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October 06, 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.
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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.