Doctor and activist


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Category: Market Failure

NDIS and Health System in Crisis- what is the answer?

27 January 2025

The health system has been in crisis for years and now NDIS is the same.
State and Federal governments are locked in crisis talks, and now the NDIS is over budget and looking to ‘transfer services’ to other parts of the health system.
Why does all this go on, and what is the solution?
The short answer is that there are many sources of health funding and the main policy objective of all of them is to transfer the cost to someone else, and if they are a private source, to maximise the profit.
This ‘transfer costs’ imperative means that no one is concerned about the overall cost, merely their bit of it.
The major players are still the State and Federal government. In simple terms the States look after the hospitals and the Federal government looks after non-hospital services.
Medicare is being starved and pays less and less to doctors relative to inflation. The private health funds pay what they have to, the CTP (Motor Accidents) and Workers comp systems are either private or use a private model and pay as little as they can get away with and the patient pays the gap, unless they decide that private health insurance is not worth the money, which in most cases is true, and get a bit of Medicare and pay the rest.

Examples of cost shifting are easy to find. The Federal government has let Medicare rebates to GP fall to 46% of the AMA fee. It was 85% when Medicare started, so many doctors simply don’t bulk bill and charge a fee. So people go to the Emergency Departments that are free, but funded by the States. A visit to the ED is 6x more expensive than a GP visit, but the Federal government has shifted the cost to the States, so they don’t care. When you go to the ED and get a script, the hospital used to give you all the drug course. Now they give you a few tablets and a script for a pharmacy outside. The script was needless, and generates the costs of the trip to the pharmacy, the pharmacists fee, the PBS Federal government contribution and the patients script fee. A lot of wasted time and money, but the State saved a bit. When you went to the ED, you used to be followed up in a hospital outpatient clinic where the consultant was paid a sessional fee and oversaw registrars checking the cases and learning. You could also just book and go to a specialist clinic. These have largely been stopped to save the State money. Now you go to the specialists’ rooms and the State saves money, but the total cost per visit is much more.

If you look at the overall efficiency of health systems, Medicare as a universal system has overheads of about 5% counting the cost of collecting tax generally. Private health insurance overheads in Australia are about 12%, Workers comp 30% and CTP over 40%. These figures are approximate and very hard to get, because the dogma is that competition drives down prices, when clearly the system is more efficient if there is a single paying entity. Interestingly, the Productivity Commission made no attempt to quantify these overheads when it looked at the cost of the health system- you may ask why. The point is if you take out profits, which are the same as overheads from the patients’ point of view, and make everyone eligible, you do not have to have armies of insurance doctors, investigators, lawyers and tribunals to see if the insurer has to pay or if it can be dumped on Medicare and the patient.
As far as foreign people using the system are concerned, universal Medicare for people living in Australia is administratively simple, and the cost of treating tourists who have accidents is cheaper than policing the whole system. Enforcement has quite high costs.

In terms of the cost of insurance, US schemes vary from 12-35%R, with the high costs ones being most profitable as they police payouts more thoroughly and naturally refuse more treatments. Note that the CEO of Unitedhealthcare in the US was recently shot, with the words ‘deny’ and ‘delay’ on the cartridges used. Surveys have shown that 36% of people in the US have had a claim denied. Claims are accepted here, but in a survey of my patients 60% of my scans and referrals of CTP patients were denied by NRMA. i.e, We accept the claim, but deny the treatment.

What Is needed is a universal system, free at the point of delivery.
What about over-servicing? The current system makes trivial problems of people with money more important than major problems of people without money. Underservicing is the major problem with ambulance ramping at EDs and long waiting lists.
In a universal system, which doctor is doing what is immediately accessible, with comparisons to every other doctor doing similar work. It is just a matter of checking up on the statistical outliers.

The problem is simple. The major political parties are given donations by private health interests to let Medicare die. Combine this with the Federal/State rivalry that makes cooperation very difficult and a reluctance to collect tax and you have the recipe for an ongoing mess.

The NDIS is an even bigger mess. It is a privatised unsupervised welfare system that arbitrarily gives out money and is subject to massive rorting.

The welfare system that looked after people with disabilities, both congenital and acquired by age or circumstance had grown up historically in institutions that were fossilised in their activities and underfunded to prevent expansion or innovation. People with disabled children looked after them with whatever support they could find. As these disabled cohorts reached middle age, their parents, who were old, were worried about what would happen when they died and wanted to lock in funding for their adult children before they died. They were an articulate lobby group with real problems and were quick to point out the flaws in the existing systems. They visited institutions that had no vacancies and thought that they had put their names on waiting lists. But no central list existed, and the institutions tended to give their beds to whoever came first when a death created a vacancy. ‘Just give us a package, and we will decide how to spend it’ was the parents’ cry. But then NDIS experts came in and interviewed people and gave away ‘packages’ based on an interview. A new layer of experts was created. District nurses or others who might have been able to think of more innovative or flexible options, or who could judge who in their area needed more than someone else had no input. People with real disabilities were given money, but did not know how to assess providers, so dodgy operators snapped up the packages, delivering dubious benefits. The government had no serious regulation or control system. Now the cost of NDIS has blown out, so the solution is to narrow eligibility and force people off the NDIS and onto other parts of the health system. Sound familiar? People with disabilities and their relatives are naturally worried; and rightly so. The lack of these services was why the NDIS was created. The answer is to have universal services. Set a standard, make it available and police quality in the system. Private interests may have a place, but there is no need for profits, non-profit organisations have been the mainstay of providers for years. For profit providers tend to cut costs, which in practical terms means either services or wages or both to concentrate on shareholder returns. The best way to allocate resources optimally is to empower the people actually doing the job, who also have the advantage of being able to see relative needs as they go about their routine work.

