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"...public opinion deserves to be respected as well as despised" G.W.F. Hegel, 'Philosophy of Right'

health care reform: a suggestion « Previous | |Next »
October 6, 2005

Ross Gitten's op. ed. in yesterday's Sydney Morning Herald is about health care reform and the Productivity's Commission position paper on the health workforce. It is unusual because there is little commentary on health care reform in the media. What we have is a health poltics based on newspaper headlines about huge hospital queues. not health policy.

Gittens starts his op. ed. on health policy by noting the significance of health care reform:

If you want to see the future, think health care. Report after report tells us the health industry's likely to be one of the fastest growing parts of the economy and the factor putting most upward pressure on the taxes we pay. Now we learn that health care's likely to be one of the areas of most pressing labour shortages.

Health care reform is big --it is much bigger than the much heralded waterfront reform of the 1990s. But you would not know that from the media.

Gittens grasps a key problem of health care as it is analysed by economists. He states that spending on health care will continue to rise as demand increases, and outruns supply of the services provided by the health care workforce. This disequlibrium will deepen because the shortages of the health workforce will get worse. Gittens says:

So, if we're almost certain the health system's present shortages are set to get a lot worse, what should we be doing?The obvious answer is spending a lot more money on extra training places...But it's equally obvious that such a response won't be adequate... merely throwing more money at problems quickly gets to be too demanding on the pockets of the taxpayers supplying the money. So the Productivity Commission's main message is that we should be doing a lot more to raise the efficiency with which people are trained and used in health care - which would, of course, raise their personal productivity.

What does efficiency and productivity mean?

Gittens addresses this by pointing to the direction in which health care reform needs to go: --that we ought to be investing a lot more of our effort on health promotion and preventive medicine. The health care focus needs to shift from acute illness and hospitals to good primary care. That shift is a big reform. Very big.

Will it happen?

Gittens grasps the central blockage to this pathway of reform: the patch protection by doctors and specialists. He gives a classic example:

Then there's the way doctors try to hog all the tasks (and the income that goes with them) - always in the name of preserving the quality of treatment and the safety of patients, naturally. Take the celebrated attempt to have properly trained "nurse practitioners" take over some of the more routine tasks performed by doctors. Doctors have resisted this all the way, and still are. From the initial investigation of the concept in the early 1990s, there are still only a handful of nurse practitioners in Australia.

There are plenty of other examples: the resistance to midwives, the GP's refusal to refer patients with muscloskeletal conditions to chiropractors, and the denigration of allied health care professionals by orthodox medicine. Efficiency means removing these blockages.

Gittens notes the way that the Medical Benefits Scheme reinforces "medical dominance ", as it is premised on doctors doing things that less trained (and less expensive) health professionals could do just as well:
Because most services provided by other health professionals and nurses are excluded from a Medicare rebate under the scheme, many patients prefer to have the service provided by a doctor. Doctors should be able to delegate routine tasks to other professionals - possibly working for the doctor - but, if they do, no one gets a rebate.

Thus we have the wasteful allocation of scarce resources. So you can see why Treasury and the Productivity Commission are interested in, and are driving, health care reform in the name of efficiency and productivity.

What Gittens does not address is the different pathways of primary health care. Not every allied health professional wants to be deskilled by working in a GP practice. Health care reform would recognize, and accept, that allied health care professionals can provide a different primary care pathway to that of the GP's. Gittens, by remaining too doctor focused, does not see the big consumer shift to a lifestyle or wellness conception of primary health care. It is this conception of primary health care that will lead to big productivity gains within the health workforce.

| Posted by Gary Sauer-Thompson at 7:21 AM | | Comments (25)


I agree with that. Primary care should be like pep-boys or jiffy lube. Cheap and fast. It will also mean wresting that responsibility from doctors if it is to become cheap and fast.

'cheap and fast"?

