Doctor and activist
10/07/2021
10 July 2021
I felt that something was wrong when a Soldier started advising me about vaccinations.
Here is a good summary from Crikey of what seems to be happening.
www.crikey.com.au/2021/07/07/administration-with-authority-how-putting-the-vaccine-rollout-in-military-hands-is-corrosive-for-the-country/?utm_campaign=Weekender&utm_medium=email&utm_source=newsletter&wkndr=RFdETTg0am9ucG5qc2dpcVpTeTU2QT09&success=krsmvj
10/07/2021
10 July 2021
The current issue in the NDIS (National Disability Insurance Scheme) is the government’s efforts to introduce ‘independent assessments’ of people on the scheme and those who want to get on the scheme. The idea has been abandoned for the present, but that is not the end of the story. It is the beginning.
Some context is needed here. I was on a State Parliamentary inquiry into disability funding during which we heard evidence of inefficiencies within the disability sector where often there were shortages of appropriate services, and in some areas there were none at all. The real crunch time was when parents with children with disabilities realised that they were going to die eventually and wanted to make a plan for the rest of their child’s life. People would apply at various facilities, and be turned away as there were no places. They then assumed that they were on a waiting list, but usually no lists were kept. When a vacancy occurred, whoever applied at that time got it. It was mainly luck. Naturally the people trying to help their loved one wanted a guaranteed package that would continue after their death. More articulate parents and carers, who had struggled for years just wanted the money to buy the services that they felt that they needed. Many carers simply wanted more services, and hoped that a national system that guaranteed services for disability.
Given the political context of privatisation and reducing government involvement in everything, the scene was set to have disability services delivered by the private sector as a massive market for services. The private sector naturally wanted to get access to services that had been provided by government as a source of business and profit.
Government also had a real estate agenda. Some large institutions were on valuable land. The large facilities at Peat Island in the Hawkesbury and Stockton Disability Centre was on beachfront land just north of Newcastle. There was a residence for the grossly disabled opposite Wollongong Hospital that had taken years of fundraising for the parents to achieve. These could be sold off as the mental health facilities had been a few decades earlier, with the catchy slogan of putting the residents ‘back in the community’. The idea that the residents were better off isolated in a suburban homes with few facilities rather than in a community of people with the same problem and a well-structured programme of activities seemed a dubious proposition to me. Resident groups such as the relatives of long-term psychiatric facilities at Bloomfield in Orange were very scared of the suggested changes. There had been problems with the old system and some inappropriate facilities, but an overall lack of facilities was the major problem. It was not even throwing the baby out with the bathwater; it seemed more like smoke and mirrors.
The key question in dealing with any problem is how big a task is it? When the Committee asked how many people with disabilities there were, there was no answer. No register was kept. The two ways of calculating it were:
The latter method gave figures about ten times greater. So clearly if help or services were made more available, the numbers involved were going to blow out hugely from what was currently funded.
John Howard passed the Aged Care Act in 1998, which was the blueprint for the privatisation of the sector. Old people are very vulnerable. They have often sold the family home, so they are temporarily cashed up, looking for accommodation and long term care with mental and physical facilities failing, or they would not be there. Carers faced with responsibilities that they were not used to and uncertain of what care was needed were easy pickings also. The whole sector is more like a dysfunctional real estate market; a market failure due to insufficient ‘consumer information’, but also distorted incentives and priorities.
The NDIS was similar. Private operators with slick marketing made promises which would not be tested for some time, but people were signed up now. The not-for profit sector had never paid staff well, but most had a ‘care ethos’. Some of the private providers did not, and regulatory supervision was minimal. The government was pro-business and trying to give away responsibility.
But an absolute shortage of services was still a big factor. A neighbour who was a 95 year old retired academic widower wanted 2 hours a week of home help. For some reason he could not get a community nurse. The best deal he could get was 2 sessions of 2 hours at $65 an hour. The lady delivering the service was paid $21/hr. So much for private services; the ‘overheads’ are huge. I had suggested to Kevin Rudd’s 2020 Vision in 2000 that the Government needed to licence service providers as individuals if they wanted a market model, and our neighbour could have selected a person on a one to one basis. (I never even got an acknowledgement).