An interesting tome on the subject is ‘The Political Economy of Health Care’ by Julian Tudor-Hart, which looked at the changes in the British National Health System from when it started as an idealist post-war initiative run by those working in it with management overheads of about 0.5%, to when it was fully bureaucratised with overheads of about 36%. He was also responsible for the ‘’Inverse care law’ which is the principle that the availability of good medical or social care tends to vary inversely with the need of the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.

The key point of that people have been taught that governments are hopeless and that you should pay as little tax as possible, so instead of good universal services being developed, a market has developed which is on its way to an American system.. People all agree that the US has the worst system in the developed world at delivering health care. But they overlook the fact that the US health system is the world’s best at turning sickness into money. That is what it was designed to do and that is why it is sustained and maintained. The same drivers are all here.

Note the Federal/State bickering in the article below (and weep).

My recipe for change is to have a Swiss style of government where the people can initiate binding referenda on governments and could simply answer a question like ‘Do you want to pay 5% more tax to have a universal health and welfare system?’ If a question like this got up against the doomsayers, we might have a chance. But of course the change to the constitution to get the referenda in the Swiss model is almost impossible to achieve, the Swiss having been discarded when the Australian Constitution was written in about 1900.

www.thesaturdaypaper.com.au/news/politics/2025/01/25/exclusive-albanese-shut-down-hospital-talks-pressure-states?utm_campaign=SharedArticle&utm_source=share&utm_medium=link&utm_term=VT5jI6Zo&token=Z3cA3Py

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Banks Charging $3 a withdrawal- the logical end of capitalist thinking?

11 December 2024
Once upon a time banks functioned to store your money safely giving you some interest for the use of it or lending it to you for a bit more interest.
Then the government made a quick buck by selling the bank to people who had the money to buy shares.
Then the concentration of wealth changed so that most of the money was held by fewer people. And technology changed and the people with the most money used the new higher tech ways of banking.
And then there was less profit in the little people.
And the accounting changed, the CEO salaries went from several tens of multiples of the normal people’s salaries to hundreds of times. But they had to show results to the shareholders to justify this.
So they closed most of the branches and replaced them by Automatic Teller Machines to save all those rents and staff salaries.
And they decided that even to stock the ATMs was too expensive so they put fees on them to use them, but they got criticised for that, so they lessened the number of ATMs, which saved even more.
A few people actually still wanted to go to the few branches left and wait until they could get to the reduced service, but the accountants said that the return on capital to the shareholders from this aspect of operations was not as much as the returns on internet transactions. Clearly the shareholders wanted ‘user pays’ in every aspect of the business so the banks decided to make these little folk pay a fee to get their own money, as had been so successful with the ATMs.
And no one even commented that the function of banks was to provide a service of looking after people’s money, the question was really how to ensure that the shareholders’ returns could be maintained.
And they all lived happily ever after.
THE END

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Nuclear Power

13 December 2024
In the Nuclear power ‘debate’ Dutton is using the exact words of a nuclear power lobbyist who I heard at a Royal Society meeting last year. He says in essence that all the other countries have nuclear, so we need it too, which is silly in that we have far more renewable energy than they do.

So the message is the that Liberals have given in to the nuclear lobby, because of course a couple of nuclear power plants are necessary for the AUKUS submarines, though both Liberal and Labor have been carefully avoiding this fact, as they know that the Australian people currently do not support either nuclear power or AUKUS submarines and they want to get us to accept it all in two bites rather than one.

The hasty inquiry into nuclear energy, which I flagged last month conspicuously did not have the AUKUS submarines mentioned in the their terms of reference despite the fact that in discussions about the AUKUS submarines it was mentioned that Australia will need two nuclear reactors larger than the Lucas Heights one, and a lot more trained nuclear scientists and technicians. Labor just wants the Committee to find nuclear electricity unnecessary and criticise the Liberals.

The sad reality of our two party duopoly is that when one side is voted out, the other comes in with all the policies it wants to bring in. So if you dump Albanese because he did not do much and you think Dutton can help (not a view I support), you get nuclear whether you wanted it or not.

In countries such as Germany , where Winston Churchill wrote the constitution so that no single party could ever get a majority, they have to get coalitions so that each issue has to get considered on its merits. It is not a winner takes all and gives all the policies of whichever lobby group has been successful lately. It seems that the Teals are the only hope; the thin Teal line holding democracy

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Social Media Ban misses the point- it’s about Algorithms

25 November 2024

Social media is not a fixed thing to be either accepted or banned.

I was surprised to find my son in favour of a ban, thinking it would stop communications between kids. He assured me that with groups able to be formed easily on WhatsApp, kids could still exchange whatever social relationships or information they liked.

It got me thinking about why social media might be harmful. Presumably kids can gang up more easily as they can all see what others write, just as minority groups can find and reinforce each other for good or ill. But this would also be a problem on WhatsApp.

