minimise biases) and triangulating findings
• be well resourced and facilitated
• be non-burdensome and respectful of participants’ contributions .

It should also be meaningful for participants, i.e. the findings should be linked to some genuine policy processes, such as suggested above. This list may seem a tall order, but in our opinion most of it is viable with careful planning.

What is already happening?

AHCRA are planning a very simple consultation this year to pilot some of these approaches and to feed some early community perspectives into the National Health Summit in July 2007. The Alliance will also be talking to private funders to seek funding for some further pilots of the proposed approaches, and approaching governments over time to discuss these proposals.

Benefits of Community Engagement

There would be a broad set of benefits from the practices above:

• giving Australian citizens and consumers a variety of opportunities to become involved, and helping provide a citizens’ vision for health care;
• enabling citizens and consumers to make thoughtful and productive contributions that can act as building blocks to shape the future of public health care;
• increasing public awareness about the difficult choices of health prioritising in a cost-constrained environment;
• tapping the public’s ability to give meaningful information to policy-makers about their important underlying values and principles;
• increasing social cohesion by ensuring that diverse voices are heard;
• increasing understanding among those involved about how deliberations with governments proceed, and of what is or is not possible in a representative democracy; and
• building some consensus and community trust, hence decreasing the fear of change.

Costs

Good quality consultation does not, and should not, come cheaply. There is a litany of poorly resourced and implemented consultations in Australia to prove that case. However, the likely costs are still very modest. The smaller scale approach (citizens juries, televoting and smaller scale deliberative councils) might just be able to be run for under $600,000. Adding an Australia-wide communications strategy to stimulate country-wide debate would probably cost several times that amount.

These costs are a drop in the ocean, in the context of making a system sustainable which currently costs over $87 billion per year[14]. They are also minimal in relation to estimated cost savings if a more rational health system, based around citizens’ stated values, could be created. Recent analyses estimate that one to two billion dollars are wasted each year in duplication within the current system, where both State and the Commonwealth run parallel bureaucracies[15].

Crucially, the findings from a national consultation could move us towards a system that is more closely based on what Australians want and need, not just what the diverse interest groups in health care want. This has been neatly described in the title of the Victorian health participation policy ‘Doing it with us, not for us‘[16].

Conclusion

The proposals above are ambitious. However, the future of the health system is a crucial issue. The current system has clear gaps (although blind spots to decision makers) and a significant degree of unfairness. We believe that creating a health system based on a national set of values and principles (regardless of who actually runs the services) is a necessary step forward to create a sustainable and sensible system. And of course, citizens and consumers clearly need to play a central part in shaping that move.

[1] John Dwyer, 2006, ‘Health care reform: a journey of courage’. Accessed at http://cpd.org.au/node/3858

[2] Centre for Policy Development, 2006, ‘A health policy for Australia: reclaiming universal health care’. Accessed at http://cpd.org.au/paper/health-policy-australia-reclaiming-universal-care

[3] http://www.healthreform.org.au

[4] Maxwell, J. et al, 2002, ‘Citizen’s Dialogue on the Future of Healthcare in Canada’, Commission on the Future of Healthcare in Canada. accessed at www.healthcarecommission.ca

[5] Australian Council of Healthcare Standards, 2006, ‘The ACHS Evaluation and Quality Improvement Program (EQuIP) 4, Standards’

[6] Quality Improvement Council, 2004, ‘Health and Community Services Standard – 5^th Edition’.

[7] Victorian Quality Council, accessed at www.health.vic.gov.au/qualitycouncil

[8] Department of Human Services, 2006, ‘Doing it with us not for us – Participation in your health service system 2006-09: Victorian consumers, carers, and the community working together with their health services and the Department of Human Services’. Melbourne.

[9] www.participateinhealth.org.au

[10] MacFarlane, D. 1996, ‘Citizen participation in the reform of health care policy: A case example’, Healthcare Management Forum, Vol. 9, No. 2, pp. 31-35.

[11] Romanow, R.J. 2002, ‘Building on Values: The Future of Health Care in Canada- Final Report’. Canadian Government Publishing, Ottawa. Accessed www.healthcarecommission.ca

[12] Menadue J. 2003, ‘Health Reform; Possible Ways Forward’, MJA 179(7) 367-369.

[13] Health Canada. 2000, ‘Health Canada Toolkit for Public Involvement in Decision-Making’. Health Canada.

