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Focusing on health policy

John Dwyer

Australians are only too well aware that their health care system is increasingly unreliable, indeed dysfunctional.

Public hospitals have major problems because of ever-increasing demand, under-funding and shortages of health professionals. The continuum of care that should link primary, community and hospital services is made all but impossible because of the inefficiencies associated with the great divide between the Commonwealth and the states. Planned surgery is rationed. General practitioners must raise their fees to survive. The fees for specialists make it increasingly difficult for many citizens to benefit from their care. Individual financial capacity is increasingly a major determinant of health outcomes.

This is not good enough for a wealthy country like Australia, particularly when the major barrier to progress is political intransigence, rather than any lack of policy options. This chapter outlines proposals that have been generated by the Australian Health Care Reform Alliance, following a national conference and an extensive series of discussions with health professionals and consumer associations.

What sort of a health care system do Australians want? This question has been explored in detail over the past four years by the Australian Health Care Reform Alliance, an organisation composed of 50 of the leading health professional and consumer associations. The Alliance speaks with one voice on health-related issues and hosted a national summit in August 2003. The imperatives identified in the resulting communiqué were re-endorsed at a second conference in November 2005.

A broad consensus within the Alliance has reaffirmed what many others have assumed; namely, Australians want to provide health insurance to each other through payments indexed to taxable income so, that timely access to quality services is available universally on the basis of need, not on the basis of personal financial circumstances. It is true that at no stage has Australia perfected a system based on these principles. But, until the last ten years, the nation was moving in this direction, and was committed to continuing to do so. Now an obvious ideological divide finds Australia at a crossroads. Through both its words and, more importantly, its actions, the current Liberal-National coalition government led by John Howard is comfortable with the concept of the Commonwealth providing its definition of a 'safety net' to help less economically advantaged Australians, while the rest of the population moves increasingly to supporting their own health care in a user-pays system.

Critics of a universal scheme, which upholds the principle of equitable access and outcomes for all Australians seeking health care, claim the model is utopian. That argument will only be worthy of debate when the obvious efficiencies that could so markedly improve quality and cost-efficiency have been implemented. With nine health departments and some 15,000 health bureaucrats for 20 million people, there is between $2-4 billion to be saved annually in ridding the country of duplication, which could be invested in creating a system that would be far more successful in preventing illness.

"There are numerous obvious major health-related problems that urgently need to be addressed."

There are numerous obvious major health-related problems that urgently need to be addressed. Australia's mental health care programs are grossly inadequate. Mental health problems rob more Australians of wellbeing than any other cause. State and federal programs to address the issue are so disorganised and distanced that many who need help receive no co-ordinated care. There are far too few inpatient beds available for the management of psychiatric emergencies. Many with the worst problems wander our streets or populate our jails. The lack of forensic psychiatric units, where the dangerously disturbed can be detained and treated with dignity, is a shameful reality. While this year's promise by the Council of Australian Governments (COAG) to inject $500 million into the support of mental health programs is to be welcomed, the lack of any detail about the spending has left many concerned that the structural problems will not be addressed. Money alone cannot provide the needed reforms.

Other obvious urgent problem areas concern services for our Indigenous population, dental health and people with disabilities. Our Indigenous citizens continue to have disgraceful health outcomes, equivalent to those of the poorest countries on earth. In this rich nation, we are constantly confronted with the tragic demonstration that social disadvantage - a sense of hopelessness associated with a lack of opportunity and cultural disintegration - creates lifestyles featuring abuse, with disastrous effects on health. There is an urgent need for a national dental health scheme, which should be funded like our medical benefits scheme. Poor oral health detracts enormously from health and wellbeing and is the cause of much malnutrition, especially among older Australians. Indeed, oral health problems are the lot of a poorer underclass in our so-called classless society. And far more attention should be paid to the health care needs of Australians with disabilities. There can be no more important indicator of the equitable nature of our society than the manner in which we help those burdened with a physical or mental disability. There is a most unfair demand made on families caring for the seriously disabled, with inadequate financial aid and a lack of affordable respite.

There is also much that obviously can be done to improve quality and safety in our hospitals and community care settings. The last national survey of avoidable misadventure in hospitals, for example, documented as many as 18,000 avoidable deaths a year in the over-stretched system. An excellent first step to improve this situation would be the long overdue introduction of modern information technology. Electronic prescription writing would eliminate 90 per cent of medication errors. The introduction of electronic health records, which could be shared by all professionals, would add information at the point of patient contact and provide for advances in safety and quality that are already available in many other countries. We need approximately $2 billion to bring Australian health-related information technology into the 21st century, an amount which expert analysis indicates would be returned within a very few years.

Against this general background, what follows is a discussion of the four main reforms required to facilitate improvement. The discussion principally addresses the federal-state divide, workforce issues, primary care and hospitals.


John Dwyer is Emeritus Professor of Medicine at the University of New South Wales and until recently the Director of Medicine at Sydney's Prince of Wales Hospital. He was also the foundation Chairman of the Australian Health Care Reform Alliance. This is an extract from the "Chapter 7: The journey to better health care" by Professor Dwyer published in the Evatt Foundation's new book, The State of the States 2006, where you can read the full analysis and directions for change.


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