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Funding Health

Evan Hadkins' archive is here; his most recent piece was Housing Affordability.

So far in this campaign there has been talk of who is to run hospitals.  State governments or the Federal government which will somehow mean local control (what’s wrong with this picture?).

To be fair to our pollies (not my natural inclination) health policy is an incredibly difficult area.  Health has the potential to absorb as much money as we can devote to it.  Even one area (say cancer research) could absorb our entire government spending.  This seems ridiculous (and it is of course), but consider: if it was your child dying of cancer . . .

These are the types of decisions that health policy involves.  And who is the brave politician who wants to make them?  I see no hands go up.  One result is that the politicians mostly let others make the decisions (though they don’t say this).  The result is that health policy is largely policy to deal with sickness (yes, they’re different) and the discussion is dominated by well organised and resourced groups (governments, doctors’ unions and so on).  One wit, I forget who, said that having doctors setting the agenda on health was like having panel beaters determining roads policy (cruel, but fair, I think).

You’ll be pleased to know that those who are concerned with health policy largely have a consensus on the direction for health policy.  You may not be surprised to know that this has little influence on politicians.  This consensus was on display last night at a discussion run by the Australian Health Policy Institute and the Centre for Policy Development at Sydney Uni.  This being a discussion of Australian Public Policy it featured the usual overseas speaker.  (Note to self: go events run by these people in future: the food is great.  Good enough to eat as the evening meal and even a wine or beer after.  I saw one poor uni student peering in through the glass wall at the food on display and invited him in.  He shook his head and I mouthed at him that all he had to do was say he was coming to the discussion, but he shook his head and wended his sad way homeward.)

The consensus is shared by those in the health policy field is: re-allocation of funds towards mental health, disability services, and prevention (ie public education) and less toward large hospitals.  This agenda has been around for a long time.  Those as old as me will remember it from the 60’s and 70’s.  And it is no closer to being implemented.

Which leads us to another consensus: that the health funding problem is political.  As one speaker put it (John Menadue – ex-bureaucrat, ex-diplomat, currently chair of the Centre for Policy Development) “the problem is the minister”.  This is partly right.  It will be a brave (in the Sir Humphrey Appleby sense) minister who closes a hospital however much of the funds is allocated elsewhere.  But this leads us to the position that getting change in health policy means praying for a good minister.  John Menadue should know better. 

Another speaker, Lyn Carson, from Sydney University’s US Studies Centre provided lots of information on alternative politics.  She spoke about the mechanisms that can be used to involve citizens in decision making (citizen’s juries and such).  These, when run, lead to all parties involved being happy with the outcome.  A gift to a minister you would think.  You would think that until you met a minister whose attitude is: it’s my job to decide on health policy.  (It doesn’t matter much which party they come from).  How do these processes get their decisions implemented?  Back to the problem of the minister.

So the problem of health funding is a political one.  And the current political process is part of the problem rather than the solution.  Another speaker at the conference was from Choice, which has an interest in consumers influencing health policy.  Choice has a large membership and these are the kind of numbers that could, if they were organised, start a debate on health policy.  They could, if mobilised, be a big enough block to stand up and be counted with doctors’ unions and governments.  They could move the debate from sickness to health.  It seems to me that this is the hope for the future of health policy debate.

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Who's your daddy?

At ScienceAlert, Mass screening of 'iron men' needed contains the elements of a general strategy that for too long has been accepted without question by the media. In this case, Dr Olynyk may appear at 6.30pm to encourage you and me to part with our tax dollars.

The presenter should ask him -

1) What are the costs, wholesale and retail, of the DNA test for the HFE mutation?

2) If the test is approved for the Medical Benefits Schedule, how much does the test's patent-holder expect to make?

3) Does Dr Olynyk (or his cousin, or his university) have any commercial links to the marketer of the test?

4) Would Dr Olynyk be able to explain to his target audience of 10m Australian males that his test is a surrogate paternity test? Suppose a company offers to pay for all male employees to have the test. About one in 200 will be homozygous, that is, at high risk of having iron overload. What happens when one of the affected men decides to test his children, after the partner is also tested and found to be heterozygous (a carrier of the gene), and they find one or more of the kids do not carry the mutation?

