Health - an awful 'debate' and meaningless 'reforms'

• We were second worst in the numbers who skip tests or follow up.
• We were the third worst in the numbers who do not fill prescriptions or who skip doses.
• We were third worst in the numbers who pay more than $US1000 for their care in one year.
• We were the fourth worst in the numbers of people who do not see a medico when they are sick.
• We were fifth worst in being able to access after- hours care.

Added to that we have black Australians living twenty years less than white Australians and with worse levels of almost everything that can be measured.

If we want a better system we need to get this awful debate back on track.

Coherent rationing is essential if the system is to survive and if the system is to have the capacity to introduce anything new.

We do not have an honest debate about rationing now. No-one talks openly of what we can and cannot do, what we will and will not pay for - and essential rationing decisions are made "off stage" by people the general public might not select and away from the people who bear the effects of the decisions.

For example, a decision that only so many hip joints will be made available to orthopods in any month, rations the number of hip replacements any hospital can do, or the Victorian decision a few years ago that uncomplicated cataract removals could not be paid for in public hospitals, was a rationing decision.

Queues are a form of rationing. The non availability of beds is a form of rationing. Waiting times in emergency departments or for tests are forms of rationing. Limitations on operating time are a form of rationing. And so on.

In some overseas jurisdictions citizen juries listened to learned counsel arguing for or against certain interventions - after which they voted on the alternative initiatives. A much better idea.

However there are necessary but unpopular interventions - things like treatment of drug addicts, or the care of people afflicted with HIV/AIDS, or measures to prevent unnecessary hepatitis C infection, or mental health expenditure. These are interventions that people may not want to vote for - but which a compassionate society should provide.

Some publicly funded procedures will have to go or be limited in number so that other procedures can be accommodated or introduced. I call this rational rationing. And as our clientele becomes older, we might have to consider withdrawing public funding for some procedures at certain ages. For example, we might decide to withdraw public funding for certain cardiac procedures at (say) the age of seventy-five. There are many more examples.

A friend was told that if he had been two years older, his cardiac valve replacement would not have been done. So age-related procedure withdrawal already exists. This approach might outrage some people, but it frees resources to treat others - to do hernias and cataracts and prostates and varicose veins and provide good quality palliative care for more people.

We cannot do everything possible for everyone. That unpleasant reality must become part of the public discourse. The sooner we decide what we will do and for whom we will do it, what we will not do and for whom we will not do it, the better off we will be.