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paying nurses to play doctor? « Previous | |Next »
March 22, 2010

Jeremy Sammut from the Centre for Independent Studies is a long term critic of the central thrust of health reforms under the Rudd Government towards prevention and primary care. He's a hospitals man. Health is about hospitals and acute care, not prevention.

His political philosophy contests the view that the state has a particular duty to help people lead a healthy life and to reduce inequalities. Sammut argues that the great lesson of the 20th century is that central-plan bureaucracies defeat any attempt at reform and streamlining. The only way is to replace them with independent, competing producers. This means freeing local hospitals from the stifling sameness of bureaucratic interference and mobilising the power of grass-roots problem solvers, with the hospital boards being held financially accountable for performance, as well as directly responsible to local communities.

So it is no surprise to find Sammut arguing against nurse practitioners being allowed to bill the Medical Benefits Scheme for treating patients with minor illnesses and prescribe certain medications on the Pharmaceutical Benefits Scheme in The Australian.

The basic argument is that spending too much money on treating the 'worried well' rather than patients who are actually sick--someone who spends years being treated for high blood pressure and high cholesterol - only to die of a rapidly invasive thyroid cancer. He says:

what Medicare has produced is an irrational and immoral rationing in the form of an inverse care law. People with no or relatively minor health problems can see the doctor free of charge and virtually on demand an unlimited number of times at taxpayers’ expense, while people with serious illnesses are denied timely access to care and are forced to wait and suffer in the long queues for essential treatment in overcrowded hospitals. Paying nurses to substitute for doctors so the ‘worried well’ don’t have to wait is the wrong priority. This will simply pour more money into the part of the system that will do the least to improve health.

He adds that paying nurses to play doctor will see taxpayers money subsidise a new class of health entrepreneurs. It will not do what all good health reform should promote: the efficient use of scarce resources to ensure the truly sick receive better care.

Sammut's concept of the ‘worried well’---ie., people with no or relatively minor health problems---- ignores that with an ageing population and the increased prevalence of lifestyle diseases, preventing illness and keeping people healthy is Australia's best long-term insurance policy for the nation's health and managing the financial challenges ahead. Instead he says that:

the nurses union has flexed its considerable political muscle and convinced the government to use taxpayers’ money to pay nurses to do the kind of community-based clinical work that many university-trained nurses now prefer to do.

This political argument ignores the argument that the prevention of chronic diseases argument: that good nutrition, exercise, and maintaining a healthy weight and regular health screenings for high blood pressure and high cholesterol can reduce the risk of stroke and heart disease. Healthy lifestyles may prevent a large proportion of mortality from chronic diseases in that they aim at modifying the conditions that make disease possible, or likely.

The 'worried well' scenario with its implication of disease mongering ignores the argument that, as the burden of chronic diseases increases, and as societal expectations in terms of quality of life and longevity also increase, prevention may offer an increasingly valuable alternative to treatment--- a focus on prevention rather than cure.

| Posted by Gary Sauer-Thompson at 12:38 PM | | Comments (12)


the term "the worried well" often refers to hypochondria or people who have concerns about their health. In other words they are not sick from a disease. They are people that think they might be ill because they have a few aches and pains.

Behind the worried well is the view --articulated by the IPA in Australia--- that the logic of welfare statism ensures that the unduly protective Nanny State enters into every sinew of our daily lives. The Nanny State then becomes the Bully State.

The inability of many in Australia to lead healthy lives--there are so many alcoholics, gamblers, smokers, and fat people ---coupled to public information often failing to persuade individuals to take the appropriate actions to keep themselves healthy---requires state intervention to change individual behaviour.

So we have the Bully State that conducts campaign to shame and coerce those who rejoice in the individual's right to pursue their own pleasure.

Here we go again. Do the preventionistas ever tire of trotting out the lines about chronic disease prevention?

Firstly, there is next to no evidence of what actually works to prevent lifestyle disease in those unwilling to change unhealthy habits.See

Secondly, the ageing of the population means people will inevitably get ill due to the onset of ageing related conditions and need hospital care. The evidence shows that coordinated primary care actually uncovers unmeet need and increases demand for hospital care. See

That is why I'm a 'hospital man' - because of overcrowding, because of not enough staffed beds to cater for existing demand let alone the tsunami that is to come as the baby boomers grey.