[14] http://www.aihw.gov.au/mediacentre/2006/mr20060929.cfm

[15] Drummond, M, 2003, Presentation to National Health Summit on Estimates of Savings, August 2003, Canberra.

[16] http://www.health.vic.gov.au/consumer/pubs/doing.htm#download

The Canadian Government’s first and seminal action was to create a Health Transition Fund (HTF) to stimulate creative thinking about how to change the culture and practice of the system to make it more responsive, effective and efficient. The premise was that building up an inventory of evidence-based innovation would smooth that transition. A joint effort of federal, provincial and territorial governments with a budget of $C150 million, the HTF supported about 140 different pilot projects or evaluation studies across Canada between 1997 and 2001. Initially, four key theme areas were studied: primary health care; pharmaceutical issues; home care and integrated service delivery. As the program developed and submissions were received, other topics were added: children’s health; seniors, mental, rural and indigenous issues.

The impact of the first HTF was out of all proportion to its moderate cost. With four fifths of the investment devoted to provincial projects, cooperation between federal and provincial authorities improved dramatically. Many projects actually altered policy and practice: a most significant outcome has been the distinction drawn between ‘primary medical care reform’ which is concerned with the way the initial contact between a patient and a medical care provider – usually a GP – is provided and ‘primary health care reform’ which is concerned with population health, preventive medicine, health education and promotion.

Almost half of the HTF projects were concerned with primary health care, focusing on broadly based community health programs that feature the best use of a region’s health providers to maximise the health of the patient population and the best use of the health resources of the system.

The importance of keeping people well as a strategy for minimizing the pressures and costs of acute care was strongly advocated. Health Canada identified three major challenges in 2001 and I suggest that these apply equally in Australia today:

First, disadvantaged groups have significantly lower life expectancy, poorer health and a higher prevalence of disability than the average Canadian

Second, various forms of preventable disease and injury continue to undermine the health and quality of life of many Canadians; and

Third, many thousands of Canadians suffer from chronic disease, disability or various forms of emotional stress and lack adequate community support and help.

In addressing these challenges, Health Canada initiated a Royal Commission on the Future of Health in Canada. The Commissioner, Dr Roy Romanow, once First Minister of Ontario, summarized his recommendations thus:

In terms of modernizing the system’s foundations, I propose establishing a Canadian Health Covenant that expresses Canadians’ collective vision for health care and that outlines the responsibilities and entitlements of individual citizens, health providers, and governments in regard to the system. We need consensus on why the system exists, what it is intended to achieve and how its component parts should fit together. This is vital to restoring the public’s confidence in the system.

I also am proposing to modernize the Canada Health Act by updating the principle of Comprehensiveness to include priority diagnostic and homecare services, by clarifying the principle of Portability to guaranteeing portability of coverage within Canada, and by adding a sixth principle of Accountability.

Finally, I am proposing the creation of a Health Council of Canada. This inter-governmental Council would serve as a meeting place and focal point for collaboration among governments, providers and citizens in establishing overall system objectives, common indicators and benchmarks, criteria for measuring, tracking health and reporting to Canadians on system performance.

It is too early to claim that these initiatives have transformed the Canadian health system. There are still delays in accessing some elective procedures and access to needed medical care is still far from universal, but there are strong signs of improvement and some constructive innovations are changing ideas about the priorities a modern twenty first century health system should adopt.

For example, there is a clear indication that equity and economic efficiency are inseparably linked. We too must find ways of keeping people well, of providing timely solutions to simple problems before they become complex and costly to fix.

We know that the burden of disease falls most heavily on the least affluent, the most disadvantaged. Do we care? Do we care if someone cannot afford to see a dentist, a podiatrist, a physio, a GP or to get a prescription filled? We wring our hands about the health of aboriginals and their appalling life expectancy but is our anxiety for their welfare or about the reflection their condition casts on international perceptions of our culture? The homeless, the mentally ill warehoused in our prisons, do we care? Population health demands proactive thinking. It is about more than the provision of primary care services even if those services are adequate – and they are not.

The example of the Association of Ontario Health Centres is explicit:

Our vision is rooted in a care model that provides comprehensive primary care services, delivered by multi-disciplinary teams of professionals practicing within a health promotion framework. This means that by working with individuals, families and groups we increase individual and group capacity in building health communities. In fact, we are a key source of community infrastructure with which to deliver a range of integrated community-based services and to respond to health-related community concerns. Our member centres are specialists in delivering primary health care that is integrated with other social and health services partners.