Now the government wants ‘independent assessors’ to evaluate cases, presumably to lessen costs. A number of points can be made about this. It assumes that the assessors will learn more about the patient in an interview than the people who work with them already know. The new management philosophy since the 1980s always assumes that a manager at the top will know more than the person actually doing the job. Naturally if the object is to save money and have the person at the bottom paid minimally, requiring no skills and interchangeable in staffing, this may be true. But if the people at the bottom were respected, trained and empowered, the need for the middle level experts might be much less.
‘Independent Medical expert’ assessors are used in the Workers Compensation and CTP systems. They work for agencies hired by insurance companies. Often they find the patients either have nothing wrong with them, or it is degenerative and not related to their injury. These experts are even flown from interstate and save insurers money by denying treatments. Presumably if they find in favour of the patients, their agency gives them less work. The agency takes its cut and has to please the insurer. So the systems are more complicated and an ever higher percentage of the money is spent in trying not to give services. The NZ National Accident Compensation scheme, though it was government owned, went to a private insurance model and the same thing happened. Doctors who had a track record of denying liability were flown around the country to do their medicals.
The assumption may still be that well intentioned assessors still can do better. My widowed mother lived alone in the family home and had a stroke. A neighbour noticed her confused, walking on the balcony. She recovered, but seemed to have lost some judgement. She was assessed by an ACAT (Aged Care Assessment Team) who said that she could live alone in supported accommodation. So we got her into a unit in the grounds of an old house, where she could book a dinner at a days’ notice in the communal dining room, have a nurse onsite during the day, and had a right to a nursing home bed if she ever needed one. Seemed perfect. She said that she could look after herself. Can you microwave a dinner? Yes. OK. Do it. It got done. No problem. Dinners in the frig. Sweets in the jar on the mantelpiece; see you in 2 days. Arrive in 2 days. Dinners still in the frig. Lolly jar empty. Very hungry- can we go to lunch? She could do anything when asked, but could not initiate a process. She could not think to get a dinner from the frig, or book lunch tomorrow in the communal dining room, nor ask for help. The one-off team could not pick this. Neither did the family. But it emerged when the situation at home was known. This is just a story, but a carer who is savvy and properly trained will know more than a university-qualified assessor who has only a short knowledge of the patient. And naturally the person on the job actually delivers the service and is not an extra cost. They can also judge relative needs of people on a run or in an area if resources are limited.
So the scheme to bring in assessors is the tip of an iceberg.
Private insurance models have huge problems at many levels. The overheads of Medicare are a bit under 5%. The overheads of Private Health Insurers are about 12%, and they cannot refuse to pay doctors. The overheads of US Health insurers are about 12-36%, as the best way to improve profits is to cut costs (payments to patients) rather than increase services and then try to prove you have and sell on that basis. At the bottom of the efficiency barrel is our own NSW CTP system with overheads of almost 50%. The question has to be what is the focus of the system? Delivering services, or saving money? The US health insurers, like our CTP scheme are very good at making money. What they make their money from just happens to be people rather than widgets. The main cost savings of privatisation seems to be destroying award conditions and lowering ‘staff costs’. The immense administrative savings from universal systems, where determining entitlement and paying for profits are eliminated cannot be matched by any private system, despite what the ideologues might pretend.
The NDIS is currently a fund supposedly to help people with disabilities. These people apply to get ‘packages’ of money and services. Businesses persuade people to spend their packages with them. It is a market. But there are more people with disabilities than was expected, for the reasons discussed above. So a new level of assessors, were to be rolled in, but a huge outcry has prevented this temporarily. But the problems that led to the need for the assessors remain implicit in the design of the NDIS, which is fatally flawed. The government, particularly this one, is not going to take this very large bag of lollies from the private sector. The totally inefficient Private Health Insurers (PHI) give money to political parties and advance by stealth, letting Medicare become irrelevant for health care. Disability is now also privatised, and a new private lobby is in there. It has not yet generated a Royal Commission into its rip-offs, but it will, not that the Aged Care Royal Commission has stopped the privatisation of aged care. The political forces are too great. It is ironic that as Medicare is starved and pays less and less of the doctors’ fees its levy was increased, using a wave of sympathy for people with disabilities to make a bigger pool of money for increasingly private disability providers.
How to fix the problem?
