Health and hospitals and the polls
March 8th, 2010 by Mark Bahnisch | Published in Health, Polls | 8 Comments
We’ve had close to a week of public debate on Kevin Rudd’s health and hospitals plan, and today’s Nielsen poll shows resounding majorities among every demographic and voters of all parties for the proposition that the Commonwealth should take more responsibility for funding hospitals. Over the fold, I’ve borrowed a table from Possum to illustrate the results.
What should be of most concern to the Opposition is the very large number of their own voters who support such a policy. It might, of course, be objected that support is soft, but that ignores the fact that this plan was launched on the basis of reinforcing well entrenched public attitudes about the failures of the states in hospital management; attitudes Tony Abbott would have been well aware of when he frequently proposed a Commonwealth takeover as Health Minister.
No doubt it will also be claimed that support will ebb, as with the ETS (though it still has majority approval). But the introduction and selling of this plan has been very different – a high profile announcement, followed by a media blitz – much more akin to a budget. And interest groups which will resonate positively with public opinion – doctors, nurses, have reacted supportively.
I’m interested in the interplay between Brumby and Rudd. It seems to me that, with elections for both this year, they are playing out a script which sees both of them trying to get the best for their constituents.
With a comparatively good health system, Brumby needs to show that he can get the most out of the Federal Government for Victorians. With a possible fight, and two state elections in the works, Rudd needs to show that he can stand up and deliver reforms on state-based systems; ending the much hyped ‘blame-game’. It also helps him seem more like a man when he can ‘yell’ at someone like Brumby, and takes the spotlight well off the Opposition.
Some very subtle collaborations between press offices, maybe?
A key aspect of centralized management of hospitals is attaining some consistency of service delivery and quality that does not put the hospitals at the mercy of local budget shortfalls and poor local economic conditions. It also allows hospitals to be easily compared to one another such that those that are not well operated can be investigated to find efficiencies or more effective administrators.
I can see no reason why every state has to start off in Rudd’s system. Much smarter to start with the willing and demonstrate that what Rudd is proposing is a winner.
Well he was never going to get much of a no-vote by asking people if they wanted hospitals fixed, was he? And running against a faceless ‘bureaucracy’ is a tried and true political strategy in Australia and elsewhere. In the meantime, he’s wedged the Coalition a treat. There’s no way they want to defend ‘bureaucracy’ either let alone state governments
So the politics are great for Rudd but the states are faced with a rather more sharply defined reality: there’s nothing on the table other than a statement about switching current State and Commonwealth funding responsibilities for public hospitals and introducing the Victorian casemix model nationwide. How all this is going to happen, what it looks like, who has responsibility for what, what about prevention? Community and Mental Health etc remains shrouded in mystery.
Australia delivers pretty good health services overall but the public has a very different perception, as Mark observes.
I think the Victorian model is working well but it should be remembered that Kennett introduced it over the violent objections of the very medical interests who Rudd declared the other day – without a shred of evidence – were best placed to decide on, develop and manage health delivery systems infrastucture. It doesn’t augur well.
Kevin Rudd’s proposed shake-up of hospital management systems may be a monster project in its’ own right, but realistically it should only be a part of a broader health debate, and changes.
Ever spiraling health costs show the absolute necessity for a more determinedly preventative orientated, community wide approach.
This must aim to see less of us ever needing hospital interventions, rather than them being the begining and the end of our health care. Otherwise we will have a never ending gouging of budgets. And we will be completely in hock to the pharmaceutical and equipment manufacturers, forever.
I think the Coalition will have trouble countering the proposition of local boards, since they were suggesting it recently.
But I am very skeptical about hospital boards.
Gavin Mooney canvassed a range of problems in Crikey
http://blogs.crikey.com.au/croakey/2010/03/05/why-the-ama-is-happy-about-rudds-plans-and-the-rest-of-us-should-be-worried/
In terms of allocating funds, my philosophical inclination is that the closer to the bed-side, the better. However, the festering sores of local power really comes to the fore in things like local hospital boards.
Since 1973 I have worked in the public and private health systems, and in both in big city hospitals and small country ones.