It should also be effective. Are we not looking for a primary health system that delivers better health outcomes as well as being cheap and fast

Gary, Yes, cheap and fast. Improved efficiency and productivity lead to that outcome. Health professionals need to have their labor market, and education market expanded as well. I have not needed a doctor in the last five years (not since I broke my leg), but I have needed health professionals when I have had health issues (including getting shot with steroids to stop a bout of poison ivy).

Health can be broken into two parts. Preventive and catastrophic. Insurance works for the latter, but not the former, which is part of the reason why the US health system isnt working. It is reliant on insurance, and this makes the preventative too expensive, and administratively driven.

The preventative should be like a chain restaurant. Similar aulity of service and expectation no matter what health professional I visit. It should also be quick (10 mins max), cheap because of the quick visit and the wide choice of health professionals (no more than an oil change IMO). If it costs $50 AUD, I will go more often, probably as often as I get the oil on my car changed.

Hi Gary,
The problem of hegemony with bio medicine is not overlooked. As you report, the issue is getting bigger as iatrogenic problems increase.

The shortage of good community funded health care will continue to become more obvious as GP's work less hours. The answer is simple.

Allow all registered health providers access to community funds. One stroke of the pen will do it. They have all completed the tasks the community expects of them in regards to accountability, education, registration, CPD and ethics. We are all here waiting.
Now, someone please make a decision!

I remember what Bruce Shepard said when he was AMA president: "We cannot stop Chiropractors from working, we can stop them from getting public money." We call this "containment".

Allow the community to access the health care they want. Whoever does the job best will get paid. A free market works best.

PS. The small type on your website is hard to read. Please increase the font size.

why should preventative health care be like a chain restaurant, rather than a collaborative network of allied health professionals.

I'm not sure that dealing with obesity or painful back is no more than an oil change.

Nor do I think that the human body is equivalent to a car. For instance, one is organic the other is mechanistic. The former is self-determining whilst the latter requires a driver.

you are right about opportunities opening up due to the shortage of doctors and iatrogenic problems increase. Things are beginning to shift.

You then write:

The answer is simple. Allow all registered health providers access to community funds. One stroke of the pen will do it. They have all completed the tasks the community expects of them in regards to accountability, education, registration, CPD and ethics. We are all here waiting.Now, someone please make a decision!

This pathway is what has been blocked off by Treasury. Rising health care costs for publicly funded health services are what needs to be reined in.

Chiros need to be clever. They need to find positive way ways to help reduce health care costs and to improve health outcomes.

What do you suggest?

Gary, We are using different definitions of quality.

Gittens seems to have come up with similar findings to Manga's Ontario health commission study from the mid 90's. The problem will be getting the GP gatekeepers to allow reform without them being seen as "losing face".
The containment by the medical profession in Australia of allied health has been much smarter tactically than what I have seen in other countries.

good health policy should reduce costs and improve health outcomes.That is my understanding of quality---you need two legs in Australia.

If only it were so.

There is talk by the Productivity Commission of breaking down patch protection, work force subsitution as ways to improve the efficiency and effectivenes of the health workforce so as to make it more response to changing health care needs.

But we are a long way from the Pan Manga kind of Report about the effectiveness and cost effectiveness of chiropractic care for musclo-skeletal disorders.

Do you know if the Manga report is online?

Dear Gary,

Have you read "Medical Dominance" by Australian sociologist Even Willis?

He documented how the allopathic medical profession dominates other professions, such as chiropractic and midwifery, in Australia.

I like this new CAA member service!


Dennis Richards

Yes I read the Willis text many years ago. It was medical sociology from memory. Willis argued that 'hierarchy preceded technology' with the medical profession achieving its dominance over the Australian health system by the 1930s, and that it has defended this dominance against other health care occupations since.

I always thought that it was pretty accurate in its big picture account of medical politics in Australia. ‘Medical dominance' is the general term used to describe the power of the medical profession in terms of its control over its own work, over the work of other health workers, and over health resource allocation, health policy, and the way that hospitals are run.’