The key point was one that I made a few posts ago. The object of social media is to keep people online so that they will see the advertising and make money for the social media owner. The way that this is done is to put people in touch with people like them or who believe things like them, particularly if their views are unusual. It is also helpful to upset or disturb people as while they are stimulated they will stay online.

The converse of this is that calming people down, or giving them sensible information has no financial advantage.

What viewers get in their feed is determined by algorithms, which are AI (Artificial Intelligence). These algorithms could be set to give good o]knowledge to anyone who asked for it or was open to it. Google searches often give a series of ads where someone paid to be the first thing found in the search, followed by a ‘top pops’ of replies or hits. It could rate the academic reliability of knowledge sources and give greater weight to more credible sources.

The same principles apply to social media. It is about what the object of the algorithm is, and thus what content it favours and directs.

Algorithms are of course ‘commercial in confidence’ which is code for ‘making money and therefore unable to be accessed or interfered with’. In other words, making money is more important than any social distortions or effects are merely tough luck for those affected.
But it seems to me that a more intelligent approach is needed to social media.

It’s about algorithms stupid!

www.change.org/p/oppose-australia-s-proposed-social-media-ban-for-under-16s

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An Explanation of Corruption in the Building Industry

20 October 2024

The key enabler is the privatisation of both the project and the inspectorate.

https://michaelwest.com.au/cfmeu-whistleblower-on-gangsters-unions-and-workers-entitlements/?utm_source=newsletter&utm_medium=email&utm_term=2024-10-20&utm_campaign=Today+s+news+from+Michael+West+Media

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The Australia Card and Data

16 March 2024

The Australia Card debate, which was from 1985-7 was whether we should all carry a card that would link all the information about us.

I was in favour of it because my concerns at that time in occupational health and safety was as to whether exposure to various workplace chemicals had an adverse effect on health.

The best data came from Sweden, where people’s occupation was on a database and their mortalities could be compared. Nowhere else had comparable data.

It seemed to me that the data was going to be collected inevitably and we should have a debate then and there as to who would collect it and what could be done with it.

I was in the Australian Democrats, who were usually quite sensible and given to rational argument, but the view was that people would be safer if the data was not collected at all so they opposed the card and the naysayers won the day in the Party and the nation.

The Credit Reference Association was already collecting data about unpaid bills and there was a debate as to whether the subject of the data, (who was usually only alerted to its existence when they could not get a loan), could have access to their own record to respond with reasons for whatever was on it.

Naturally financial data was of use to the tax office and now buying habits, web-search histories and emails result in changes to the feed of ads on social media.

Now that financial data is collected, the discussion can move on to more socially helpful data.  Apparently Facebook can announce a flu epidemic earlier than the public register of viral tests or hospital admissions just from reading the frequency of the words ‘flu or sick’ on the posts.

In life I have progressed from dealing with acute diseases in heroic medicine and  intensive care settings to looking at how to do prevention. Prevention is always the poor cousin, because if you spend money on it is hard to show results in the short time frame that accountants and politicians want.

As I moved from medicine to social policy and tried to advocate for ‘preventive social policy’ the situation became even more difficult, despite the well known fact that increasingly social disadvantage gives rise to poorer health outcomes. This is acknowledged with lip service, but the late-stage capitalist growth in inequality powers on regardless.

In 2001 as a NSW MLC I initiated an inquiry into DoCS (Dept of Community Services), which was then called FACS (Family and Community Services), and is now called DCJ (Dept of Communities and Justice).  My inquiry showed that the Dept was dysfunctional, which we knew already, and the changes since have not helped much. Initially the problem was that they wanted to concentrate on the children most at risk, which meant still minimal supportive prevention for cases that were not at risk yet.  Then the Department became even more defensive and privatised cases, so the kids became a commodity with NGO and ‘for profit’ corporations getting packages to look after kids with problems and then giving them to carer families for about a third of the money that they were given.  ‘Management’, it seems, is a very expensive and lucrative business.

Obviously looking after kids whose parents are dysfunctional is a very difficult undertaking.  Does one take the child and give it a good foster care family?  What is a good foster care family? How much do you support dysfunctional parents?  Are the grandparents, who presumably brought up the dysfunctional parents a good bet? Who makes the decision and what appeal mechanisms are there?  Presumably all this is rendered ever more difficult by the fact that the gap between rich and poor is rising, there is no longer anywhere near enough public housing, and welfare payments are not really enough to live on.

It seems that the best way to see what policy works is to follow the kids in a lifetime study and see how they turn out. The criticism is that the OOHC (Out of Home Care) system has a hugely higher percentage of kids graduating to juvenile justice and then adult prisons.  But data is hard to get as the Department, despite its numerous renamings, will not release the information as it is politically embarrassing.  Naturally the privacy of the children is cited, but the data could easily be de-identified as much epidemiological data is.

We need to get data to make better decisions, ones based on facts as far as possible, with transparent assessment procedures with honest assessments of what is happening and a minimum of political or bureaucratic interference. With ‘issues management’ aka PR BS getting more sophisticated all the time, it will be an increasing struggle.  The Aust Bureau of Statistics, which tries to produce facts, but can only work with the data it is given and presumably cannot be political in trying to get better data, was significantly defunded by Tony Abbott as part of his war on facts. Meanwhile the private sector hoovers up personal data and a few diehards try to keep using cash.