Our care model is highly effective for all Ontarians. At the same time, it is a resource for people who encounter a diverse range of access barriers such as language, literacy, poverty and geography. It also works for those with other social-cultural barriers and who are at high risk for developing health problems.

Our Association engages in research, develops policy and advocates in support of this community centred primary health care model. Our member centres are located throughout the province and we work directly with communities who want community primary health care.

The need to staff their multi-disciplinary primary health care teams has obliged the Canadian Provinces to devote very significant resources to recruiting and training Nurse Practitioners and other health therapists, educators and allied health professionals. As more patients experience their care, Nurse Practitioners are proving increasingly popular wherever they have been employed. And graduate RNs are beginning to appreciate the new career paths and the much increased job satisfaction that post-graduate Nurse Practitioner qualifications provide.

Election year directions for Australia

We have not yet seen the pre-election health care proposals of the major parties but we can hope that they will include some of what Canada has done. For example,

• An Australian Health Covenant through which the Australian people express ‘their collective vision for health care’ and ‘outline the responsibilities and entitlements of individual citizens, health providers and governments in regards to the system’ is surely overdue.

• An Australian Health Council should monitor and report to the people on the health of the health system, encouraging cooperation between the states and the Commonwealth, fostering innovation and communicating best practice. The Australian Institute of Health and Welfare (AIHW) does a wonderful job in collecting and publishing the health system data, but it is not independent and does not report to the people.

• A broad ranging committee of enquiry similar to Romanow is needed to address medium to longer term health issues that need public discussion and expertise. The State based Enquiries, the Australian HealthCare Alliance, the Productivity Commission and the Blame Game reports have identified significant shortcomings in the arrangements now in place in Australia but all of these lack the authority of a Royal Commission.

• The regions of Australia are not homogeneous and one size does not fit all. Social, economic, climatic, demographic variables should dictate a need for an effective, routine public consultation process. An Innovation Fund to support and pilot test new approaches in the delivery of primary health care would, as in Canada, deliver major benefits.

• First things first. The basis of an effective health system must be primary health care, the service provided to the patient when they first recognise that they have a problem. The ‘one-stop-shop’ neighbourhood health centre, always open, is increasingly seen as the most efficient and effective use of resources, where a multi-disciplinary team is able to provide most non-acute care, including diagnostic procedures and maintenance procedures such as renal dialysis for which most patients must now visit a public hospital. The need for such centres can be seen in the crowded Emergency Departments of public hospitals, crowded because the people have nowhere else to go for often trivial problems.

• General Practice is changing, the traditional family doctor now rare with doctors ageing as fast as the rest of the population. Increasing numbers of female GPs work a two or three day week; perhaps no more than one in five urban GPs works a five day week. Many practices have been acquired by commercial interests and now employ considerable numbers of salaried and part-time GPs and Practice Nurses. As in New Zealand and Canada, some practices now employ effective teams of allied health professionals. For this trend to have a major impact on population health, there must be a reconsideration of the Medical Benefit Schedules to ensure that the least affluent in society – who have the heaviest burden of disease and the most destructive lifestyles – have access to the full range of these services.

• The restrictions placed on medical school places for doctors and nurses a couple of decades ago – a knee jerk reaction to rising health care costs – is responsible for serious and growing shortages of doctors and health professionals. The recommendations of the Productivity Council’s exhaustive Report on Australia’s Health WorkForce must be implemented. The costs of medical education also need examination. If HECS fees are so high that specialisation attracts too many graduates away from general practice, that effect should be recognised and countered.

• The funds invested by Commonwealth and State authorities in prevention, health promotion and health education are totally inadequate. It seems extraordinary that, when the positive returns from preventive programs exceed four times their cost, there is so little interest in them. For example, current debate about national curricula ignores the need to provide all children with a knowledge of health theory and practice; and very many schools now fail to provide students with regular participation in compulsory team games and physical activity. It is not enough for people, young and old, to have a theoretical awareness of their personal responsibility to maintain a healthy lifestyle: they need easy, affordable access to the providers of interesting, challenging community based recreational activities.

Finally, the involvement of the people, locally and nationally, in decisions about priorities for their health system and the delivery of their health services – envisaged by Romanow as a Covenant, and mooted in Australia as citizen juries – would introduce a most important element of realism into decision making. John Menadue has spoken about ‘the hospital tail wagging the health system dog’ and glamorous, exciting acute techniques and drugs will always attract headlines. But the things that matter most are the basic necessities involved in keeping people well. And Government seems reluctant to establish effective, affordable, accessible strategies for keeping Australians well.