Good news for those fighting the battle of the bulge.

Highlighting how a bit of bulge might help you, the scientists said that in 2004 there were 100,000 fewer deaths among the overweight in the US than would have been expected if they were all considered to be of normal weight. Put slightly differently, those Americans who were merely overweight were up to about 40 per cent less likely than normal-weight people to die from a whole range of diseases and risks including emphysema, pneumonia, Alzheimer's, injuries and various infections.

Aside from escaping diseases, tipping the scales a little further may also help people recover from serious surgery, injuries and infections, Dr Flegal suggested. Such patients may simply have deeper bodily reserves to draw on in times of medical crisis.

Its looks like being a little on the overweight side may actually be beneficial. So much for diet puritans.

Radical as Planck's ideas may be, the case she makes for them strikes me as eminently sensible. I consider myself an enlightened eater, but when I finished her book, I threw out half the contents of my refrigerator, including the soy-based fake bacon bits, the tofu hot dogs and the nonfat sour cream. That was a few weeks ago. It is, I guess, a measure of the extent to which I've bought into all these years of nonfat propaganda that I'm still working up the nerve to eat the skin on my chicken.


Fitness is probably more important than weight alone (within reason of course).

Most of the studies don't separate weight and fitness so are quite flawed.  They tend to presume that leanness = fitness which is not always the case by any means.

MJA and Alfred Hospital

Something is going on at Melbourne's prestigious The Alfred Hospital. From Surgeon divides hospital:

Since 2004, several surgeons working at The Alfred hospital have avoided operating with Professor Kossmann due to concerns about whether his treatment of some patients was excessive. They also complained about his billing arrangements with the Transport Accident Commission — which pays for medical treatment of road crash victims in Victoria.

 From the editorial in The Age, Hospital accountability is good for our health:

What is clear is that many of the complaints are longstanding — some date back to 2003 — and that hospital management has repeatedly failed to act and subject them to the sort of scrutiny that should be mandatory when issues that have significant implications for the safe and effective delivery of public health care are involved.

The main article observed:

It is believed the review into Professor Kossmann was ordered by Alfred chief executive Jennifer Williams after she was recently given a series of patient cases that doctors believed warranted scrutiny. Hospital insiders say Ms Williams is now taking the issue seriously and may not have been aware of all the previous complaints, with senior managers and department heads not passing them on.

This CEO is the very same who was out front and centre for the government line during the recent nurses strike. Why would senior managers and department heads NOT pass on complaints about a surgeon? Answers, please, in neat copperplate written on fresh one hundred dollar bills.

Hospitals consume more than their fair share of taxpayers money, and the demand for more of everything is insatiable. They are hotbeds of intrigue, mean-spirited competitiveness and frank antipathy. There's so much heat dissipated from all the internal shenanigans of a typical major hospital that the management could tap into it as a source of renewable energy. As it is, the administrators have so much useful knowledge in their files that resolving a crisis requires nothing much more than a nod in the right direction. In the case of questions about a surgeon's competence, for example, they have no need to request independent comparators, even if they did exist.

The current edition of the Medical Journal of Australia is full of the politics of health care. For example, Challenges in health and health care for Australia :

Australia has not come to terms with medical error, neither recording its occurrence nor adapting systems from other high-risk industries, such as nuclear power and aviation, to reduce it. Rigid, fault-seeking, blame-allocating cultures are tolerated, even enshrined, in professional hierarchies. There is a new agency for quality and safety, built on a succession of preceding committees and councils, but its effectiveness has yet to be demonstrated.

An article in that MJA has been written up in the lay press, Prostate screening not worth it:

But with screening for prostate cancer, things get complicated. No government anywhere recommends prostate screening. The International Union Against Cancer does not support it, nor has any major review of the evidence on whether screening saves lives. This is not the message that Australian men are getting about prostate cancer screening, where the main messages overwhelmingly promote screening as a lifesaver, plays down the common, serious treatment side effects and, appropriating the rhetoric of gender equality, simplistically urge "hey guys, women have their screening tests. We have ours. Be a man!"