Ross Gittins, the SMH Economic Editor who generally writes good commonsense in a digestible form and has recently been recognised for his good work, has penned the article below in today’s SMH.

Australia Card anyone?

 

How the digital world is getting better at measuring us up

Ross Gittins, Economics Editor

SMH March 15, 2024

These days we hear incessantly about “data”. The media is full of reports of new data about this or that, and there’s a new and growing occupation of data analysts and even data scientists. So, what is data, where does it come from, what are people doing with it, and why should I care?

Google “data” and you find it’s “facts and statistics collected together for reference or analysis”. The advent of computers has allowed businesses and governments to record, calculate, play with and store huge amounts of data.

Businesses have data about what goods and services they’re making, buying and selling, importing or exporting, and paying their workers, going back for 30 or 40 years.

Our banks have data about what we earn and what we spend it on, especially when we use a credit or debit card – or our phone – to pay for something.

Much of this data is required to be supplied to government agencies. If you ever go onto the Australia Taxation Office’s website to do your annual tax return, it will offer to “pre-fill” your return with stuff it already knows about your income from wages, bank interest and dividends.

Try it sometime. You’ll be amazed by how much the taxman knows and how accurate his data are.

Another dimension of the “information revolution” is how advances in international telecommunications – including via satellites – have allowed us to be in touch with people and institutions around the world in real-time via email and the web – news, entertainment, social media, whatever.

Last month, the Australian Statistician – aka the boss of the Australian Bureau of Statistics – Dr David Gruen, gave a speech outlining some of the ways these huge banks of “big data” about the economic activities of the nation’s businesses, workers, consumers and governments can be used to improve the way we measure the economy in all its aspects: employment, inflation, gross domestic product and the rest.

We’re getting more information and more accurate information, and we’re getting it much sooner than we used to. But we’re still in the early days of exploiting this opportunity to be better informed about what’s happening in the economy and to have better information to guide the government’s decisions about its policies to improve the economy’s performance.

Gruen starts by describing the Tax Office’s “single-touch” payroll system, software that automatically receives information about employees’ payments every time an employer runs its payroll program.

Not all employers have the software, but those who do account for more than 10 million of our 14 million employees.

Gruen says the arrival of the pandemic in early 2020 made access to this “rich vein of near real-time information” an urgent priority. The taxman pulled out the stops, and the stats bureau began receiving these data in early April 2020.

With a virus spreading through the land and governments ordering lockdowns and border closures, they couldn’t afford to wait a month or more to find out what was happening in the economy. Thus, the whole project of using big data to help measure the economy received an enormous kick along – here and in all the other rich economies.

So, in addition to the longstanding monthly sample survey of the labour force, we now have a new publication: Weekly Payroll Jobs and Wages Australia. These data allowed the “econocrats”—and the rest of us—to chart the dramatic collapse in jobs across the economy over the three weeks from mid-March 2020.

They show employment in the accommodation and food services industry falling by more than a quarter in just three weeks. Employment in the arts and recreation services industry fell by almost 20 per cent. By contrast, falls in utilities and education and training were minor.

The monthly labour force survey has a sample size of about 50,000 people, compared with the payroll program’s 10 million-plus people, meaning it provides information on far more dimensions of the workforce than the old way does.

So, the bureau’s access to payroll data taught it new ways of doing things. And the pandemic increased econocrats’ appetite for more info about the economy that was available in real-time.

With household consumption – consumer spending – accounting for about half of gross domestic product, improving the timeliness and detail of the data was a great idea.

So, in February 2022, the bureau released the first monthly household spending indicator using (note this) aggregated and de-identified data on credit and debit card transactions supplied by the major banks. This indicator provides two-thirds coverage of household consumption, compared with the less than one-third coverage provided by the usual survey of retail trade.

The bureau has also begun publishing a monthly consumer price index in addition to the usual quarterly index. This is possible because big data – in the form of data from scanners at checkout counters and data scraped from the websites of supermarket chains – is much cheaper to gather than the old way.

The bureau has also started integrating different but related sets of big data from several sources, so analysts can study the behaviour of individual consumers or businesses. It has developed two large integrated data assets.

The one for individuals links families and households with data sets on income and taxation, social support, education, health, migrants and disability.

The one for businesses links them with a host of surveys of aspects of business activity, income and taxation, overseas trade, intellectual property and insolvency.

The purpose is to allow analysts from government departments, universities or think tanks to shed light on policy problems from multiple dimensions.

For instance, one study showed that people over 65 who’d had their third COVID vaccination within the previous three months were 93 per cent less likely to die from the virus than an unvaccinated person. But that’s just the tiniest example of what we’ll be able to find out.

 

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‘Health Policy’

Chesterfield-Evans, A. (2024)

Journal of Australian Political Economy  No. 92, pp. 98-105.