Willis explains how the doctors have used tactics of subordination, limitation, exclusion and more recently incorporation to ensure the continuance of medical dominance. Medical dominance has to with control over their own and others’ work and knowledge base, the clinical role of diagnosis and treatment and the requirement that doctors request and supervise other health practitioners.

Although initially effective in excluding chiropractors, the latter struggled and campaigned on, so now they are able to practice but chiros have been contained to treating musculo skeleto conditions and not holistic health care.. Chiros have been excluded in that they do not have the legitimacy: very few doctors recommend or refer a patient to a chiropractor, research money is not used on their methods or clinical practices, and they are not part of Medicare though private insurance covers their treatment regimes them under 'extra benefits.'

If orthodox medicine has historically maintained a position of dominance and power within the health care system, then there are signs that contemporary social trends such as managerialism, proletarianisation, and the corporatisation of the health care system are resulting in challenges to medicine's traditional power.

In Australia we are seeing various signs of declining medical power associated with an increasing interest in alternative health management and intraprofessional competition.

The response by doctors is interesting. Unable to exclude alternative healing practices because of public demand, medicine has tried to incorporate some of these therapies. You will find doctors who have done acupuncture courses (much shorter than the usual ones), who have studied naturopathy, iridology, psychology and so on. Rather than risk losing clientele, doctors have sought to incorporate the ones that seem most helpful, so they can be seen as multi-skilled.

Quackery is now inside the medical profession. Ii always was but it was not widely recognized as such.

In this interesting discussion ensuing, one may ask the question: What actual "protective effect" has been afforded chiropractors in being largely outside the medically dominant system? Has denial of research dollars (accounatbility?), public prestige (patriarchal), and inclusion of self-generated marketing and clinical-results-driven promotions actually allowed the profession to survive for a century?

Is remaining outside the system, along with political advantage such as government registration since 1978, and educational status such as the double-degree program, actually a desireable state that GPs many envy increasingly in the future?

I certainly see the value for my patients of becoming more mainstream, but then when one views products such as the niche markets that brands like Porsche, Apple, Nutrimetics or even something as antithetical (in healthcare) as Red Bull offer consumers, where is the real wisdom in joining the sinking ship?

It is not a case of joining the sinking ship--which I presume is the public health care system.

However chiros are part of the health care system as they provide primary care in a different way to the GP's. Is this not so?

The argument is that good primary health can help to reduce public hospital costs and the costs of the PBS.Is that not the general claim by chiros with respect to holistic health care and wellness?

So in what way can the holistic/wellness model of primary healthcare help Australian consumers stay well and healthy?

If the answer is yes, then do chiros actually walk the holistic talk in their clinical practice?

Dear Gary,

Thank you for your comments re the book "Medical Dominance". I am impressed that you are familiar with it.

Would you happen to know if Canberra public servants in general are aware of the book and the type of information in it?



I guess, once again, Gary, it comes down to research dollars coming our way. The clnician (me) finds it very, very demanding to conduct research and direct a clinical practice. The chiropractors have done an amazing job of generating research funds through ASRF ( but this is not enough? Even beyond the so-called "wellness" model, I suspect chiropractic works on certain conditions and syndromes even better than designated accepted "treatments". Eg: I'd like to see a study comparing 1000 or so children with chronic ear infection undergoing antibiotic therapy or specific chiropractic care.

Dear Gary,
Thank you for your work thus far, it promises to be rewarding for a large number of fellow Australians.
To be included in the outgoings of the public purse it seems we need to be confidently seen as a cost-effective alternative or more realistically, a co-management option, by Treasury. The political rallying needed to place it on the agenda is obviously important and is rightfully in your domain and those chiropractors who have the energy and tenacity to cope with 'the system'.
My comment would be an equally important issue is in the question, 'Are we ready as chiropractors to be included?' Medical containment does not have the capacity to lower our standards of practice even if it attempts to challenge its scope. Have we though settled in comfort on the outside of a potentially complex health system because our clinics are busy?, and in the process (through possible professional arrogance) failed to extend our responsibilities to working with our other local primary care providers for the best possible management of the patient. If the answer is yes, we do not deserve to be funded. If I was in Treasury I would say 'let us not open the can of worms while the worms are happy because we are not sure if they would provide a quantifiable difference anyway' As a chiropractor who tries to provide co-managed care I would argue desperately we do make a quantifiable difference! I just do not have the figures with me today!
Does the DVA inclusion of chiropractic care provide the HIC a means of identifying the actual difference in health care costings? I realise the DVA scenario is a relitively narrow selection of the population but it would be interesting to hear of any feedback or dare I say 'goss' from inside the walls of the bill makers in their perception of chiropractic in this model.
Thanks for your time, keep at it.
Cheers Shawn McLindon.