My first job in a rural hospital was in the late 1970’s, where the local public hospital board was unashamedly and overtly political.
Maybe the shake-ups instigated by the Goss and Beattie governments has helped and practices may have irrevocably changed (perhaps we could make Tony Fitzgerald the auditor?).
But if you can show me that land developers no longer have local government dancing to their tune with all and sundry lining their own pockets – while baltantly working against so many community hopes – then I’ll believe that local hospital boards may be consituted so they won’t be beholden to short-sighted local elites.
In a rural district that I was a part of, the hospital board was controlled by one of the smaller towns. The GP there was the significant player. In fact he was the hospital doctor with the “right” to private practice, but you’d be forgiven for not knowing it was supposed to be this way round! His facilitator was the shire chairman – who also happened to be the chairman of the public hospital board and a top-dog in the National Party, including running election campaigns and fund raising.
At one stage almost all the hospital office staff came from the smaller town, including the hospital manager and Director of Nursing.
This GP clearly out-gunned far better qualified doctors and specialists in the adjoining bigger town that was also where the “Base” hospital was – including a general surgeon and specialist radiologist.
Who you knew, over-ruled medical practice every time.
The GP was a law unto himself – to the detriment of the health and well being of those he treated – and sometimes also those he refused to see.
That many locals viewed him almost as a saviour with almost paranormal powers was astonishing. Or they hated him and went to adjoining towns. He did what he liked.
He wouldn’t see the local policeman – he didn’t like him. On one occasion when this policeman had been bashed, he had to go to another town to be seen, and the QPS Union called for his de-registration.
He wouldn’t see blacks. They knew not to attend the hospital and the QAS knew not to be bothered stopping there.
He wouldn’t ever see pregnant women at the hospital. They had to see him privately – or go to another town (under the control of the same hospital’s board).
He performed an interesting range of surgery, including at one stage, miniscectomies. While the resident general surgeon on call 24/7 at the base hospital sat idle. The last time I talked with the surgeon, no referrals had ever come from the GP.
The GP performed so many colonoscopies, that for some time saturday morning was “Colonoscopy day”! (I’d suggest it was not because this tiny district had so many people suddenly needing their bowels explored, but because there was no suggested schedule of fees for GP’s to do this investigation – GP’s just weren’t expected to be conducting this sort of specialist proceedure.)
Rumour had it he preformed ECT, while also giving the anaesthetic – surely a first!
He so rarely went to the nursing home – in the hospital grounds and as hospital doctor it was part of his alloted tasks – that you would have to say: he wouldn’t go to the hospital’s aged care unit – which he always called “the senile annex”.
Why was this GP’s practices possible?
Simple – he had the ear of the local people who controlled the purse strings – the hospitals’ board and higher.
When the little town had its’ hospital rebuilt (also the subject of speculation – the figure of a $52,000 brown paper bag donation comes to mind), this GP and the hospital board chairman went to the local politican with a wish list.
The jewell in the crown was x-ray equipment. The exact model written down – so the pollie wouldn’t stuff up. It was of a calibre you had to go to Rockhampton General to find. (Remember we’re talking a very small town – a one policeman town.)
The hospital got this piece of equipment – but there was no staff competent to use it!
Emergency x-rays were taken by some of the wardsmen and nurses who had received very basic training to permit emergency shots (with an emphasis on limb fractures).
The fact that there was a qualified radiographer and specialist radiologist in the adjoining bigger town, was beside the point.
Best medical practice meant nothing – the minimally trained staff were used to taking x-rays of pregnant women’s abdomens; did barium swallows; decided that if one shot was a bit crook, what else they might do.
If they thought something on the x-ray looked odd (eg on an anterior / posterior chest shot), they could decide themselves to do a few more (eg left or right lateral).
Why did they get away with this?
The local hospital board was in the pocket of the GP and local political elite.
In the early 1990’s, after a protracted wrangle to bring the wayward hospital’s x-ray protocols up to some sort of standard, the base hospital’s radiographer had the temerity to remove excess developing chemicals. The shire chairman conducted a campaign in the national media about how far-away bureaucrats were destroying the health system in rural towns.