HEALTH POLICY

Arthur Chesterfield-Evans

Just before the 2022 federal election, Mark Butler, now the Minister for
Health in the Albanese government, spoke to the National Press Club,
praising the courage of the Hawke government in creating Medicare in
1984. His speech also set modest priorities for a prospective Labor
government, committing to (1) improve the digital health record and make
the MyHealth record actually useful; (2) develop multidisciplinary care;
(3) establish a new funding model for ‘MyMedicare’; and (4) grow the
medical workforce, with special mention of nurses and pharmacists (Butler
2022). Significantly, Butler did not commit afresh to Medicare as a
universal health scheme free at the point of delivery, the key element of
the original 1984 scheme that he praised. In an environment where,
politically, it seems that taxes cannot be increased, perhaps this ideal may
be an impossibility, but it is surely significant that it is no longer stated as
an aspiration.

Currently, Medicare is quietly dying as the low rebates cause doctors to
abandon it. Australia is moving to a US-type private system by
default. This has resulted in large amounts of hand-wringing rhetoric, but
so far little action. This short article comments on the changes initiated by
the current Labor government during its first year and a half, contrasting
these with the deep-seated problems needing to be addressed if better
health outcomes are to be achieved.

Labor’s reforms

The government has made some minor changes to Medicare which came
in with great fanfare on November 1, 2023. There were new item numbers

for new specialist technologies or treatments and an increased Medicare
rebate for GPs, up to $41.40 for a standard visit for a RACGP member,
which is 40.6% of the AMA fee. Doctors without the RACGP qualification
still get $21, which is 20.6% of the $102 AMA fee.

When Medicare was born, the Medicare rebate was 85% of the AMA fee.
The rebate has risen at half the inflation rate for 39 years, so doctors now
feel ripped off every time they see a Medicare patient. Labor blames the
disparity on the rebate freezes of the previous LNP Coalition governments,
but its own record is poor. Successive governments of all types have
deferred to the private health lobby and are starving Medicare, slowly
defaulting towards a principally private system, as in the USA. This is a
deeply-troubling prospect because the US health system has been
recurrently criticised (Commonwealth Fund 2021) – and rightly so –
because it makes access to health care dependent on ability to pay. Notably,
however, it is the world’s best system at turning sickness into money.

The other recent Labor ‘reform’ was to allow pharmacists to process
prescribed medications to cover patients’ requirements for 60 days, rather
than 30 days, thereby halving the costs of prescribing and dispensing.
While this may seem helpful, patients are often confused by complicated
generic names and generic brands; and compliance or discontinuation of
medicines is a largely unquantified problem. These are existing problems
with the current arrangements for dispensing medications: the recent
policy change, while well-intentioned, does not redress them. It transfers
resources from professional staff to the pharmaceutical industry.

The ‘Strengthening Medicare Taskforce’ had good medical and allied
health representatives and support. Its December 2022 report defined the
problems but, trying to avoid controversy, positive suggestions were thin
on the ground. A deeper analysis and more comprehensive approach to the
redress of health issues is needed.

Basic problems in the health system

Diverse funding sources causes cost-shifting

Fundamentally, no-one is in overall control of the health system. It has a
number of different funding sources: the Federal and State governments,
the Private Health Insurance industry (PHI), Medicare and individuals

themselves. Workers Compensation (WC) and Compulsory Third Party
(CTP) insurers also put in a bit. These arrangements lead to a situation
where each funding entity attempts to shift costs without any real care for
the overall cost of the system. Private entities such as pathology and
radiology also have an interest in providing more services, whether they
are needed or not.

The broad division of the health system is that public hospitals and
emergency departments (EDs) are State-funded, and non-hospital services
are Federally, PHI or self (patient) funded. There is some overlap,
however, because the State’s provision of some community-based services
allows them to save on hospital-bed days; and private funds paid to State
hospital in-patients are eagerly sought. The starvation of Medicare (which
reduces the Federal government’s spending) has resulted in more patients
going to EDs at higher (State) cost, as well as increasing PHI and patient
costs.

This cost-shifting has evident implications for the affordability of health
care: notably, a recent study showed that Australia, when compared to 10
other countries, scored poorly on its measure of affordability
(Commonwealth Fund 2021).


A new health paradigm is needed

Yet more fundamentally, there is a huge problem with the conceptual
model of the health system. In common parlance, the ‘health system’ is the
‘paying to treat illness’ system. Paying doctors to see and treat patients is
seen as the major cost and is the most politically fraught element in the
system.

Historically, everyone was assumed to be healthy and had episodes of
either infectious diseases or surgical problems. They went into a hospital
for a brief period and either recovered or died. The legacy of this is that
heroic interventions are over-resourced and the more cost-effective early
interventions are under-resourced.

Infectious disease is now relatively uncommon, notwithstanding the recent
and ongoing coronavirus concerns. Most disease is chronic; and the
objective is to maintain health for as long as possible and to support those
who need support in the community rather than in institutions. ‘Health’
must be re-defined as a state of physical and mental wellbeing; and
maintaining it as ‘demand management’ for the treatment system.

Life-style diseases of diet, obesity, smoking, vaping, alcohol, drug-use and
lack of exercise need attention. It might be commented that these habits
are more determined by the political economy of the products than by any
health considerations; and the government should intervene to re-balance
this market failure.