Simon Chapman provides raw figures for working out who benefits from all those consultations, tests and procedures involved in the war against prostate cancer.  I predict Chapman's reputation will be assaulted by cancer lobby groups, media stars and The Royal and Ancient Guild of Stonecutters. It will be interesting to watch who sponsors the Urology Society Conference 2008.

Mersey muddle (cont.)

Medical practitioners practising and living in rural locations usually create their own social dynamics. Personalities, skills and attributes, and the special characters of a town, combine into a truly unique complex for each situation. These factors underlie the difficulties faced by Tasmanian Health when they sought to rationalise services in the north-west region around Burnie. Jeff Richardson, renowned health economist and strategist, recommended relocation of some services, including vascular surgery being moved from the Mersey to Burnie.

For now, I leave aside the question of how a speciality like vascular surgery could have been established, and remain feasible, in a nook like Devonport.

It's difficult for outsiders, and for those employees whose livelihood depends on an institution, to make an objective assessment on the viability of health service, especially a hospital. Hospitals are good employers, and form significant parts of a town's infrastructure. But someone has to be responsible for seeing that quality and safety standards are acceptable. Any service reconfiguration must be built around improving S&Q, in the belief that the economics will follow.

The body that most health care facilities appeal to for their accreditation is The Australian Council on Healthcare Standards. Participation is by subscription, and voluntary, but most (not all) facilities want to have their ACHS inspections. ACHS is not the only vehicle for accreditation, though. See Digestive Health Centre, for example. I know this day procedure centre, and some of the principal owner-physicians, but am not associated with it in any way. John Goy (see Specialists page) has been in this field for decades, was a pioneer in specialist endoscopy clinics, and knows very well how his reputation requires him to keep up to date. There are four logos on the home page and they are all concerned with standards. ACHS, the RACP (the physicians' college of education), GESA (one of the societies that gastroenterologists will belong to; there is at least one other) and MDAV (this medical insurance body has recently affiliated with another and changed names; 'MDAV' is very interested in risk reduction, for obvious reasons). There is another layer of interest in the minimisation of complications - the private health insurance industry.

The North West Region Hospital participates in ACHS. The vascular surgery at the Mersey would be amenable to performance criteria set by a similar set of bodies that oversight the professional standards of gastroenterology. The bottom line is, though, that none of the performance indicators of any facility are available for public scrutiny in Australia. Even the results of coded comparators are confined to the participating subset. That is, an orthopedic surgeon in Hospital A may be given outcome figures on joint replacements for hospitals A to K, but he will never know how his competitor is performing.

The strategy being advertised by Howard's government, that of dumping cash into an institution to preserve jobs, could undermine good practice. Considering the extreme difficulty of obtaining performance comparators, and the complex relationships of hospital and town, any reconfiguration should take years to plan and execute. The knowledge needed to relocate services is pretty much the same as that needed to continue without change. What I mean is, if the hospital in any of Abbott's target towns is dependant on the services performed by a particular medico, such as a specialist surgeon, Abbott needs to know what he is propping up. I suspect he either does not have a clue and does not care, or has been given faulty advice. Inbuilt inertia and sheer bloodymindedness will crush his vote-grabbing initiative, and may set the process of service improvement back by decades in some cases.

It's a real pity that Abbott did not put his energies into national oversight (like the Australian Commission on Safety and Quality in Health Care) and the mediation of safety and quality standards through collection of data. The stupidity of this grab for glory is that, if Howard wanted crowds cheering from balconies, he only needed to go to the local pubs and shout a few rounds.

Mersey muddle

A morning of contrasts. Backed onto Tony Abbott's muddle over the Mersey Hospital was the news that the Victorian Government had slipped the final decision about the Channel Deepening Project over to the federal environment Minister. With one slick announcement, followed by John Brumby scoring points over Jon Faine on this morning's radio broadcast, Victorian Labor has done a big favour for Lindsay Tanner. The campaign for Tanner's seat of Melbourne will be lively, but the argument over the Channel is now not so easily given away to The Greens, because prospective Labor voters will be looking to a friendly federal minister to put on the brakes.

