JOHN DWYER. The curse of political mediocrity; the informed, bold, courageous policies that Australia needs in health are nowhere to be seen (Part 1 of 3).

This “fair go mate” country of ours is wealthy but in reality ever less egalitarian. Increasing Inequity is palpable and most notable in the problems we have with housing, education and health. Health outcomes for Individuals are increasingly dependent on personal financial wellbeing. Australians are spending about 30 billion dollars a year to supplement the care available from our universal health care system. Many, of course, do not have the resources to to cover “out of pocket” expenses. Many of these problems have become chronic as political intransigence inhibits the development of bold, informed and even courageous policies. Policy development, such as it is, is often insular, ignoring the successful tactics of other countries in addressing similar problems. The Commonwealth Fund, which compares the worlds health systems for quality, is critical of our efforts to swing our health system around to focus on the prevention of disease. Eleven other OECD countries are currently doing a better job than we are.How can we change this unsatisfactory situation? PART 1 of 3.

The catalyst for these ruminations was Bill Shorten’s Press Club speech addressing private health insurance (PHI).  For a moment it looked as if he was considering abandoning the taxpayer support for PHI if elected. The response from the insurers and the government was vitriolic and soon Mr. Shorten was announcing that Labor would not remove the subsidy. Of course Labor knows just how much more health could be purchased with the nearly eleven billion dollars of support the highly profitable insurers enjoy but, oops, the backlash saw a retreat from such a position. This in turn left the Labor leader looking weak so he responded to this pressure with a promise that he would cap increases in the cost of PHI to two percent for two years.Surely most of us are frustrated by all the excuses our politicians trot out to explain why they cannot support bold initiatives no matter how evidence based they are. “ Politics is the art of the possible” or “I can’t do anything for you if I don’t get elected”. All too often it seems that our short election cycles confine political thinking to how one might get an immediate “pat on the back” as tactics to stay in power dominate. In this climate vested interests and generous donors can  readily perpetuate the status quo.

A current problem illustrates this issue. Many of us who are advocating for healthcare in Australia  to be underpinned by credible scientific evidence of clinical effectiveness, are frustrated as health care fraud is rampant in our country. Unsubstantiated or false claims being made in advertisements for “supplements” and vitamin preparations have  many Australians spending $80 a month on such preparations which will provide the majority with no benefit at all. The supplement industry is hugely profitable and donates generously to political parties. Although obviously far from perfect, at the moment advertisements making therapeutic claims are subject to pre-vetting by agents contracted to do so by our Therapeutic Goods Administration (TGA) and there is an independent Complaints Resolution Panel (CRP) that adjudicates when advertised claims are challenged.

The TGA which is 100% funded by the industries it supervises (what a conflict of interest)  tells manufacturers that they must hold evidence for the claims they make and that random checks will look for compliance. Those random checks routinely find that in 80-90 % of cases there is no such evidence. Despite this, the industry push for more self regulation and less TGA oversight has been successful. Despite vigorous campaigning by many public health experts, the Consumer Health Forum, Choice magazine etc. the government has agreed to abandon the pre-vetting of advertisements, disband the CRP and allow the labelling of products to use “As used traditionally” to provide satisfactory evidence for effectiveness. All too prevalent is the self-serving promotion of the idea that you can neutralise an unhealthy lifestyle with something from a bottle! Wither consumer protection?

How could we embolden the political process so that the fear of an immediate and politically damming backlash from vested interest won’t stop progress before its started? A longer federal election cycle would certainly help but in my opinion, a key is the presentation of a desired outcome in terms of an appropriate  long term strategy. If Labor was to announce that if elected, it would abolish the PHI rebate all hell would break loose but if Labor was to announce a ten year program to achieve the needed structural reforms to our health system among which would be the gradual phasing out of the PHI rebate as better primary care initiatives took pressure off public hospitals the response would be quite different. Inherent in the message is the concept that only when related initiatives have been successful will the rebate disappear. Of course the needed structural reforms and the advantages that would follow need to be explained. As Reserve Bank board member Heater Ridout said on a Q & A recently ten year plans, clearly outlined, take the wind out of opposition.

Inherent in successful change management are clear and exciting visions for outcomes, initial “coalitions of the willing”,bottom up modelling, a change management instrument (for health the Health Care Reform Commission so often discussed herein) and transparency and flexibility. When it comes to improving healthcare, a matter of great importance to everyone, I am convinced that the plans need to be presented to Australians as a “Big Conversation” initiative, in this day and age using everything from “Citizens Juries”, Town Hall meetings and of course social media. Its almost 15 years since I had the opportunity to tour Australia as a result of a University of Queensland initiative, participating in public meetings to ask Australians what they wanted from their health system. We listened and presented a model emphasising prevention, equity, and many other desirable changes to our system and the response to the exercise was overwhelmingly positive. Politicians take comfort from the use of focus groups to determine what the punter wants. This is the same idea but far more inclusive.

Though health literacy in Australia is distressingly low there are many frustrations understood ( experienced) by the majority that would have them support change. The never ending argument between State and Federal governments re health care because of the wretched jurisdictional division of responsibilities that is so damaging to integrated cost effective care, the exorbitant out of pocket expenses required  for adequate care, the inequities in the provision of health care to rural communities, lack of a government funded scheme for oral health etc.

So while it may all sound utopian we need to seek a partnership between government, the health professions and the public to promote the transition to a shared vision. In 30 years of advocating structural reforms needed for better, fairer healthcare in Australia, I have not seen a better time to promote change, for many of the crucial players are ready to embrace reforms for which there is now a consensus. We now need to flesh out and present for debate just what we believe should be the characteristics of Australia’s Health system in ten years. I will discuss in some detail my vision for the journey and the outcomes desired in parts 2 and 3 of this presentation.

Professor John Dwyer is an Emeritus Professor of Medicine at UNSW and has been involved in the promotion of structural  reforms to Australia’s health system for many years. He was the Founder of  the Australian Health Care Reform Alliance.



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