Paradoxes in public v private debate running the system down
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.