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a two tiered health system? « Previous | |Next »
January 22, 2008

A key question in health policy is whether Australia's public health system can deliver safe and good hospital service given the current hospital structure and imposed budget constraints? Bundaberg, with its deaths and injuries, implies no. The Labor governments, state and federal, say yes, despite the shortages of hospital beds, shortages of doctors and nurses, the lack of funding for primary care. Public health, they say is now commonwealth as well as a state issue and co-operative federalism will ensure adequate patient health and safety.

It is a good question to ask in the light of the forthcoming Australian health care agreements. As Geoff Davies pointed out in an op-ed in The Australian on January 16 ('Patients risk death in our sick hospitals') these agreements:

are based on the assumption that all all Australians, irrespective of wealth, are entitled to free hospital care and treatment, including operative treatment; not just emergency care and treatment, but also elective procedures. What has not been considered, and what politicians have so far been reluctant to consider, is whether that assumption is a realistic one.

The quick and dirty response is that under a neo-liberal mode of governance, it is not a realistic assumption. A two tiered health system will develop as it has happened in education with its dual private and public systems. We already have a public and private health care system with the public one starved of funds under the Howard regime.

Geoff Davies acknowledges this possibility:

It is possible that, in the end, the only realistic choice may be between, on the one hand, a system that provides can provide free hospital care and treatment of all kinds to all people, but only inadequately seriously risking patient health and safety; and, on the other hand, one which can provide a safe and adequate system but not to all categories of people or not to of all services presently promised. But the possibility of that choice is open that politicians have, so far refused to confront.

Have they? Haven't we by default actually got the former kind of health system? The services are limited and rationed, and as adverse events in our public hospitals is the norm, this health care is unsafe and inadequate. What hasn't happened is politicians publicly admitting that the system cannot provide free health care delivered safely and adequately, and that they have failed to provided the resources to ensure a safe and adequate free public hospital system.

| Posted by Gary Sauer-Thompson at 9:02 AM | | Comments (14)


When this article came out others responded with international comparisons showing Australian hospitals rank in the top 3 worldwide. The US has slid to twentysomething over the past few years. From memory I think the rankings were preventable deaths per million and France came first.

What's the system in France?

A couple of points on health.There will always be adverse events in any hospital system. The important thing is to have mechanisms that limit their occurance. In spite of the publicity this subject recieves Australia has made good progress in improving things.The trouble is we are dealing with people and man made systems often under tense situations. Things will go wrong.More so if resource are inadequate.
You are quite correct when you say politicians have failed to provide the resources to ensure a safe and adequate free public hospital system. The States have been saying that for 11 years.Even former Minister Wooldrige agrees.That does not mean that such resouces can not be provided. That is money and people.You can argue for ever as to when the resources being supplied are adequate.There will always be someone or some organisation that thinks they are insufficient. But seems to me at this moment we have the best chance yet of finding an acceptable solution.The Gov. and the States do agree that resources are inadequate,as does every professional body connected with health. There is also agreement that our model of care in Australia needs a rethink. More focus on keeping people healthy.
Gossip tells us the Gov. is close to appointing a Chair for the Health Commission and I see Mick Reid {a former NSW d.g. for health with a good reputation and lots of experience] has been appointed Minister Roxon's Chief of Staff.The Gov. in my view is getting on with providing solutions.I am afraid the Murdoch press still can not accept that the Howard Gov.lost the election and a new order is about.

First of all, if equity is at all an objective of health systems, 2-tiered ones fail miserably. The literature unequivocally supports this (eg. Waiting time 14x as long for elective surgery in public compared to private in the UK – Marber et al). While we have been continually sold the line that private takes the pressure off public, signs are that the opposite is, in fact, true. One of the factors behind this is that specialists as well as general medical staff prefer to work in the private sector due to increased pay, better conditions. The compounding effect of that is lowered morale in the public system.
Secondly, as Len indicated, things will go wrong and, this being technologically advanced health care, the effects can be catastrophic at the level of individuals. The media, of course, loves a good 'Dr Death' story, and in this fashion, these aspects of health system 'failure' are probably disproportionately represented in the public consciousness. To me the important questions we should be asking are more systemic and to do with the ethos underpinning health care delivery, such as: what are the priorities in health care? What do we value in the way we treat our sick (ie. health care as a defacto expression of important values such as compassion and benevolence) and do we, as a society, accept that the amelioration of suffering of our fellow citizens is a commodity distributed according to ability to pay or a more integral part of the social contract? Etc...
Moreover, we tend to operate under a 'sickness model' – we wait until people are unwell until we try to make them better. Big Pharma has a huge role in this, of course, as there's not much money in prevention, is there? Switching to a 'wellness model' and promting health lifestyles would be a massive step towards taking pressure off health systems (of course, banning junk food advertising would be key in this, so let's not get too optimistic).
Thirdly, I think health care is viewed as too separate to other, socio-economic aspects of our society - especially the way wealth, power and property rights are distributed. One of my main arguments against 'work choices' was that it polarized power and influence and this would have adverse effects on the health of many unskilled workers and their families. 'Social Determinants' of health (education, literacy, income parity, sanitation etc) are slowly being recognized as the main factor behind the health status of populations, with the actual health care delivered coming second. This is one of the reasons why relatively poor nations such as Costa Rica or Kerala (a state in India) boast better health indicators than many developed countries. It is also one of the main reasons why we should focus mor on HOW things are done in health care as opposed to WHAT is done (technologically). Could a health system itself be part of the social determinant cohort of factors in how fair or equitable it is??