The Mersey blueprint is a botch, but who to blame? It could be due to Abbott's lack of capacity, or due to the PM pushing him into it for the campaign, or it could be due to poor advice from Abbott's department. By "poor" I mean advice that was not up to the usual Public Service standard of servicing the needs and desires of the Minister. At least, not the Minister of that department. That is, maybe Abbott was dudded by his own key advisers.

Some specific points should have risen to view when DoHA was working out how to take over a provincial hospital. Not the least of these would have been about performance indicators, and where to go for comparisons. Some of the crucial issues would have been related to the specific community where intervention was being considered. Outcomes of, say, vascular surgery, can be followed to some extent by Medicare data in the private system, and Casemix-like data in the public institutions. I know vascular surgery has come a long way in the last 30 years. In the bad old days, a person with peripheral vascular disease (usually male of 60+ years, smoker, with bad lungs and additional serious health problems) could be counted on to provide useful training for the surgical registrars, with a succession of procedures from arterial bypasses through to amputations of toes and eventual bilateral above-knee amputations.

There is a nugget buried in this Mersey business, I'm sure, but maybe I will do a bit more digging before saying too much.

Organise, or get done over

The doctors union, the AMA, was out last week condemning the public hospital system and demanding another $3bn for hospitals. Whether or not the power elite of the AMA have financial interests in private hospitals will be something that no self-respecting journalists would ever inquire about. 

On the other side of the ledger, Australian Healthcare and Hospitals Association bills itself as "the only independent advocate for the public healthcare sector at a national level". 

The editorial of the recent edition of the AHHA's journal, Australian Health Review, is available for online view. From Health professional education: perpetuating obsolescence? :

The current suite of health professions was established to respond to health care needs of the distant past. Organisation of health professional skills that is based on health care practices of previous centuries is unlikely to serve the public health care system in the future. Judging by the number of papers on health professional education we received, it appears that health care practitioners, policy makers and educators may be slowly realising that, just like many of the health care technologies of the 18th century, the organisation of our health professional workforce has become obsolete.

In view of the recent industrial action by Victoria's nurses, it's worth asking whether, in the lead-up to the action, the dinosaurs in the AMA offered to discuss working conditions with the ANF. Moreover, it seems to me there is an urgent need for all the service groups in any given public hospital to organise themselves at the industrial level. It won't happen, of course; too many entrenched fiefdoms, but it would make the managers sit up and take notice.

Let's be Fair Dinkum Abbott.

The recent decision, embarrassingly given by the expected Leader of the Opposition, [after the election] Tony Abbott, to give support in terms of screening and nursing for Breast Cancer patients, is an almost complete copy of what they took away previously.

I am of two minds about this man. I get the distinct impression that this person  is taking the "front running" for the Howard "New Order" in the possibility that the "New Order" may lose the election.

I believe that Howard and Costello hate each other due to the normal Howard betrayal of any "non core" promises.  Or, as Howard's Wife has stated, her Husband is not into "firm committments".

Hopefully, the result of the election, free of bias and secresy, will open the doors of 11 years of secrecy and abuse of privilege.

While a significant number of caring Australians have a craving for the truth of so many significant issues, the Howard government will deny our knowledge to the very end.

There is no truth - only the powers that be.


Here's a scenario...

I'm surprised this one hasn't been put forward in response to the Government's proposed "community" model.  Goes like this (imagine a well off community, like Sydney's East for example):

  1. In response to community disquiet, as voiced to local member, control of local hospital/s is given over to the community via a local board, federaly funded.
  2. Local board decides to raise additinal funding from local businesses, high net worths, lotteries etc.
  3. Extra funding used to pay over the odds to attract the best quality doctors and specialists who then divert their attentions primarily to the local facilities.
  4. Bingo!  Multi-tier health system, the rich get vastly better care than the rest.


I think you have hit the nail on the head, David.

