A Different ‘Health’ Debate is needed now

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Two years ago my wife developed a sudden and severe abdominal pain on New Year’s Eve. She was taken by ambulance to the emergency department of the large teaching Hospital where I spent 20 years as student, intern, resident, registrar, research fellow and visiting medical officer. We spent the night there while staff members, run off their feet, did what they could for the many people, some violent, pouring in through the font door.  It was a big job and they did magnificently – but, as members of the public, we waited (patiently) all night long for our turn. I sat in that ward with my wife for about eight hours.

If the debate about ‘health’ does not change dramatically we will see the portfolio become even more politically sensitive than it is now.  We will see governments defeated on public perceptions about hospitals – because the debate is faulty.

At present citizens think the system will care for them when they get sick. The reality is different. The system only cares for people if it can – and too often it has no capacity, in spite of good intentions and the soothing words of politicians. People are resentful that this is so and will become increasingly resentful over time. They might even change their voting practice on this issue. After all, at least two by-elections that I recall centred on the state and future of the local hospital.

The promise today is that everything possible will be done for everyone all the time.  This is what people expect and what politicians promise implicitly, election after election.  The system has never delivered that. It does not do it now. It will never deliver it. It cannot deliver it.

People are not fools and they see that the system does not deliver what they expect. They see a deficiency. They have their admissions put off, their surgery deferred; they suffer and they sometimes die earlier than they should. They have those experiences themselves and they see it happen to those close to them. People that are well off are fleeing to the private system; everyone else is suffering and doing with less than they should. Some conditions (e.g. uncomplicated cataract extractions in Victoria) are no longer carried out in the public hospital system at all.

If the promise to the electorate is wrong, then politicians should stop making the promise, explicitly or implicitly.

There is a bottomless pit for the wish list of clinicians. Even 100% of GDP (that is, all our national wealth) spent on hospitals would leave some needs unmet. Costs continue to increase, the population increases, people are living longer, and trained staff is in short supply. Efficiency gains will provide something extra but it will not be enough to provide what is needed – now or ever, in spite of what economists say. Reorganisations of health departments will not provide the necessary answers. Neither will culturally driven abuse of administrators.

If the amount of resources which the community will allocate to hospital care is finite then the debate will have to change. What the debate should be about is how to use that finite resource to the best effect. People at the top will have to admit publicly that we can deal only with the most serious problems with the resources available. When it comes to less serious matters then choices have to be made about what can be provided in the publicly subsidized part of the system. At present decisions are made ‘off stage’ by clinicians, by governments, by public servants – but not by the public that bears the consequences. The problem often concerns what economists call ‘opportunity cost’ – that is, the choice between intervention A and intervention B. Such choices need to be made, using some measures of cost and benefit. For example, heart transplantation is possible but its performance might mean putting off a large number of hip replacements.  Which choice does the society make in such a situation? It is not a ‘real world’  answer to assert that both things should be funded.

It is right that the public which endures the deficiencies in the system should play a part in the setting of priorities. At present it does not. 

The system could only change in Australia if the Prime Minister and Premiers decided together that a change was more honest and more desirable than what we have now.  Ministers for Health (a misnomer as they are often Ministers for illness) are weak in Cabinets and lonely too. Their colleagues know that for them to get more of the cake might mean lesser slices for everyone else.

We need a transparent system for making choices. At present we do not have one. The Western Australians have done some experiments with citizen juries as a way of making choices. In this model juries are empanelled as normally happens and then are presented, by trained advocates, with arguments for and against a particular intervention together with the opportunity cost consequences of going down any path.The jury then votes and a decision is made by citizens, not by experts. That model has promise for the whole nation and might be promoted further.

The current system is unsustainable in the long term. Action to change the debate should occur now, so that changes to the system are possible in the next decade.

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