Australia may well have a world class health---all policy discussion start from that point--- with some pressure points that point to reform. Most concede the need for some reform--even Tony Abbott, the ex Liberal Minister of Health and Ageing.

The point is whether we can afford to keep it going---free hospital care for all with safe and adequate care and treatment. What is coming up is this kind of choice: limit the services presently promised or limit the categories of persons to whom they are presently promised.

isn't the Bundaberg scenario an indication that Australian governments--both state and federal---have consistently failed to provide a safe and adequate free public hospital system?

That scenario also indicates that the mechanisms that limit the occurance of adverse events were not in place. Where are the audit reports that indicate Australian hospitals have made good progress in improving things. Has there been such a report?

I fully support your argument:

..we tend to operate under a 'sickness model' – we wait until people are unwell until we try to make them better. Big Pharma has a huge role in this, of course, as there's not much money in prevention, is there? Switching to a 'wellness model' and promoting health lifestyles would be a massive step towards taking pressure off health systems (of course, banning junk food advertising would be key in this, so let's not get too optimistic).

Geoff Davies does not mention this. What he does say is:
Australia's national real healthcare spending has been growing faster than the Australian economy every year since 1900.

Budget constraints point to the possibility that public hospitals providing all services to all of the people to whom they are promised at no cost and at a safe and adequate level is becoming increasingly difficult. Davies' phrase is 'increasingly remote', given the failure of governments provide a safe and adequate free public hospital system.

I agree that the long term solution is better primary care; but I also agree with Davies that the social democratic promise of free, safe and adequate public hospital care and treatment is becoming threadbare, and that the promise for this kind of free hospital care and treatment for all will be increasingly questioned.

This is one big challenge for co-operative federalism working within a neo-liberal mode of governance. How will that challenge be faced? It's unclear so far.

I'm not a health expert, but I can't believe that you would interpret the Dr. Death scandal at Bundaberg Hospital, Queensland in terms of

The trouble is we are dealing with people and man made systems often under tense situations.Things will go wrong.More so if resource are inadequate.

The hospital system at Bundaberg was dysfunctional; there was professional coverup of the deaths and the whistleblowers were treated very badly.

If this is normal then it is unacceptable. How many deaths are caused by inadequate services a year? Is it more than road deaths?

You then say that I am afraid the Murdoch press still can not accept that the Howard Gov.lost the election and a new order is about.
Geoff Davies was the former judge of the Queensland Court of Appeal who conducted the commission of inquiry, not a conserv ative headkicker.He is arguing that:

there is convincing evidence that they [inadequacies that cause serious and death] are widespread throughout Australia.

He adds that the solution to this problem has been mired in political point scoring and mutual criticism between the commonwealth and state governments.

With Rudd the pointscoring and mutual criticism has gone for now, but that leaves us with the problem of the widespread inadequate services causing serious injury and death. You come across as whitewashing the problem Davies is raising into a nonproblem.

re you question about the number of adverse events in Australia's public hospitals.

This report by The Australian Institute of Health and Welfare:

analyses 130 events that caused or had the potential to cause serious
harm to some of those patients.The events analysed in this report are called ‘sentinel events’ because they are regarded as potentially or actually leading to serious harm to patients, as probably signalling serious failures in the system and as events that should be the subject of robust analysis to determine causal factors and to prevent recurrence.

I thought that the numbers were much higher--I've seen numbers that are higher somewhere. They must be given that this WA Report says:
WA Health’s finalised incident reports show that in 2006 there were 25 769 clinical incidents of which 15 614 were adverse events. Of these 820 were rated as critical causing serious harm or death. The Quality in Australian Health Care Study (1995) found that around 50% of adverse events may be preventable.

820--that's two planeloads in WA alone. If two planes crashed at Perth airport and there were 820 serious injuries and deaths there would be a public outcry about safety and quality control. And a commission of inquiry etc etc to ensure consumer protection and make airlines more accountable to consumers.

So why doesn't this happen around healthcare? Why do the health professionals and administrators keep quiet? Is it a culture of denial?