Anyone with an iota of health knowledge would have been taking aggressive steps to prevent medical malpractice.
Flick on a few years and these same hospitals are now controlled from a major Queensland provincial town, about 120 k’s away.
Can those medical professionals and health department staff look after the health needs of the locals more appropriately? I bet they can!
They might not initially understand some of the peculiarities of rural life and the attendant health issues – that only comes when you have to start focusing on the job at hand.
This local hospital board was an utter disgrace – a narrow-minded, politicaly motivated group of self-centered people looking after their own agendas.
Other aspects of this hospital boards behaviour – eg how and why items were tendered for and disposed of – was looked at by some unit within the Goss government, but no legal actions were ever undertaken.
This was in stark contrast with the board of the local private hospital which worked tirelessly and immensely hard to keep afloat and to provide as good a hospital as they possibly could. I say this despite my preference of public over private hospital systems.
Is behaviour like this inevitable when you have local actors jostling for their own self-importance?
Can local hospital boards know enough and be independent and selfless enough to make enough good calls to make it work?
On balance, I wouldn’t be hopeful. Again the cosy relationship between developers and councils seem to me the closest parrallel.
So a major and immediate necessity remains: the lynch-pin of better health for all of us will be from society-wide preventative health measures.
And the flip-side – immense savings in future budgets.
Then all our effecient and fancy hospitals – with their crucial life-saving work – will occupy a decreasing profile within the overall life of a healthy community.
Mervyn, I get the distinct impression that the “local” hospital boards will cover considerably more territory than the boards you’re describing.
That said, there does seem to be a bit of a problem with the model with the very high-end medicine that’s only done in the very biggest hospitals. Who’s going to bite the bullet and decide that no, the outer eastern suburbs of Melbourne don’t get the Machine That Goes Bing, which instead should go to the Royal Melbourne?
Robert, I accept that of the 3 hospital boards I’ve had contact with, all were very narrowly focused. The one I detailed would hopefully have been amongst the worst in Oz. And of a nature that many people could not conceive as possible.
The answer to the eternal question of how to allocate increasingly sophisticated and expensive equipment is out of my league.
But what so often gets completely left out and which is, from my standpoint, the more importaant issue – preventative health – encompasses issues we should all concern ourselves with.
One of the elephants in the room is that many of the advances in medical technology are often driven by narrow sectional interests – eg how much of current and future health budgets have to be re-directed due to the current obsession with IVF? How much money should go to keeping younger and younger neonates alive? etc, etc.
Consider this example alongside your query about a bling machine for one Melbourne hospital:
Most days of the week a bus leaves an aboriginal community in central Queensland and travels a round trip of 350 ks to take people to a big hospital for renal dialysis. The aboriginal community concerned actually has a dialysis machine! But it is not operational, nor is there a nurse there who knows how to use it.
And so a bus sets off every day to take people all that way to the major centre – a very big day for ill people and consuming ridiculous amounts of dough.
Would a local hospital’s board manage to retify this obscenity? (Would a white community with a similar number of renal patients suffer this in stoic silence?)
But why is there the prevalence of kidney failure amoungst the people of that community? And how is treating it once it has developed, going to stop subsequent generations of people becoming subject to kidney failure – and sitting on ever growing waiting lists and needing on-going and ever increasingly expensive treatment?
How would hospitals’ boards a la Kevin Ridd or Tony Abbott look like?
I sincerely hope that it is better organized than hospital boards I’ve seen.
How far removed these decision makers are, should not compromise their ability and willingness to work for the best possible outcomes for the people needing those beds.
But I can’t get away from the obvious: that hospitals – full of wonderful, essential and life-saving equipment – should only be a part of the answer.
Oh, agreed. But as I understand it, part of the plan is to transfer funding responsibility for allied health services to the commonwealth exclusively.
It would seem to me that given most of the money for hospitals, and all of the money for everything outside hospitals, is going to come from the federal government, there will be a considerable financial incentive to use allied health services to keep people out of hospital if at all possible.