Hierarchies, cartels and corporatisation

The medical system is hierarchical with specialists at the top and GPs at
the bottom. The specialist colleges have produced less practitioners than
would have been optimal. The starvation of General Practice has led to
increasing specialist referrals for simple procedures. Most patients are
happy to go along with this, though often much less happy about the rising
costs. Practitioners tend to work down to their station rather than up to
their capacity. GPs, if given the appropriate additional education and
empowered to act, could do what quite a lot of specialists do now, while
nurses could take the load from GPs; and, in terms of home support, a more
comprehensive and flexible workforce needs to be developed.

Private medical insurance systems are a further source of problems. They
have marketing, churn, profits, liability and fraud issues; and they make it
necessary to account for every item of every procedure. While the
corporations watch every cost, the regulator cannot. Corporations buy
medical practices and take up to 55% of the gross revenue. Smaller
radiology practices are being gobbled up as investments (Cranston 2020).
If overheads are defined as the amount of money put in compared to the
amount paid for treatments, Medicare costs about 5% and PHIs, as they
are regulated in Australia, about 12%. In the USA, the private health funds
take up to 35%, and Australia’s CTP system got close to 50%. A universal
health insurance system could avoid many of these costs and would be far
superior from a social equity point of view.

Similar problems are evident in the provision of care for people with
disabilities. Labor pioneered the NDIS when last in office a decade ago,
and rightly claims this as evidence of its commitment to redress the
previous neglect. However, the NDIS can be considered as a privatisation
of the welfare system. It overlaps medical system functions and is poorly
regulated. If its efficiency is judged by the percentage of money put in that
is paid to the actual workers delivering the service, care is not very

efficient. There have also been significant criminal rip-offs (Galloway
2023).

Retirement care arrangements have major flaws too. Aged-care
accommodation is largely driven by the real estate industry; and access to
continuing care is an add-on of often dubious quality.

What should the government do?

The problems described above are diverse, deep-seated and not easily
rectified. However, a government intent on staying in office for a series of
terms could heed the call for some big thinking, drawing on the experience
of health practitioners themselves. Here is a list of what might be done,
becoming more medical and more politically difficult as it progresses:

Keep people healthy with education, clean water, sanitation, housing,
good food, regular exercise, high vaccination rates, road safety,
universal swimming lessons, CPR and first aid training and the active
discouragement of smoking, vaping, alcohol and drug use, junk food
and gambling.

Provide housing with graded community support options for those
people with disadvantage or impairment. Create a registration and
insurance system for home and community support services, so that
individuals can buy standardised services from other individuals.

Maintain fixed staff-patient ratios related to the disability
classification of residents in institutional care.

Make maximum use of community and school interventions and
support services such as District and Community nurses and School
nurses, mental health support networks, Aged Care Assessment
Teams, Hospitals in the Home etc.

Address health problems as early and as low down the support and
treatment hierarchy as possible, by empowering those who provide
the services.

Create a meaningful regulatory, inspection and enforcement system
for support services, both community and residential, and for
workplaces and recreational facilities.

Use the medical information system to research drug and treatment
effectiveness.
Support General Practitioners and try to increase their ability to solve
problems without referral. Have GPs work in Health Centres with
community support workers as far as possible; and improve
communication with data collection a by-product of normal work, not
an additional imposition.

Have independent evaluation of the numbers needed in the specialties
and pressure the colleges to provide these numbers. Use waiting times
as an initial index.

Initiate either university-based or college-based continuing medical or
professional education, with mandatory refresher exams every
decade.

Have universal professional indemnity insurance, with doctors and
other health professionals unable to be sued if they report all incidents
of sub-optimal outcomes within 48 hours of becoming aware of them,
and participate in regular quality control meetings.

Publicise and promote organ donation, end of life plans, wills and
enduring powers of attorney as sensible steps in life-management.

Evaluate Intensive Care interventions in QALY (Quality-Adjusted
Life Years) terms, researching their outcomes and comparing them to
earlier intervention initiatives.

Change the composition of the Pharmaceutical Benefits Advisory
Committee so that it has no pharmaceutical industry representative on
it; and remove ministerial discretion from its decisions. The previous
system evaluated new drug listing approvals with a cost-benefit
analysis (Doran et al. 2008), but the Howard reforms of 2007,
following the Australia-US Free Trade Agreement and lobbying by
Pfizer, put a drug industry representative on this committee, making
its negotiations more transparent and thus more difficult for the PBS
to negotiate prices (Access to Medicine Working Group 2007).

Work towards replacing Workers Compensation and CTP insurance
schemes with income guarantee schemes (this will only be possible
when Medicare allows timely treatment).

Create a credible and indexed scheme for paying medical
professionals which does not have KPIs that distort performance.
Make Medicare a universal taxpayer funded health system that is free
at the point of delivery and stop subsidising PHI. It might be noted
that the Government currently quotes Medicare and PHI costs
together as a sum rather than itemising the two, which serves to
disguise the subsidy to PHI (Parliament of Australia 2022).

Conclusion
The current federal Labor government has made statements about health
policy reform and done minor tinkering during the first year and a half in
office. Based on this start, it is doubtful that it will have the courage to
make the necessary major changes, addressing the systemic problems.
Fine rhetoric is unlikely to achieve much. That makes it doubly important
to develop proposals for more fundamental reform. Written with this
intention, the suggestions made in this article could be the basis for
tackling the fundamental institutional and political economic issues
problems associated with personal and societal ill-health.