I do not pretend to have all wisdom on this, but in dealing with difficult political problems I think it is wise to set a direction, take some basic steps and consult widely, looking for advice particularly from those who do not get an immediate financial benefit.
Here is a start:
Recognise that disability is not a sickness. Some disabilities are inherited; others are acquired due to accident, illness or aging. The sector is quite diverse, often divided up by the type of disability or how it was acquired. Sickness has an ‘episode’ model, based on traditional infectious diseases or surgical treatment models. Disability tends to be long-term and may improve or be worked around, or may degenerate gradually. As such it needs long-term solutions like welfare, but using the term ‘welfare’ now implies charity. Disability funding is funding to enable those less fortunate to have as normal a life as possible. From our common wealth, we give more to those who need more so that our society has equal opportunity for all. We are being taught that tax must be minimised and if we are getting less than we pay we are being ripped off. A better model is to consider the statement by Rhonda Galbally, ex-CEO of VicHealth, ‘There are two populations, the disabled and the not-yet disabled; if you are lucky enough to be in the second group, you should be happy to help pay for the first’.
The idea of a universal service obligation is the cornerstone. We should start with the assumption that people with disabilities should live in our society with as normal a life as possible and we should adapt to support them in as cost-effective way as possible.
My suggestion is that the Community Nursing service is the basic structural framework. We assume that people with disabilities will be living in society, and need varied and integrated support. If they are born with a disability or acquire one, they will come in contact with the acute hospital system, which will hopefully document their situation and alert the community support system. People on the ground will then liaise with family to see what support there is for independent living, and organise resources, calling in specialists of required. The cost of home support may be part of a package or allowance. Individuals may register to offer services for everything from shopping, cleaning and lawn mowing to medical or paraplegic support services. The government will register and insure both practitioners and those who use their services and may put training requirements on those who wish to register for some skills. A market with consumer feedback as exists for restaurants or other practitioners will allow people to hire help directly without big corporations adding massive overheads.
Whether the monies are paid separately of via Centrelink is an administrative question, but Centrelink has to have a major makeover so that it is not the niggardly decider of the ‘worthy poor’ with its chief function being to avoid paying anyone, or paying as little as possible. If society cannot find everyone employment, we must share what we have to those who are disadvantaged by disability or circumstance. This will collide head on with the problem of increased numbers of those with disabilities, but the extra load must be seen as part of having a decent society.
The way we are going seems to be privatising, allowing huge profits, then running out of money and shutting the gate on those who do not yet have packages. The independent assessors were merely the instruments of Managers who were not able to make their own assessments and did not trust the people who actually deliver the services. The assessor problem was the tip of the iceberg of a system that has all its underlying assumptions wrong, but sadly has a lot of political power that having been created, may not be able to be undone. The first step is to understand what is happening. Hence this lengthy post.
www.abc.net.au/news/2021-07-09/ndis-disability-independent-assessments-model-dead-after-meeting/100277324
09/07/2021
9 July 2021
Here is an article from The Conversation talking of the effect of Chinese resistance to certain views on their history. Teaching is already distorted by the need to pass students who have paid a lot.
04/07/2021
25 June 2021
The much publicised rape allegations against Christian Porter have been released.
People can judge their veracity for themselves. Click on the link in The Saturday Paper:
www.thesaturdaypaper.com.au/post/max-opray/2021/06/25/porter-dossier-released
04/07/2021
4 July 2021
The collapse of the front wing of a 12 storey Florida beach residential tower block on 24 June has sent shivers around the world. The rest of the building, more than three quarters of it, is now to be demolished before a tropical storm comes in (ABC News today). Another similar condominium 8km away has been evacuated (SMH- Unsafe Florida Condo evacuated 4/7/21).
It has always been assumed that tall buildings do not fall down in first world countries unless earthquakes are very bad. We need to look again.
I did a locum in Sydney’s Eastern Suburbs in the early 1980s and found that a number of quite famous and prestigious buildings were being treated for concrete cancer, which is what happens when the steel reinforcing rods rust, expand and the overlying concrete flakes and falls off. Presumably the treatment of the Eastern Suburbs buildings was successful as they are still there. When I was at Sydney Water head office, it had a 7 storey old part from 1927 (which is still there repurposed as a hotel) and a ‘new’ building, which was 26 floors in concrete. Though not at all pretty, (the word brutalist comes to mind), the new building had won an architectural award. A fortune was then spent removing the asbestos. Some years later a nice big front overhang was built over the footpath outside. I discovered that this was because the concrete cancer was so bad that bits of it were falling off and might be dangerous to the citizens on the footpath outside. None of that was mentioned at the time of course; that building was demolished some years later.
