Para­doxes in pub­lic v private de­bate run­ning the sys­tem down

The Weekend Australian - Travel - - Health - JOHN MILLER

THERE’S a cri­sis in our pub­lic hospi­tal sys­tem. Peo­ple are al­ways com­plain­ing about wait­ing lists, staff are over­worked, bud­gets stretched to break­ing point, and there’s not enough doc­tors and nurses .

The prin­ci­pal rea­son for the cri­sis is the fail­ure of gov­ern­ments to make the dis­tinc­tion be­tween what’s a pub­lic health re­spon­si­bil­ity and what’s a private health re­spon­si­bil­ity.

The foun­da­tion of good pub­lic health as sup­plied by our gov­ern­ments is about as good as it can get — clean wa­ter, deep drainage, im­mu­ni­sa­tion, ac­cess to good food, build­ing stan­dards, health in­spec­tion, and af­flu­ence. Re­gret­tably it’s a foun­da­tion that a lot of peo­ple seem re­luc­tant to build on.

Our hos­pi­tals are about as good as you’ll get. What hap­pens in hos­pi­tals it truly amaz­ing. You only have to watch RPA to know that.

I’m not so sure about the qual­ity of gen­eral med­i­cal prac­tice — it’s patchy and the pub­lic should be dis­cour­aged from go­ing to doc­tors for things they can fix them­selves.

It’s not pub­lic health we have to worry much about; most of that worry is done for us. On the con­trary, it’s our own private health we have to worry about, and if we don’t, the symp­toms of body sys­tem dys­func­tion ul­ti­mately rear their ugly head. A large pro­por­tion of th­ese dys­func­tions are per­son­ally gen­er­ated. For in­stance, I don’t think my tight trousers, breath­less­ness af­ter one flight of stairs, hack­ing cough, el­e­vated blood pres­sure, lack of en­ergy, sleep ap­noea, re­flux and piles are a re­sult of poor pub­lic health pol­icy.

One of the key driv­ers of the hospi­tal cri­sis has been the med­i­cal­i­sa­tion of pub­lic health and the trans­fer of the costs of pri­vately gen­er­ated body sys­tem dys­func­tions from private pock­ets to the pub­lic purse. It would be OK if ev­ery­one was fit and healthy, like many peo­ple were when the idea was first floated. How­ever, it’s been at­tended by an un­sus­tain­able and dra­matic de­cline in per­sonal lev­els of health and fit­ness. And the more un­healthy peo­ple have be­come, the greater the costs borne by the pub­lic, no ques­tions asked. There is no con­trol on pub­lic ex­pen­di­ture, and no proper ac­count­abil­ity or del­e­ga­tion; just a blank cheque drawn on pub­lic funds.

As a case in point here’s what’s hap­pen­ing in the ACT. In 2006 there were 9000-odd cases in­volv­ing elec­tive surgery at the Can­berra Hospi­tal. Just over half, 55 per cent, of the fund­ing came from the ACT Gov­ern­ment, while 22 per cent came from the Com­mon­wealth Gov­ern­ment and 12 per cent came from all other sources, in­clud­ing private health in­sur­ance, self-funded pa­tients and the De­part­ment of Vet­er­ans Af­fairs. The NSW Gov­ern­ment chipped in 11 per cent.

In dol­lar terms, the ACT Gov­ern­ment’s bill was a stag­ger­ing $76.4 mil­lion — roughly $8000 for each cus­tomer. No won­der state and ter­ri­tory gov­ern­ments are cling­ing to their stamp du­ties and let­ting other es­sen­tial ser­vices run down.

The state and ter­ri­tory gov­ern­ments are go­ing broke be­cause they’ve been dud­ded by a com­mon­wealth-state agree­ment that doesn’t al­low the hos­pi­tals to send out ac­counts. Har­vey Norman would rub their hands with glee if 9000 cus­tomers came in with a cheque for $8000.

There’s no means test­ing. Re­gard­less of your in­come or as­sets, if you’re pre­pared to wait long enough and com­plain loud enough, you can go to a pub­lic hospi­tal for free. This is very strange pub­lic pol­icy.

Cer­tainly we need a safety net, but it has to be di­vorced from the health sys­tem, as it is for trans­port, food and power. Mix­ing the health and wel­fare sys­tems to­gether has not been a good idea. And nei­ther the health nor wel­fare sys­tems should be sub­si­dis­ing ser­vices of any kind for peo­ple who have as­sets and in­comes that can sup­port the oc­ca­sional bit of body main­te­nance.

And it gets worse. If you pay your med­i­cal in­sur­ance you go to a private hospi­tal, have your op­er­a­tion and pay the dif­fer­ence be­tween the bill and the in­sur­ance re­bate. If you don’t in­sure your­self, you go to a pub­lic hospi­tal at the tax­pay­ers’ ex­pense. It is not a fair sys­tem.

So there you have it. Send out ac­counts and the hospi­tal cri­sis is solved. And if ev­ery one did what the Prime Min­is­ter does be­fore break­fast ev­ery morn­ing, you could con­ser­va­tively cut the na­tional ill-health bill in half.

Hos­pi­tals are the poi­soned chal­ice of Aus­tralian pol­i­tics. From a state’s point of view, the La­bor Party’s pol­icy to take over hos­pi­tals that don’t come up to scratch sounds like an ex­cep­tion­ally good deal, though not for the good of the coun­try as a whole.

In the long run the hos­pi­tals will al­ways be in cri­sis while gov­ern­ments of any per­sua­sion are sub­si­dis­ing the treat­ment of per­son­ally gen­er­ated body sys­tem dys­func­tions.

Ul­ti­mately the best thing to do would be to pri­va­tise them and/or out­source a lot of the ser­vices. If you can suc­cess­fully pri­va­tise banks, wa­ter, power and telecom­mu­ni­ca­tions util­i­ties and trans­port, why wouldn’t you pri­va­tise the pub­lic hos­pi­tals? Think of the ag­gra­va­tion gov­ern­ments would save them­selves, the peo­ple they would no longer need to em­ploy.

So this week’s three big ques­tions for gov­ern­ments are: firstly, how do you get peo­ple to pay for the ser­vices they use in pub­lic hos­pi­tals? Se­condly, how do you get gov­ern­ments out of the busi­ness of run­ning hos­pi­tals al­to­gether? And third, how to per­suade peo­ple to keep them­selves fit and healthy to the best of their abil­ity and avoid the costs in the first place? John Miller is man­ag­ing di­rec­tor of Can­berra-based cor­po­rate health man­age­ment con­sul­tancy, Miller Health.

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