Health: Health crisis obscured by ideologyby Bob BrowningNews Weekly
, August 12, 2000
Bob Browning explains how ideologues of both big government and free market forces have obscured the facts behind declining health standards.
It is becoming harder for governments to obfuscate the fact that under-funding of our public hospitals is causing people to suffer, some even to die unnecessarily. Barely a week goes by without further disturbing incidents. Recent events in Perth, Canberra and Sydney provide examples.
A cancer patient at Canberra Hospital died after waiting six hours for emergency surgery on his bowel. His surgeon, Dr Phillip Jeans, a senior gastrointestinal specialist and Chairman of the Hospital’s Medical Advisory Committee, resigned “in disgust”, claiming this latest incident was further evidence that hospital operating systems were deteriorating. Clinical research was also being starved of funds, he said. Surgeons like himself were falling behind the levels of expertise being achieved elsewhere.
ACT Health Minister Michael Moore finally announced a “review” of Canberra’s operating theatres, and a “summit” at Old Parliament House to discuss the growing acrimony between the Government and the health carers.
At the same time in Western Australia, Premier Richard Court promised to “re-evaluate” the management of his state’s public hospitals.
Complaints about inadequate hospital resources had culminated in the resignation of a dozen doctors from the Metropolitan Health Service Board’s advisory panel.
A tragic incident the previous day helped spur the government’s move. A toddler at Perth’s Joondalup Health Campus was apparently given the wrong medication. The hospital prognosis was that the baby would not survive.
In Sydney, more doctors threatened to resign unless sufficient operating times were made available for treating emergency trauma cases.
Administrators at St George’s Hospital, one of the city’s top public teaching hospitals, threatened to sack and sue three of its leading surgeons, Drs Drummond, Siekel and Viglione, if they attempted to carry out their threat.
Another Sydney surgeon, Dr Ian Harris, operating at St George’s and Liverpool public hospitals, also complained publicly about serious delays for trauma surgery. He told how a 28 year old woman with a complex fracture was fasted for 48 hours waiting to get admittance to an operating theatre. Surgery was cancelled five times, once when she was already about to receive anaesthetic. Dr Harris claimed this incident was not untypical. Elderly patients, suffering from complex hip fractures, waited around for up to three weeks to get into operating theatres.
The latest NSW government figures (published in the Sydney Morning Herald, July 23, 2000) showed that as of May this year only four Sydney hospitals were meeting all the benchmarks for the urgent treatment of patients in emergency departments.
According to government figures, more than 20 per cent of NSW hospitals failed to resuscitate 99 per cent of the most critically ill patients within the required time. Half of all hospitals did not treat at least 80 per cent of patients in the second most critical emergency category within the set time.
The NSW Opposition spokeswoman on health, Mrs Jillian Skinner, said the figures showed a “shocking deterioration” in the ability of major hospitals to cope with the sickest people — despite a reduction in the number of patients being admitted to emergency departments.
At least for the more ideological of critics, the present decline in Australia’s once internationally renowned health system is easy to explain and simple to solve — given the political will. For many on the Right, all problems stem from Medicare. They see is as a “socialist” system which they claim is proving unaffordable and unworkable.
For the Left, it is the fault of “greedy” doctors whom they accuse of continually using their “monopoly” of health care to thwart reform through special interest trade union obstruction.
For the Right, the answer lies in “getting government out of the system”. Individuals should be free to buy their own health care as they do their food, clothing, homes and other essentials.
Why should government continue to dominate the purchase of people’s health care, they challenge, when that process forces government to ration people’s health care to control expenditure.
The Left want government to intervene and spend more to make the public system work. Better management and the economies of scale of a single, universal, tax-funded system, they say, could eliminate costly inefficiencies, waste, over-servicing and fraud. Instead of putting millions of taxpayer dollars into bolstering private health funds, the money should be spent on making the public system function satisfactorily.
If there is one thing, however, that both the Right (at least the economic Right) and the Left agree upon, it is that the medical profession has to be brought to heel. Both see health care as too important to be left to doctors.
Nationally, health is becoming ever more costly and complex — and in some cases highly profitable for the private corporate sector. Health services are no longer a cottage industry, they say, that can be managed efficiently by doctors.
