Health: The new cargo cult

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The cargo cults that developed in Melanesia in the late 19th century based their culture on goods that would arrive from supernatural sources, and ignored or abandoned their traditional ways. They developed a view that there was no need to ensure that they looked after the resources that had sustained them over the years, on the basis that sustenance would fall from the sky.

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Health in Australia is a little like those cults, in that our community, including health professionals, continues to expect more money for health without looking seriously at how we consume the resources we currently use. That is not responsible use of public funds, or sustainable.

We constantly hear that there is not enough money in health, but is that correct? I suspect not, although no-one can be certain. What is certain is that the cost of health funding can be a bottomless pit, as a result of the march of technology, the ageing of the population, and continually increasing public expectations.

We need to concentrate on at least three basic areas: efficient and appropriate use of existing resources, effective workforce planning, and developing a rational set of community expectations of the health system.

The State/Federal administrative divide brings with it significant duplication of activity and resources, and the introduction of perverse incentives, and is a cause of much of the inefficiency in the system. For example, the Commonwealth is responsible for the funding of much of primary care, and then nursing home care, with the State responsible for acute hospital care. The lack of funding in primary care often means that patients are treated in emergency departments and then in acute hospitals when they may be better managed in the community. Our hospitals usually have large numbers of patients occupying expensive acute beds because less expensive and more appropriate nursing facilities are not available.

Bringing the two funding components under the one management system may allow a single administrative unit to make more rational decisions about the distribution of facilities and resources across the entire spectrum of care.

As well, there is much administrative activity in devising ways of shifting costs between the two streams of government funding, with no value added to the system as a whole.

The politicisation of the system distorts priorities. The constant attention to waiting lists as an indicator of the success of the system results in money being spent on treatments that are sometimes of dubious benefit, and which may be given a lower priority by an informed community than chronically under-funded areas such as disease prevention and mental illness.

It is difficult to argue with the view of Health Ministers that if they are to carry the responsibility for every single action within the system, they should make the decisions. There is an alternative view that the role of Government should be to set broad parameters within which autonomous health units should function. Those units could be expected to deliver an agreed level of health care to the population that is their responsibility, including clearly defined parameters such as infant mortality and immunization rates, and levels of access to clinical services, both emergency and elective, yet be given the authority to determine how best to do that. Such a service would need to be large enough to provide all the necessary basic health care, and have the necessary size to allow sufficient administrative flexibility to meet its goals.

By confining the role of the central bureaucracy to the establishment and monitoring of parameters for the service, it may be possible to minimise the impact of decisions taken for largely political reasons.

Thanks to Sean Leahy.

We often hear that we don’t have enough nurses or doctors, and of proposals to increase the number of training positions for this health professional or that. But we rarely hear of how these people are to be recruited or trained, or more importantly to be retained in the system. As an obvious example, all attempts at nursing recruitment and retention in the last 20 years seemed to have failed in the long term.

We do not hear about how we should adjust the workloads within and between disciplines to reflect changes in training. As nurse practitioners are able to assume responsibilities that have traditionally been those of doctors, should we not re-define the role of doctors to accommodate those changes?

As a corollary, as nurses are trained to concentrate on the more technical aspects of their profession, the problems in nursing recruitment seem to be in the areas of procedural nursing and pastoral care. Appropriately trained assistants in nursing have worked very successfully in those areas, and so in turn shouldn’t we redefine the role of nursing to reflect these new realities?

The response of the system has generally been to look at such things as initiatives to be developed in pockets in the hope that they may then be taken up more broadly. That hope has usually not been realised, in part because of the entrenched industrial and political interests that bedevil health.

What is clear is that, to paraphrase Einstein, the type of thinking that got us into this position will not get us out of it.

In general Medicare has been one of the best health systems in the world for 30 years, and has ensured that by and large the majority of our citizens have had access to good quality health care irrespective of social status, and without excessive cost to the individual or the community. We must retain its basic tenets. It is however showing signs of strain, and the constant band-aid solutions do not seem to be producing the long-term and major changes that are necessary for its viability.

This is not in any way a criticism of any group, political or professional, just an acceptance that the system has evolved in a way that now often dictates inappropriate, wasteful and sometimes counterproductive responses from its many committed and competent members.

The Hospital Reform Group believes we need a comprehensive review of health as a joint Federal and State initiative with the aims of maximising the structural efficiency of the system, of addressing the long-term workforce issues, and perhaps most importantly, of engaging the community in developing a set of realistic expectations of a health system in the 21st century.

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