I accept that union politics is very significant in health reform---eg., the role of the AMA---and that power relations are crucial to understanding what happens to health reform. The post was trying to point out that the core of the debate about health reform was prevention v doctors, not the union power of the nurses flexing its muscles.

My own position is that the health policy debate is too structured on primary care v hospitals. You say:

The ageing of the population means people will inevitably get ill due to the onset of ageing related conditions and need hospital care.

True. But we can keep them out of hospital longer if we keep them healthy---eg. exercise helps retain good body stance and balance and so help to prevent falls that results in the aged ending up hospital. After leaving hospital upon receiving acute care the aged need rehabilitation, and that is provided by diverse allied health practitioners at a primary care level.

So there needs to be greater integration between primary care and hospitals structured around the patient's journey through the health "system".

I also accept the other problem you raise--that the strategy to prevent lifestyle disease fails with those unwilling to change unhealthy habits. However, that is not everybody. Many do want to change unhealthy habits (smoking, too much alcohol, junk food, lack of exercise) but they need help to do this because it is difficult to change long established habits. The best place to provide this help is at the primary care level ( GP + allied health).

Your article doesn't really address the two fronts of the Rudd Govt's health reforms. One is the reform of our public hospitals into local networks funded by the commonwealth.That would be an important step for a "hospitals" man surely?

The other front is the reforms to primary care: increased funding for doctor training in universities; and nurse practitioners being allowed to bill the Medical Benefits Scheme for treating patients with minor illnesses and prescribe certain medications on the Pharmaceutical Benefits Scheme.

What you have done is concentrate on the professionalization of nurses and ignore the other bits of the reform package including work force shortages. It is work force shortages re GPs and primary care that is driving the professionalization of nurses

the health debate is still about improving hospitals and has yet to address ways to keeping people healthy and out of hospital in the first place .

What is being avoided in the politics of health debates is the advertising of junk food for children by the food companies. So far nothing is being said by Abbott or Rudd about how to help health consumers make better and more informed choices about being healthy.

Hi Peter,

Local networks isn't hospital reform. It's rearranging the bureaucratic deckchairs on the Titanic.

A constructive way to address the GP shortage would be to address overuse of the MBS by use of copayments or deductibles or means-testing the entitlement.

BTW, I have also heard rumours that the extra GP places will substitute for foreign doctors currently allowed into Australia to work. That means no new GPs. That perhaps means nurses are meant to do the substituting - which means my concerns about quality, safety, and impact on hospitals are warranted.

re the problem raised by Jeremy above and argued for in his CIS monograph -- The False Promise of GP Super Clinics, Part1: Preventive Care. The problem is that the persuasion strategy to prevent lifestyle disease fails with those unwilling to change unhealthy habits.

The monograph states:

Yet the evidence—major reports on public health policy in Australia and the United Kingdom,as well as studies of community-wide and high-intensity lifestyle interventions—suggests that decades of spending on prevention has not worked and is unlikely to work in the future. Spiralling rates of obesity and lifestyle-related chronic disease suggest that forty years of public health policies that have targeted diet and exercise habits have had limited effect on behaviour, especially in relation to long-term retention of lifestyle modification.

The monograph says that the evidence points to the demonstrated limits of prevention. It directs attention to the three basic reasons why health education and promotion campaigns have not been as successful as hoped, and have been expected to achieve outcomes they are not capable of in all cases. These reasons are:

1. Governments have extremely limited authority over the individual behaviours that cause and can prevent lifestyle disease.
2. Lifestyle modification and sustaining changes to unhealthy but often pleasurable behaviours is principally an individual responsibility.
3. Success in avoiding lifestyle disease ultimately depends on personal qualities—will, self-discipline, and impulse control—that public health policies struggle to instil in people who do not already possess them.

Therefore, the prevailing assumption that more spending on ‘preventive care’ will tackle obesity, lower chronic disease rates, and reduce health costs, has to be questioned.

On the first reason --that Governments have extremely limited authority over the individual behaviours that cause and can prevent lifestyle disease.There is a history of changing our habits --eg., the Grim Reaper ads. The policy challenge in 1987 was to change people's personal behaviour in an area in which compulsion was impossible, so only persuasion based on an awareness of risk could work. This was seen as successful.

