A healthy future

Kevin Rudd has a vague idea about taking over all public hospitals if the states fail to use wisely the billions of dollars he is prepared to offer them to make hospitals better. John Howard has bought a public hospital from the Tasmanian Government and plans to hand it over to social sector management.

Some merit can be extracted from both approaches but the changing realities of health care require much deeper thought. The idea that everyone has a “right” to all available medical treatments is now out of date so procedures for rationing must be decided. But a “market” approach is not the answer, as proved by the failure of the US health system. The integration of care from varied health providers is required, and administrative reform using new technology to cope with new realities is overdue.

Australians are generally living longer and healthier lives, despite the media obsession with death and disease. Between 1970 and 2002 life expectancy at age 65 increased by 50 per cent for men and 30 per cent for women. At the end of that period a man of 65 could expect to live another 18 years and a woman another 21 years. (Longevity and Social Change in Australia. Borowski, Encel and Ozanne.)

Some of the improvement was due to better health care but changes in lifestyles were also very significant. People smoked less, drank less, had less accidents, and so on.

As a result, when the topic is hospitals the focus is increasingly on old people. In 2002 people over 65 made up 13 per cent of the population but took 38 per cent of health expenditure and 47.6 per cent of bed-days in public and private hospitals. As the baby boom generation move into retirement, and further improvements are made in the health of younger people, the health system will increasingly be focused on elderly patients.

The growing importance of personal efforts to stay healthy and the increasing sophistication of medical treatment raise questions of entitlement. Should people who make efforts to remain healthy and uninjured pay for the obese, the smokers, or the drug addicted drunks to spend months in hospital? Should there be any expectation of personal responsibility and penalty for inadequacy?

How do we draw lines for funding surgery that can be considered cosmetic or optional? How much money should be spent on treatment for people with very limited likely lifespan? If a patient is 90-years-old and has dementia, is it worth spending a million dollars for treatment to extend their life by six months?

(Some years ago a woman with terminal cancer was given a hip replacement. Did she benefit or the surgeon? Recently a South Australian hospital announced it would bar obese people or smokers from liposuction and body contouring treatments until they could prove they were going to change their lifestyle.)

The other big issue is the need for an integration of the treatment of various ailments suffered by the chronically ill. The institutional structure of medicine is aimed at curing specific problems. But as hospitals become more focused on older patients and people with many serious problems there is a growing need for a “patient manager” to co-ordinate treatments. Medications prescribed for each ailment can conflict and cause additional problems, or simply be unnecessary. Even scheduling GP and specialist visits, therapy sessions, and the taking of medication can be a problem for some patients.

There are already moves to provide better links between GPs, hospitals and other medical service providers but only a new national institutional structure will provide a complete answer.

It is the third area of change, administration, where most public attention is focused. There are about 750 public hospitals around Australia and the states and Commonwealth each provide about half the total funding for them, though lately the states have been a little more generous. Rudd’s suggestion of a Commonwealth takeover would provide one centre of responsibility. That would save money and also facilitate the integration of care and finance provision that is a prerequisite for complex medicine. But Howard’s idea of community involvement in the administration of hospitals is also needed to provide alternative views to those of the central bureaucracy and of the senior doctors who dominate the huge hospital complexes.

In all three areas, of entitlement, integrated care and administration, there has been extensive expert debate and research. Early steps have been made in some state systems and by the Commonwealth. It is now time for national leadership to make total systemic reform. That will not happen while politicians think that throwing our money at the problem is a solution.