When I visited Cuba in 2007 the buildings along the foreshore in Havana were all 1930s reinforced concrete two or three storeys high with concrete balconies with concrete balustrades and handrails and the sort of scrolls holding up the verandahs and around the doors. Art deco if I am not mistaken. But they had concrete cancer bigtime and the balconies were literally falling off. As you walked down the footpath, some areas were roped off in case there were more falls. Some houses were condemned, which seemed just to mean that they were full of squatters rather than owners.
It is not clear whether the building falling in Florida was poorly constructed, whether it got concrete cancer, or whether the sand shifted under it. Presumably we will know eventually.
Back here in Australia the wave of deregulation in the early 1990s led to the privatisation of building certifiers, and the distorting effect of real estate money, surely the biggest problem in Australian governance, has hugely affected building standards. We have seen the fiasco of the Opal Towers building at Olympic Park in December 2018 (SMH 24/12/18), and Mascot Towers (SMH 15/5/19). We now have a new building inspectorate and the new NSW Building Commissioner seems aware of the problems. But Body Corporates do not want to report their defects. No doubt they are fully aware that if they do their property values may be totally destroyed, or at best they will be up for a fortune in repair costs if the problem is fixable. So the answer is to hide the defect if you think the place will not fall down.
The Building Commissioner says that there are 200 apartments on the lower North Shore with ‘scandalous’ defects.
When I was in Parliament it was drawn to my attenti0on that air-conditioning ducts often went through supposedly fire-proof walls, as did plumbing that was not sealed off around the pipes. One of Sydney’s major apartment builders and generous political donor was named, and I asked a question as to how many building were there in the Sydney CBD that the Fire Dept. had declined to certify as safe for occupation? I never got a quantitative response, but the company in question sued the Sydney City Council for being slow in issuing certificate of occupancy. I guess that they thought attack was the best form of defence.
A little known fact is that insurers will not insure buildings over 3 storeys.
The system of private certifiers is a farce and the chickens are likely to come home to roost. How do you buy an apartment now?
Inspectors have to have the power to refuse and guaranteed employment, so that they cannot be bullied or blackmailed. Then there have to be protections against corruption. A head of a planning dept. that I knew banned meetings in a certain coffee shop that was known as a place where developers spoke to public servants, banned meetings on a one to one basis and insisted that there be minutes of every meeting and that only what was written down was to be considered as binding. He had lessons on ethics and acceptable behaviour, but admitted, ‘I cannot check on everything’.
www.smh.com.au/national/nsw/construction-watchdog-body-corporates-are-not-reporting-known-defects-20210630-p585hh.html
04/07/2021
4 July 2021
The rise of ransomware has been a major problem for business. The government and law enforcement have traditionally cared little about scams, hackings or identity thefts. I have tried to report these, giving phone numbers of the scammers call back numbers after having proved that the scam number answers in order to demonstrate that they were the Tax Office or whatever. No interest at all. Eventually a government Scamwatch website has been developed. (There is a nice irony in the title as it watches rather than acts).
But scamming has progressed to Ransomware, where a computer system is hacked and huge sum of money demanded if the business is not to be either rendered permanently dysfunctioned or have it all its information shared to a competitor, and then still not function. The ransoms are usually paid, though no one actually likes to admit this. The fact that JBS Meat processing stopped in the whole world, and the whole East Coast of the USA could not buy petrol has stimulated law enforcement to take an interest.
Presumably, hacking and viruses are a continuation of the goodies and baddies in the programming world, with both working on the same computers and programs. The fact that it can be used as part of ongoing war against another country now seems relevant, with smaller countries seeking to take down larger ones. It seems that some hackers are nation-based, so they are termed privateers, after the pirates who actually worked for a country, like Francis Drake, who famously stole Spanish galleon gold (stolen from the South Americans) for England and was knighted for it.