I've been digging around a bit re adverse events in public hospitals and I came across this interview on the ABC's Health Report with Stephen Duckett in june 2006. Duckett says:

In about 1976 the then Health Minister Ralph Hunt said look, I'm going to give the medical profession three years to lift your game and basically nothing much happened for the next 20 years or so. And then the stimulus for serious work in quality was the Quality in Australian Health Care study released in '95. And then there was about a five-year period of denial because people just didn't want to believe that things were so bad. And then in about 2000 the council was set up and so it had a lot of work to do in sort of setting the framework and getting people to accept that there was an issue and something ought to be done about it. And they lasted till about 2005 and now we're moving into the next stage with the commission. And I think the commission is placed to move to the next stage with much more serious action.

No numbers were mentioned. Duckett says that the states are also more serious about quality issues. Queensland, NSW and Western Australia have had serious political issues about serious adverse events in their hospitals. And I think you know we can't put our head in the sand anymore.

I found what I was looking for.This 2007 research paper---Reducing the Incidence of Adverse Events in Australian Hospitals from the Centre of health economics at Monash University says that results from the 1995 ‘Quality in Australian Health Care’ (QAHC) study suggested that the quality of health care in Australia is a problem that overshadows all others in the health sector. Here's why:

In the initial study, reported by Wilson, Runciman et al. (1995), medical records for more than 14,000 admissions to 28 hospitals in NSW and SA in 1992 were individually examined to determine whether or not an adverse event (AE) was associated with the admission (prior to or during the episode of hospitalisation). A team of medical officers then made a judgment concerning the degree of preventability of the AE. By extrapolating results the authors estimated that about 470,000 admissions were associated annually with an AE and that these would have resulted in 18,000 deaths and 50,000 cases of permanent disability. In a subsequent report, Runciman, Webb et al. (2000) estimated that 50 per cent of the AEs in the QAHC study had a high preventability score. Sixty per cent of deaths could have been avoided.

18,000 deaths and 50,000 cases of permanent disability. That's around 350 deaths and 1000 permanent disabilities a week---that is over 3 Boeing 747's crashing every week. You can see why the culture of denial that Duckett mentions took over for the next 5 or so years.

You might find part of the answer by accessing report a report prepared jointly by the Australian Institute of Health and Welfare and the Australian Commission on Saftey and Quality in Health Care The Report examines sentinel events in public hospitals in 2004/2005.It does not cover the broader issue of adverse events. I do not think there has been an attempt since Carmen Lawrence's Report. But I maywell be wrong.
My comment is based on my experence with NSW Health. Considerablke effort went into improving Quality during my ten years.I believe those efforts produced good results through out the system. Every adverse event at the area level was reported and investigated to remove the cause of the incident.There was a benchmark for reporting further to the Dept. I know because I chaired our Area Quality Council. What has happened over the last three years I know not.But I have no reason to believe it has other than continued to improve.For a while I attended activities held by the previous Commission and thought it had a long way to go, although it's work was bringing about a change of culure. From the present Commission's web page it also has along way to go.It is still working through accreditation. From my own point ofview as a regular user of the public hospital system I have nothing but praise for those who ru it the grass roots level

Nan et al,
I agree Bundaberg must have been dysfunctional. I am just as concerned as the people writing these comments and in the past have been active in working to improve the situation.I certainly am not complacent about the status quo. I think there is much still to be done by governments, the health professions and by the legal profession.You will recall it was Carmen Lawrence whose report blew the whistle on this subject. We had change of Government shortly after and that Government after a delay had to be convinced there was a problem. It took a second report to convince it.If you trawl back through the history of the last 11 years you will see there was a lot of procrastination and not much action. I notice that the bench marks for the COAG elective surgery program requires reporting on adverse events and unplanned re-admissions.I guess you could assume the subject of Quality is on the agenda.But why not ask?

Gary et al,
I don't know how much coverage has been given to the Coroner's report released yesterday into the death of a sixteen year old girl at Royal North Shore Hospital two years ago.The coroner called the death unnecessary, and gave reasons for his finding. Yesterday the Premier announced a special inquiry into NSW Health.Public comments on the ABC news item are mixed.The Nurses Association has called on the Inquiry to focus on the good and bad of the system and not on individuals. {my interpretation] This situation certainly must add to concerns about the issue of quality and saftey in health care.

as you point out state governments such as NSW have lifted their game re quality and safety. Surely the North Shore Hospital sage of last year indicates that there is a long way to go.

On another issue surgery patients in public hospitals in NSW were admitted within 291 days--the worst result of any mainland state and more than double the Queensland number of 127 days.

Another indication of the lack of funding provided by the Carr/Iemma Government for NSW public hospitals during the years when big budget surpluses were all the rage.