it is an old book.The concept 'medical dominance' is not used but what it refers to to--relations of power-- is well understand.

The doctors have real power, it is difficult for governments to break that power to reform the health system and the AMA is about union power ruthlessly protecting its patch.

The Canberra bureaucracy divides ar this point: some act to defend medical dominance others seek to push it back.

I cannot see research dollars coming your way in the short term, and it is not just because of medical dominance.

Chiros, and allied health practitioners in general, have to develop a research culture in the universities. That means lots of postgraduates on top of the undergraduate training to run a clinic as a small business.

It strikes me that the allied health professionals want the research dollars without doing the hard yards of getting the PhD. Those that do obtain PhD's are not really recognized as something more than an ordinary practitioner.

That indicates little by way of fostering a research culture is being done.

you write:

"Have we though settled in comfort on the outside of a potentially complex health system because our clinics are busy?, and in the process (through possible professional arrogance) failed to extend our responsibilities to working with our other local primary care providers for the best possible management of the patient."

The answer is yes. How many chiros see themselves as primary care practitioners as opposed to cracking backs?

The chiros do not have a public presence in arguing for health care reform nor are they saying very much about addressing the problems of hospitals by shifting the health system focus to primary care?

It is Treasury and the Productivity Commission pushing for health care reform because the costs of the current system are going to unsustainable in under a decade. That means we need to be clever in reforming it.

Allied health should be leading the charge as they do have something positive to offer. A different model (holistic/wellness) of health care.

Great to see that we now have someone in the midst of it all...
I hope you are able to get the messages everyone above is mentioning to the right ears and are also able to get our voice heard that bit more. (Is it really heard at all at the moment?)

I feel that there is a section of the profession that is willing to be subordinate to the medical profession (as physiotherapy is) and others in chiropractic that are more at ease providing a more competitive (to medicine) service.
Do we need both types to be "chiropractic" or will we be better served as two distinct groups in your opinion.
Also, what is the likely hood that if we had the research to back the profession as a more cost effective method of health (not sickness) care that the medical establishment would prevail anyway. ie VHS vs Betamax (the best is not always the winner)




I concur with your observation that:

there is a section of the [chiropractic] profession that is willing to be subordinate to the medical profession (as physiotherapy is) and others in chiropractic that are more at ease providing a more competitive (to medicine) service.

If we think in terms of primary healthcare and different or diverse pathways of primary health care (medicine and wellness), then we have pathways that have a different focus that appeal to different consumers.

the market is not an either or: we have diversity. You may have doctors who tend towards the wellness pathway and allied health professionals who tend towards the medicine pathway.

Healthcare reform should encourage a mix and match and interlinking because it should consumer focused. That implies a shift away from the practitioner to consumer demand. Consumer demand is what drives the shifts in the market.

Here's one for the policy makers:
"For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis." In J Manipulative Physiol Ther. 2005 Oct;28(8):564-9.
They reviewed files from managed care programs in the USA.

we seem to have lost the comments--yours and mine. sorry.

Hi all,

I stumbled upon your discussion while searching for info on medical dominance in primary health care reform in ontario. You seem like a very 'with-it' crew and I have a question.

I am looking specifically at why different primary care reform options consistently get overlooked by GPs, and how their position in the hierarchy enables them to write thier own ticket, often at the expense of patients. Besides Willis' work, do you have a suggested reading list on this topic?