What a lost opportunity “ the first Budget in a three-year cycle, a strong economy, large surpluses and a clear majority in both houses from 1 July.
The nips and tucks in the health budget show yet again that there is really no national vision or plan for health in Australia. The response is piecemeal. The two most urgent health needs in Australia “ mental health and aboriginal health “ are largely ignored. The wasteful division between Commonwealth and State functions will continue. The grossly inefficient and archaic 19th Century health workforce structure doesn’t rate a mention.
Thanks to Bill Leak at the Australian
The government is right to be concerned about the escalating costs of health. The Productivity Commission warns that government spending on health is likely to increase from 6 per cent of GDP to about 10 per cent by 2044-5.
The Budget does not seriously address these issues. It also demonstrates how the community is excluded in setting health priorities. It is left to ministers, doctors and administrators. It is not just political parties that are run by insiders. Our health system is also run the same way.
We can’t have all we want in health; so informed choices have to be made about where the dollars should go. We have yet to hear a prime minister, premier or health minister who honestly tells us that the demand for health services exceeds the supply and we have to make hard choices “ rationing, if you will.
Demand is pushed by all the major players in the health field.
As incomes and community expectations rise, we want more and better health care. With an aging community, this pressure will increase.
Pharmaceutical companies drive the demand for their latest ‘wonder drugs’. We see it time and time again in the media with drug companies and distraught family members pushing for the inclusion of a new drug on the pharmaceutical benefit list. Hardly a medical conference is held without a subsidy or promotion by the pharmaceutical companies.
The former premier of Western Australia, Richard Court, described the medical technology race as akin to the arms race.
The hospitals want more resources. Waiting lists are often padded as the political means to put pressure on health ministers and administrators. Hospital beds will almost always be filled. It is like the family refrigerator. There is never enough room.
With this sort of pressure on the system it is very easy for particular groups to press the hot buttons and for Oppositions to exploit political opportunities. The influential, well organised and media-savvy, however, get the attention of the media and win the resources. A band aid is applied here or there to get the issue out of the media spotlight. The powerful insiders in the system are rewarded. The community is excluded.
We need an informed community to participate effectively in determining health priorities and where the health dollars should go. There are numerous ways to do this “ deliberative polling as we saw a few years ago on the republic and reconciliation, citizens’ juries where informed citizens are continually polled and consulted as to priorities, consensus conferences and town meetings. The key is ‘informed community members’ who can challenge the knowledge base of the insider experts.
There is a great deal of validation and experience overseas on these methodologies of community involvement. In Australia this expertise has not really moved out of academia into the mainstream.
In every discussion or analysis I have been involved in or seen, an informed community has clear views on health priorities. The high priority issues almost always stand out. They are mental health, aboriginal health and the health problems of women and children subject to violence. Mental health is always at the top of the list of community concern, but in recent weeks you would think it was IVF.
At the bottom of the list of priorities are life-extending interventions in the last stages of terminal illness, some fertility treatments, ‘non-essential’ surgery and hospital super specialties, such as transplants.
That ordering of priorities seems sensible to me, but it depends on individual judgements. My point is that whatever those judgements, there is no process available for the community to express its views on health priorities.
For good policy reasons, Australia has decided that the supply of health services should not be restricted by price. But we are left with a major problem of mediating and managing the demand. Priorities have to be set and choices have to be made.
I don’t think that the community can be expected to fine-tune the demand, but it does have clear views, once it is well-informed where the priorities lie. Because we do not attempt to set priorities, the money and resources are spread around with little coherence or priority. The community must not be shut out of important decisions about their health. The budget again ignores this problem.
Unless all governments grasp this nettle of unlimited health demand chasing limited health resources, they will always be in catch up and finally overwhelmed by cost. The worried well can protect themselves, but the most needy will lack the political clout to demand a fair share of services.
We badly need a transparent process to ensure a health system that is fair to all and reflects community priorities. The Budget confirms how far the allocation of resources for health falls short of this goal.
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