Money won't help

It wouldn't matter how much money they throw at the current health system. It will make no difference, other than becoming more expensive. The only way to improve the system is to change the approach to one of preventative and curative health approach. The way it is now, all that happens is they give you a drug to cover the symptoms. If that doesn't work, they try to destroy the symptoms with more powerful drugs, which actually destroy the body. The next step it to remove the affected part or replace it using even more drugs and hope for the best. When you consider that the companies provide the chemicals, additives and preservatives in food products and just about everything that goes in and on peoples bodies are the same ones who provide the pharmaceuticals used to cover the symptoms, it's a win win situation for the pharmaceutical and drug companies. The only outcome is richer and richer drug companies and a sicker and sicker population, becoming reliant on more and more pharmaceuticals which never cure anything.

Until some form of sanity come into our approach to health and people are educated about how to look after themselves, and health facilities are orientated to preventative, curative, traumatic and genetic medicine, nothing will change, only get worse and more expensive.


Thanks Alga.

To come out of the closet: I trained in acupuncture.  So I, like you, am appalled at the role of the drug companies and think the current focus on sickness and hospitals is crazy.

The only sane way is to concentrate on preventive medicine and then look after the things that this can't.  (There'll always be accidents.)

Citizen juries and such (if they had power) would possibly move medicine in this direction. 

Wish List

There is a good wish list of worthwhile medical funding options on the ABC News website.  The opinion section of the election coverage.

It is by an Australian GP representing a GP organisation, so it is slanted that way.

Well worth reading.

Funding America's Health

On the New Dimensions program on Radio National an American doctor is talking about the funding crisis in the American health care system – the program is Solving the health care crisis in America. You can listen to it on line - but only for the next three weeks.

Instructive, as we seem determined to go down this path.

Thanks Trevor

Walk often, think peaceful thoughts and you may get the blood pressure down.

I do think there is a huge place for us knowing more about our health.

There is a website that will mail you a weekly newsletter with simple tips - even if you don't follow them it is nice to have a reminder.  There are several of them but this is the one I know.

Transactional analysis

This debate about funding for health care is totally confounded by lack of basic information, that is, our information about our own physical measures. I am fairly confident my blood pressure, as an average of three measures during the last 15 minutes, was pretty near 155/82 and my heart rate was about 73. I bet that's more than your average Webdiarist of 50+ years can say about such basic data, even including one spot measurement, only, in the previous 12 months. 

I know about my own BP because I, as one who should know better, was encouraged to have a check up. It was my first visit to the family GP in a year (or four). The first thing he did was measure my BP with a fancy digital machine. (A private agency has supplied any GP office that requests it with a digital device, and it is certainly a more productive and user-friendly tool than the old-fashioned mercury manometers. Although the efficiency of BP measure is far greater, the machine supplied retails for about $1000, which is more than most GPs would pay for themselves.) So, my BP was a lot higher than I expected. Pills were recommended, and I did not hesitate due to a family history of strokes.

Now, I went away from that consultation without any record of the BP measurement. I had some basic laboratory tests, and remembered to ask the GP for a copy of those results, for my own records.

I know this hypertension is going to be with me for the next 20 years, and because it might take more than one pill a day to keep it under control, I want to know more about how the blood pressure behaves during the day. I bought a digital manometer from the local pharmacy.

What I am getting around to is that every bit of health information about myself, assuming I want to collect it, is derived through one or several transactions. Witness the latest DoHA initiative - enabling (some) doctors to operate card readers so that clients' Medicare cards can be used to send the invoice for the rebate directly to Medicare Australia, thus cutting out that visit to the Medicare office to claim the rebatable portion of the fee. I think that's how it works, anyway, the College of GPs has negotiated for a fee of $0.18 on every transaction. Most medical services are assigned costs according to the agreed schedule of fees. Someone is getting a cut from all those transactions. The funding arrangements are complicated enough, but there is a vested interest in keeping it that way. That's the problem with statements like "eliminate one level in the funding pyramid and save a billion dollars". Those efficiency gains would sacrifice a lot of clerical and administrative jobs.

However, I reckon the biggest obstacle to more equitable and accessible funding lies in our (the public) lack of interest in keeping our own health records. The Ministers probably know that, and rest easy. They also know that the cost of my pill, a dollar a day, is minuscule against the money wasted on beer, pokies and leisure.

Thanks, Evan. Perverse incentives, special pleading or a free lunch will win against rationality, every time.

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