Dr Arthur Chesterfield-Evans trained as a surgeon in Sydney and the UK
and is a Fellow of the Royal College of Surgeons. He currently works as a
GP with interests in workers’ compensation and third-party injury. He has
been a tobacco activist and an elected member of the upper house of the
NSW Parliament. He has Master’s degrees in Occupational Health and in
Political Economy.

chesterfieldevans@gmail.com

References

Butler, M. (2022) ‘Address to National Press Club, 2 May,’ available:

www.health.gov.au/ministers/the-hon-mark-butler-mp/media/minister-for-health-and-aged-
care-speech-national-press-club-2-may-2023.

Commonwealth Fund (2021) US Report, available:
www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-
reflecting-poorly.

Cranston, M. (2020) ‘Radiology enjoys a post-virus buying boom’, Australian Financial
Review, available: www.afr.com/policy/economy/radiology-enjoys-a-post-virus-buying-
boom-20201106-p56c7k.
Doran, E., Henry, D., Faunce, T.A. and Searles, A. (2008) ‘Australian pharmaceuticals policy
and the idea of innovation’, Journal of Australian Political Economy, 62, pp. 39-60.
Galloway, A. (2023) ‘Federal crime syndicates using cash vouchers and gifts to steal NDIS
funds’, The Sydney Morning Herald, available: www.smh.com.au/politics/federal/criminal-
syndicates-using-cash-vouchers-and-gifts-to-steal-ndis-funds-20230414-p5d0ma.html.
Parliamentary Library (2022) Health overview, available:
www.aph.gov.au/About_Parliament/Parliamentary_departments/Parliamentary_Library/p
ubs/rp/BudgetReview202223/HealthOverview.
PBS (2007) ‘Access to medicines working group’, available: www.pbs.gov.au/info Access to
Medicines /general/working-groups/amwg/amwg-jul-2007.
Sax, S. (1984) A Strife of Interests: Politics and Policies in Australian Health Services,
Sydney: George Allen and Unwin.
Searles, A., Jefferys, S., Doran, E. and Henry D.A. (2007) ‘Reference pricing, generic drugs
and proposed changes to the Pharmaceutical Benefits Scheme’, Medical Journal of Australia,
187(4), pp. 236-39.
Strengthening Medicare Taskforce (2022) Taskforce Report, Commonwealth Department of
Health, available: www.health.gov.au/sites/default/files/2023-02/strengthening-medicare-taskforce-report_0.pdf.
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Hospital Crisis is just part of the story.

6 November 2023


The hospital crisis is partly because General Practice has been so downgraded that more cases go to hospital than need to. The Federal government starving Medicare has a number of consequences:
Many GPs are simply retiring and there are no enough new ones taking their place, so we are getting towards a serious shortage
GPs cannot survive on the Medicare rebate, so now charge a co-payment.
Since Emergency departments are free, people wait until the situation gets worse then go there.
Emergency Depts are about 6 times the cost of GP visits, so the total cost of the Health Care system rises.
The other part of the Federal government starving Medicare is that the State governments pay for the emergency departments, so it is a case of the Federal government saving money by making it a lot more difficult for the States.
But an overriding fact is that Australia has been convinced by the neo-liberals that tax is a bad thing and government spending must be a small percentage of GDP. Currently this is about 38.4% of GDP, slightly less than the USA, which has very poor welfare and health systems. This means that the governments cannot actually afford to do anything, and behave like a corporation, cutting employee wages and making cuts wherever it thinks no one will notice, or it has the power to do so. Now if Labor ever tries to raise taxes, the Liberals, who are great exponents of small government accuse Labor of being ‘tax and spend’, and Labor, rather than have a serious debate merely retreats. The fact that he Scandinavian countries have government as close to half of GDP and have their citizens much better off never gets mentioned. Denmark is at 49.9%, Germany 49%, Finland 54% and France at 54%. The UK is at 45%.
We now have a failing GP sector, a problem in aged care, a shortage of nurses, paramedics on strike, a hollowed out public service that merely awards its former tasks to private sector operators that it cannot even monitor and Australia falling down the World educational standards table is not a coincidence. The governments have a virtual monopoly of these jobs. They have deliberately let wages fall, so that now people simply will not do them.
We need to stop privatising, rebuild that public sector so that it can deliver services that we need. Profit is merely another unnecessary overhead. We need to decide what needs to be done, and raise enough tax to pay the people to stay in their public service jobs. Education, health and aged care do not need a ‘market’ to function/. If one exists for comparison purposes, that is fine, but there is no actual virtue in having most of the services delivered by corporations that have the choice of good service or good profits. It is a con, and it is time we forced the government to give us Medicare and a health system that actually works for all, and education for all.
Here is a letter from my Medical partner in today’s Sydney Morning Herald.