This is contrasted with wearing seatbelts, for example, where a combination of persuasion and compulsion can be used. This is similar to getting people to reduce smoking to help prevent lung and throat cancer. Reducing alcohol is a mixture of persuasion and compulsion re the consequences (eg., the penalties for drink driving).

Reducing obesity in the population has been persuasion only up to now, and the Grim Reaper campaign is not appropriate here. One possibility is to build in more exercise and information about nutrition in schools. However, this does need to be coupled with a ban on junk food advertising --just as there is with cigarette advertisements.

This means tackling the corporate power of the food industry--and neither political party in Australia shows much willingness to do this.

Jeremy is right when he says in his The False Promise of GP Super Clinics, Part1: Preventive Care that the contemporary public health discourse redefines obesity and lifestyle disease as epidemics that governments have failed to intervene to control, and that the government’s preventive health care policy maintains that ‘ordinary Australians’ cannot modify their unhealthy lifestyles unless the government provides access to preventive health services.

He then says that:

This ignores the fact that studies have shown even high-intensity lifestyle interventions of the kind GP Super Clinics are currently designed to deliver have had a low impact on behaviour, particularly with regard to the key challenge: ensuring the long-term retention of lifestyle changes. The evidence, therefore, suggests that many recipients of Medicare-funded preventive health services will fail to change their unhealthy lifestyle, and future governments will have to fundthe recurring costs of ineffective preventive care that yields negligible health and cost benefits. The evidence suggests that GP Super Clinics delivering ‘preventive care’ will only accentuate the challenges facing Medicare.

He is right about the GP Super Clinics. So what does he propose instead?

In the conclusion he says that lifestyle modification is primarily an individual responsibility; that governments have an obligation to try to inform citizens about what they need to do to protect their health; future generations of taxpayers will face pressure to pay an increasingly large bill for treatment of lifestyle disease given increases in demand for hospital care; and that we need to address how to move beyond relying on taxpayers to finance the accelerating cost of healthcare into the twenty-first century.

His argument is that we need to move beyond the false promise of more spending on prevention and reorganise the provision of hospital care to ensure efficiency and cost-effectiveness.

Why cannot the private health funds provide incentives for individuals to address their lifestyle illnesses with some form of prevention care package?

Rudd's hospital reform agenda with its local hospital networks splits responsibility for the healthcare system between funding (Commonwealth) and distribution (states), and so it is about funding and governance.

I accept that the Commonwealth government's decision to take on 60 per cent of the efficient price of hospital care is not reform of the health system, and that it won't end the blame game between the states and commonwealth. Tony Abbott is right on this.

Secondly, the proposed activity-based funding based on efficient pricing for hospital care reinforces a health service model that requires admission and discharge from a high cost hospital bed. Nothing more. So it it does little to facilitate a health system reform that better integrates hospitals, primary care and prevention, ensures quality in hospitals, or even ensures internal reforms within hospitals.

So nothing much has really happened, apart from concentration of power in a Commonwealth system, which is the antithesis of diversity and flexibility to meet changing conditions.

Primary health care begins with what one puts in ones mouth on a long term basis.

Most of the so called foods that are sold in supermarkets are essentially packets of toxic chemicals which inevitably, sooner or later cause de-generative diseases.

Most people essentially eat their way to the doctors surgery either asking/demanding for drugs or surgery for what are in effect self-inflicted dis-eases.

We have the absurd situation where people demand either drugs or surgery for dis-ease conditions which CAN be cured by a simple change in diet.

For instance high blood pressure can be cured by a change in diet-- so to with cholesterol, etc etc etc and so on.

The latest big-ticket item is banding surgery for obese persons, including teenagers. This is absurd because obesity can be cured simply by changing ones diet. Or in other words taking responsibility for ones health.

Change of diet IS a necessary aspect of ALL attempts to cure dis-ease.
by the population at large to fresh unprocessed foods, especially fruit and vegetables would do more to relieve/cure the bottomless sink of the sickness and disease industry than any other measure.

Anyone else spot the irony that the supposed 'free market' think tanks support an absolute closed shop for multimillionaire doctors? How ironic.......