Let the people decide! Citizens’ Juries in Health

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The way forward for the WA health service – and the rest of the country?

The WA health service hit the headlines here in the West recently (yet again!). More accurately the large Perth tertiary (teaching) hospitals and especially the Emergency Departments made the front pages. Claims by a senior hospital specialist of lack of resources, lack of beds… Any visiting Martian would have reason to believe that the WA health services consist only of tertiary beds and do not stretch beyond the boundaries of Perth.

Doesn’t it get tedious after a while as the mantra of the hospital specialists is churned out yet again: ‘We want more beds! We want more beds!’ Yes but while for most of the rest of us this is a real turn off, there is good evidence that these cries from vested interests do work, as the WA government and WA Health have succumbed (again) and agreed to build more beds (again) in the tertiary cathedrals and even build new cathedrals! 

This seemingly never-ending saga needs resolution. It is bad health policy; it is bad economics; and it is bad politics. With many hospital specialists there are always the same complaints; same mantra; no solution except that we should pour more and more money into the black holes which are our tertiary hospitals. Tertiary specialists refuse to see the health problems outside the cathedral doors. They use their power to build their specialist and specialised empires.

Interestingly, so far this year the WA AMA has issued over 50 media releases. Not one of them has been on Aboriginal health. Where are the hospital specialists when the calls are for more money for Aboriginal health, for prevention, or for the mentally ill?

In March 2004,Professor Michael Reid and his review committee reported to the WA Government on the health system in WA. The Reid Report stated that of those patients in tertiary beds fewer than one in five need to be there! That is a remarkable figure. It is even more stunning given the WA government’s intent to build more and more tertiary beds. Reid was about keeping people out of hospitals. Yet we get more and more beds. In the literature on health policy there is a so-called “Roemer’s Law” which states simply: ‘a built bed is a filled bed’. In other words, open more hospital beds and patients will fill them. So what do we do here in the West? We not only build more beds, we build more, very expensive beds!

How to break this silly cycle? To whom can we turn to make better sense of all of this?

Well at the very same time as these tertiary terrors and troubles were again front-page news, I was in Busselton as a guest of the South West Area Health Service (SWAHS) facilitating what is called a Citizens’ Jury

This Citizens’ Jury consisted of randomly selected people from the voters’ roll in the South West. They spent a day together first being informed about the health of the population, the health services, the resources available and the constraints SWAHS faces. They then had to determine the values and principles they want the health service to be run on.

What they argued for was intriguing – more services for the mentally ill, greater efforts on behalf of disadvantaged people, especially Aboriginal people, and more spending on prevention. Even more interesting, if necessary, for SWAHS to pay for these, the citizens were prepared to give up some hospitals and Emergency Departments!

Eureka! Here is the way to get some sound common sense into health service decision-making.

Ask the (informed) people!

This is only the fourth time in Australia that a Citizens’ Jury in health has been held, all of them as it happens in WA. Two of these were state wide and set up through the now abandoned Medical Council. That Council was established by Alan Bansemer, the then Director General for Health, who very much believed in listening to the people’s voices. He went before he could act on these juries’ recommendations. The Medical Council was then dismantled by his successor Mike Daube who had no faith in these juries’ values.

What is intriguing is that the first of these statewide juries wanted more equity and prevention and the second placed emphasis on Aboriginal health. These values are now echoed in the South West. WA citizens are consistent!

For me it was fascinating to be with these South West citizens and watch them grapple with these thorny issues. At the very same time ‘the experts’ in Perth were again failing to get it right with respect to our tertiary hospitals.

The citizens in the South West, given good information and time to reflect, were able to see that some of the resources in their hospitals are not being used well. There is a lesson here in the West and from the West: we need to get good information to allow citizens to be able to judge if the resources in their – the citizens’ – tertiary hospitals are or are not being used well.

For that to happen we need, as I have been requesting from the WA government for nearly 5 years now, a detailed investigation into the way resources in our tertiary hospitals are being used. The information from this investigation can then be used to inform citizens so that they can judge, just as their counterparts have done in the South West, how best to redeploy resources to get a better buy in health for the citizens.

Health services are first and foremost social institutions so that the idea of getting well-informed citizens to help to make decisions on behalf of the community makes sense. It is our – the citizens’ – health and it is our – the citizens’ – health services.

The management team in the SWAHS, led by Michael Moodie, showed great guts and leadership in agreeing to be exposed to these citizens’ values. Further they have agreed to act on them. We now need health service management at state level (and across the country) to show the same guts and leadership and set up Citizens’ Juries in each state and across the nation.

Here in the west I ask our health Director General, are you listening? Will you and the WA government not only listen to but also pledge to act upon the (informed) voice of the people?

And the other states? And the Commonwealth? Citizens given good information and asked to make resource-constrained choices can do so and do so very responsibly. In my experience to date their preferences have been much more caring and altruistic than those implied by resource allocation in our health services. More equity geographically, more for mental health, more for prevention… and less for the medical cathedrals that we call hospitals.

Citizens readily accept that not all can be done, that resources are scarce. Much more than pinging machines the citizens want caring people. Especially, they want the most disadvantaged not only cared for but also cared about.

Give citizens responsibility and information and they will act responsibly and well. Treat them like sheep and they will baa.

Why does it not happen? Ah, now there’s another story…

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