Health care: good, better, but for goodness sake give up on ‘the best’!

So let’s skip to what to do.

The private sector needs to be reviewed and almost certainly scaled down - maybe severely. To try to run health services on the basis of the same values as one would a potato chip industry seems at best odd, at worst downright divisive and dangerous. If all or most of the money were in the public sector (as in various other countries such as Denmark), then the rich and powerful would be pushing for more and better public services thereby creating pressure to have more and better services for all.

Who wants private care? Well clearly many doctors do as it affords them excellent pay. Even those who do work, at least part time, in the public sector often tend to see that work as charitable. (That is perhaps understandable as one said recently he could earn in one day in the private sector what it took him the rest of a fortnight to earn in the public sector.)

Do the public want private care? Do we want “choice”? The government tells us we do. But do we? Where is the evidence?

OK there has been an increase in private health insurance cover but only in the wake of “kickbacks”, which are now costing the taxpayer $3 billion a year. Why do we need bribes to take out private health insurance?

What is crucial is to accept that there needs to be some agreement in Australia about what we, as a nation, want from our health care institutions; then we must decide how to get that; and then how to fund that.

There have been few attempts, however, to grapple with these issues. In particular we need to know what the nature of the “good” is that people want from the social institution of health care. That is the starting point for trying to do better.

My own experiences in facilitating citizens’ juries are relevant here. Ordinary citizens, randomly selected, given good information, want greater equity; more resources for Aboriginal health; more for public health and prevention; and more for mental health. These areas are not where the private sector is strong: they are where the public sector can excel.

The problem is that the public’s voice is drowned out by the medical profession, who see the determining of objectives and priority setting as being too important to be left to the ordinary punters. That is simply a statement about power. There is a need to get the public educated in the politics of health care; to recognise that while medicine is a noble profession, many doctors have lost faith both in the system and in their calling; that the public system can deliver what the punters want; and the private system cannot.

Too little debate takes place about priority setting in Australian health care. We need an Australian Romanow.

It is of note that this Canadian review was quite breathtakingly detailed and comprehensive. For example, as just one of 40 papers commissioned, (pdf file 1.08MB) together with a colleague I was asked to look at three questions:

1. What should be the criteria for determining whether a program or service should be wholly, partly or not publicly financed?
2.  Which Canadian policies and approaches are most consistent with these criteria and which are least defensible?
3. Where in general should public financing be extended and where might it be reduced?