Medical practitioners are skilled in medical science but untrained in management of resources at state or national levels. Modern health care, they insist, requires advanced modern management, whether by better trained bureaucrats (Left view) or by private sector corporate executives (Right view).
Reality is, of course, always more complex than ideologues allow themselves, or want others to believe.
There are numerous causes of the inadequacy of the present system, other than “greedy” doctors or “socialist” Medicare. Other causes include the ageing population, new expensive technology, and the increase in depression and other forms of mental illness connected with family breakdown, drug taking and stress in contemporary society.
There is also the rising demand for medical services, and greater expectation of what they can or should deliver. Many now demand more than wellness. They want enhanced quality of life.
The demand and cost of many health services are escalating at the same time as globalisation and neo-liberal policy are forcing governments to reduce public expenditure and taxes.
Pharmaceutical and other health industry corporations are seeking to expand their markets and make them more profitable.
Government cost-cutting policies, combined with the push by the new managerialism for “workforce flexibility”, results in pincer pressure on doctors to deviate from the Hippocratic tradition which puts the interests of patients — rather than the bottom line — first.
Until the advent of Labor’s Medicare, government intervention in the doctor-patient relationship, in clinical practice, and in the organisation and training of the medical profession was minimal.
Governments provided legislative support for professional autonomy and injected additional income into the profession through encouraging private health insurance and targeting some health care assistance at the needy.
Later, when the Coalition reluctantly adopted Medicare for electoral reasons but still sought to further neo-liberal policy, intervention in clinical practice escalated. Privatisation and corporatisation meant that not only government and health insurance funds sought more expenditure control over doctor decision-making, but so too, for bottom-line reasons, did corporatised public and private hospital managements.
The medical profession has traditionally regarded clinical autonomy and organisational independence as inextricably related to the quality and confidentiality of medical treatment. Governments, on the other hand, generally under electoral pressure, have devised funding systems to extend the availability and affordability of health care.
Professional autonomy remained largely intact in Australia until the early 1990s when a push began to introduce US-style managed care. The essence of managed care is its desire to intrude on clinical practice and the doctor-patient relationship for reasons of bureaucratic or insurance fund cost cutting or corporate profit maximising.
Both the medical profession and government exist ideally to serve and better society. The task is to discover ways to achieve the socially desirable aims of both parties, without throwing babies out with the bathwater.
In these times of economically-focused, radical change, society needs to become more appreciative of the values institutionalised in the medical profession, which systems like managed care undermine.
These values include humanitarian, compassionate attitudes to the sick, the injured, and the impaired. They include concern for the individual person, his and her dignity and privacy, irrespective of social status or wealth. Often this entails serving individual needs despite the conflicting political and commercial interests of third parties.
The Hippocratic tradition is the ethical model by which most doctors are affected, and by which the behaviour of all doctors is judged.
De-professionalising doctors and turning them into just another “flexible” workforce of technicians managed by corporations or obedient to bureaucrats will weaken the humanitarian architecture of our society — something painfully constructed over centuries by the highest human aspiration and effort, and something we would be inexcusably foolish not to safeguard.
Unfortunately, much of the discussion over national health funding is laced with anti-doctor animus.
Australian anti-doctor sentiment was hatched during the late 1940s during efforts by the Curtin-Chifley Labor Governments to nationalise the health system. Doctors’ resistance to nationalisation, and their on-going suspicion of Labor’s socialist intentions, convinced Labor that private doctors, especially as represented by the AMA, were their political opponents.
Labor retaliated politically, with the result that anti-doctor sentiment permeated beyond the ALP leadership into the media and public attitudes. In the mid-1990s, after the Coalition reversed its declared ideological opposition to Medicare for electoral reasons, it too began to utilise anti-doctor animus politically. The Coalition set out to maintain Labor’s universal, tax-based health system, free at the point of service, at a time of irresistible international pressure to reduce public expenditure and make government smaller. Obviously something had to give.
The Coalition tried to cope by extending the US-style system known as managed care. Managed care was introduced first under the Hawke-Keating Labor governments. The Coalition’s federal health minister, Michael Wooldridge, himself a former general practitioner, became particularly critical of those of his former profession who resisted the Government’s efforts.
Obviously, it is not in the public interest that debilitating tension between governments and the medical profession should continue. It cannot but be counter-productive to the quality and availability of health care to the Australian community.