As a safe computer system has to be developed, marketing and implemented, there is always a time lag which must surely help the hackers. Modest small businesses cannot be at the cutting edge of software systems, so will always be vulnerable- the only hope is that law enforcement gets serious about screening for miscreants and tracks them down. If they can screen every Facebook post, and act quickly there may be some hope, but I am not sure what difference encryption makes to all this.
This story is in a lot of papers this weekend in slightly different forms. Here is the SMH one:
www.smh.com.au/business/the-economy/pirates-of-the-cyber-seas-how-ransomware-gangs-have-become-security-s-biggest-threat-20210624-p5840c.html
03/07/2021
3 July 2021
AUSTRAC (Australian Transaction Reports and Analysis Centre) is a small regulator compared to ASIC (Aust Security and Investment Corporation) and APRA (Aust Prudential Regulatory Authority). But when Paul Jevtovic was transferred from the AFP (Aust Federal Police) to run it, it charged the Commonwealth Bank and Westpac with not reporting financial crimes adequately and fined them a total of $2billion.
Those who us who think that unpunished crime is rampant in the big end of town cheered, and wondered if there was any hope that this might set a new norm; regulators might actually start enforcing regulations. My private hope that they might move from banks to insurance companies, whose antics make the banks look like saints. But I note that the National Bank, who seem the next cab off the rank have just got Jevtovic to come to them to help them clean up their act, and the new CEO, Nicole Rose is known for a less aggressive style. This worries me. Regulators with gentle styles seem to prosper in the bureaucracy, and one might be willing to bet that the National Bank may change its behaviour just in time and be hit with a much lower fine. Presumably the saving will make Jevtovic’s salary look like chicken feed.
What is needed is a Police model. People speed and get fined. The Police expect them to speed, so have no qualms about fineing them. It should be the same for corporati0ons. If they can make money doing something they will. That is what Milton Freedman told them to do and what their shareholders want. If you want them to work within another framework, like an ethical one that lessens their profit, then you had better enforce that framework or it will be empty words. Police understand that. Generally ambitious bureaucrats choose not to understand it.
The Headline is about the Banks fighting financial crime- do they really care or is it just when AUSTRAC makes them?
We have to hope that Jevtovic’s move is not just another aspect of the new regulatory model.
www.smh.com.au/business/banking-and-finance/dirty-money-how-the-banks-and-austrac-are-fighting-back-against-financial-crime-20210625-p5849c.html
02/07/2021
27 June 2021
Author Bri Lee ties it to privilege in education.
We have to bring back the Gonski reforms and stop just giving money to the elite schools.
www.smh.com.au/culture/books/education-and-elitism-under-the-microscope-in-new-bri-lee-book-20210617-p581ul.html
27/06/2021
26 June 2021
The pathetic efforts of Gladys Berejeklian to blame the limousine driver for the latest COVID outbreak, which has now caused a city-wide lockdown and an increasing number of cases needs to be judged on its demerits. Obviously there should have been regulations that anyone on the front line had to be vaccinated, and surely driving a limo from the airport to the quarantine hotel is ‘front line’.
She said that she ‘could not control the subcontractor of the subcontractor.’ Actually, she could have. Now she has the regulation that she should have had months ago- front line staff have to be vaccinated.
Of course, the reason for the spread of the virus from the Melbourne quarantine hotels months ago was the fact that the support staff had many jobs, because they were not permanent and had shifts everywhere. The same problem occurred with transmission in Victorian Nursing homes- casual shifts. Now it is Sydney drivers.
The farmers are moaning that they will not be able to pick the fruit without the visas for backpackers, foreign students and Pacific Islanders. Skilled migrants? I do not think so. It is about sub award wages and poor conditions. If Australia is a rich country we need also to remember our roots as the country of a ‘fair go’. If top wage are high by world standards, so they should be at the bottom. If wages were high enough Aussies would pick the fruit, and cleaners and limousine drivers would have regular jobs and award wages.
But here was the NSW Government trying to blame the limo driver for the outbreak. But today’s Sun Herald has the Police Commissioner saying that the driver had committed no crime. Neither has the NSW Government- they are just incompetent, but no one seems to blame them.
www.abc.net.au/news/2021-06-17/nsw-quarantine-worker-may-have-breached-health-order/100223120