The horror stories now emerging about overloaded public hospitals, ambulances and emergency departments comes as no surprise to anyone following the downgrading of Medicare to a ‘‘mixed billing’’ system. This has made it unaffordable for many people to see a GP. But the real cost of turning Medicare into a two-tier system has been to the public hospital system. The only winners are private corporations, private hospitals, private health insurance funds and their many lobbyists in Canberra. We are going the way of the US, and if people don’t fight for Medicare, we are all doomed.
Con Costa, Hurlstone Park:


Here is today’s Herald Editorial

Health system needs its own emergency care
The state of health of the health system has dominated the lives of Australians for four years, but it has never been in such need of urgent care. Indicative of how working conditions for frontline healthcare workers have deteriorated, people now spend a median of three hours and 36 minutes in NSW hospital emergency departments, the longest wait ever. It’s little wonder that health workers are suffering burnout, stress and bullying and are leaving the industry in record numbers.
The COVID-19 pandemic sharpened awareness of our vulnerabilities and forced extra spending on hospitals, clinical responses, vaccinations and prevention measures.
And when we emerged from the pandemic’s worst days it became evident the health system too was experiencing difficulty recovering from years of stress. It had been deteriorating for a long time already, but post-pandemic we became uncomfortably aware that ambulances were queueing for hours to offload emergency patients and hospitals were under enormous pressure with lengthy wait times in emergency and admission.
GPs bumped up fees, forcing people who could not afford the $11-a-visit hike into hospital emergency departments. The industry is being further destabilised by the exodus of 6500 nurses and midwives a year.
If anything, the situation is worse outside the big cities. Last year, for instance, five deaths in regional hospitals could potentially have been prevented, but not in an overworked hospital system with staff shortages that make mistakes even more likely. The NSW parliament’s health portfolio committee report on rural, regional and remote health 18 months ago found a ‘‘culture of fear’’ which did not encourage or value feedback and complaints. Some workers say they were even punished for making complaints.
Now an investigation by the Herald has revealed a health system sinking further into crisis. Eight nurses and midwives have taken their lives in the past three years, while nearly 2000 NSW Health workers have lodged compensation claims for psychological injuries over the past two years. More than 33,500 NSW Health employees have also claimed they are burnt out, while 21,000 workers say they have witnessed bullying in the workplace. One in 12 ambulance employees hold a compensation claim for a psychological injury.
Experts and unions warn that the data, drawn from documents obtained exclusively under freedom of information laws and the state government’s recently released annual employee survey, People Matter, shows a workplace struggling with staff mental health concerns.
Further illustrating the stress, NSW Ambulance fielded a record 363,251 calls and fired up the lights and sirens for more than 181,000 emergency call-outs between July and September, the most of any three-month period since the Bureau of Health Information began taking records in 2010.
Money seems to be the root cause of health’s problems. Today’s national cabinet meeting will address the rampant cost blowouts in the NDIS and Canberra wants the states to take responsibility for funding treatments. On Friday, Premier Chris Minns and Treasurer Daniel Mookhey meet the Health Services Union over a protracted pay dispute threatening to collapse the NSW triple zero call system on New Year’s Eve. Minns said the money is not available.
The future funding and structure of our health systems concerns us all. It is an area where the federal and state governments share responsibility. The solution to the healthcare crisis is complex and will take time, but it is an area where increased funding must be found.
That clearly calls for a better national approach and the states responding with an end to parochial wheelbarrowpushing and finger-pointing.

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Apartheid Education Buses

23 November 2023

I live near a turning circle in a good area of Sydney.  There is a Bus Stop there and the government bus there has an ad with a picture of a forlorn looking schoolgirl saying that she cannot have a decent education, so would I donate to The Smith Family so she can.

As the ad displays there, 8 shiny new buses take private school children from the turning circle to 8 different private schools.

It seems that our governments are happy to subsidise ‘choice’ so that they do not have to fund a fair go and we are happy to tolerate an apartheid education system.

 

www.theguardian.com/australia-news/2023/nov/23/australia-100-wealthiest-schools-earnings-income-data-education-department?utm_term=655e79e42ab1fedfc11542549409ff2e&utm_campaign=AustralianPolitics&utm_source=esp&utm_medium=Email&CMP=aupolitics_email

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Climate Change- a Depressing Update

23 November 2023

In Australia the Labor government struggles mightily to get legislation through to allow Woodside to pipe carbon dioxide to East Timor’s territorial waters for supposed CCS (Carbon Capture and Storage) to allow them to develop a new gas field. East Timor is not a signatory to the Paris Accord- convenient eh?  Supposedly the carbon dioxide will be pumped into a reservoir that used to have gas, but Woodside has a track record of not meeting its CCS targets; if you think CCS is a real thing and not a cop-out farce.

 

Evidence suggests that the world is on target for a 3 degrees temperature rise, which may make human life unsustainable in its present form.  Petrostates are installing lights at beaches so that people can go for a night swim to cool off because it is too hot in the daytime!

 

The graphs below show world energy consumption tripling since 2000 and continuing that upward trajectory.  If one considers that the production of energy by a human is about a kilowatt a day, one realises that the amount of energy consumed now per person is many times that, and far higher in developed countries, the situation is unsustainable. The invention of the steam engine in 1690 and the internal combustion engine in 1872 and the use of fossil fuels, which has resulted in the energy and carbon dioxide stored as carbon over tens of thousands of years being released in a century.  It is ridiculous to think that reforestation can capture this amount of carbon as the total area of forests in the world is still declining.

 

COP28 (the 28th Conference of the Parties) of the UN Framework Convention on Climate Change (UNFCCC), will start on 30 November in the United Arab Emirates (UAE), chaired by Sultan Al Jaber, the CEO of the UAE state oil company ADNOC. How much good is this likely to do?

 

COP-out: Why the petrostate-hosted climate talkfest will fail

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