Issue 16 / 12 May 2014

SHOULD we pay more from our pockets for health care and less from the public purse?

What current institutions in health can we do without? Should prevention be a major concern of government or should it be left to the individual?

These questions should be addressed by a national government elected to oversee — among many things — the health of the nation.

Much health care in Australia is paid for from taxes. A long history explains why this is so, much of it expressing humane concern for people who are sick and assuring access to care for those who are not so well off financially.

Our politicians have choices — they can leave the health system as it is or they can try to change it by changing the underpinning policy. In seeking to make change they inevitably provoke the interest of those who stand to lose or gain as a result — doctors, nurses, patients, managers, insurers, pharmaceutical companies and many others.

So, whether they leave the system mostly in place and merely fiddle, or propose branch and root changes, politicians are engaging in policy decisions whether they recognise it or not (policy in this case being deciding how to apply resources available for health care).

These policy decisions affect people’s lives and are not trivial. For example, increasing the privatisation of health care, as has been proposed in Queensland, carries costs for those least able to pay.

The more privatised the system, the less the needs of the poor and the marginal are met. This in turn means that society is changed and the values that it expresses — a fair go for all and concern for the weak — are hammered in the promotion of profit.

The results of a two-tiered health system are rapid access to quality care for the rich, who pay privately, and inferior care with long waiting times for the poor through a publicly funded safety net, a system well known in less developed countries.

Because it involves money, the health policy debate occurs in the context of other public policy discussions, most notably those that have to do with the Budget. Former senator, doctor and colleague, Professor Peter Baume, used to say that matters of principle usually turned out in politics to be matters of money, while matters of high principle usually turned out to be matters of lots of money. He could have been talking about matters of health policy.

As the word implies, policy has to do with the polis — the people. In a democracy the people expect their voices will be heard, alongside those of experts in health, the financial controllers and other interest groups. They also expect that changes to the system are canvassed with them before being announced and that they have a chance to have their say.

Optimally, a competitive, comprehensive statement of intent for health care would be provided by contestants for our vote at each election. This did not happen at the last federal election and we have not been canvassed about proposed changes.

Instead we have been bombarded in the past few weeks by government and the media about proposed cuts in tomorrow’s federal Budget, rumours of extinctions (eg, the Australian National Preventive Health Agency and Medicare Locals), increased costs to visit GPs and nothing much about our public hospital system.

It would be healthy if tomorrow’s Budget acknowledged the need for people-based health policy.

We should be presented with options that emanate from clear-headed policy thinking as well as a sound budget. The publication recently of the National Commission of Audit report is not reassuring. It focuses heavily on the supply side of the cost equation for health care but does not provide any insights into what can be done to achieve real efficiency through structural change. Instead, we just hear about rising charges through copayments and by forcing high-income earners out of Medicare and into private insurance schemes.

How to achieve more efficient (and generally more effective) care is left unconsidered. For example, in the Western Sydney Local Health District in the past 2 years, we have cut millions of dollars from our recurrent budget with an 8% increase in activity by attending to contracting, procurement and not using expensive part-time staffing from a budget of a mere $2.4 billion.

Let’s have less haste and hysteria, and more speed towards an efficient and humane health system, thank you.


Professor Stephen Leeder is the editor-in-chief of the MJA and professor of public health and community medicine at the University of Sydney. He chairs the Western Sydney Local Health District Board.


Should maintaining a universal health care scheme in Australia be a policy priority for the federal government?
  • Yes - it's the best system (51%, 79 Votes)
  • Yes - but some change is needed (44%, 68 Votes)
  • No - should be user-pays (5%, 7 Votes)

Total Voters: 154

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8 thoughts on “Stephen Leeder: Policy means people

  1. CIAP - NSW Health says:

    We could learn from the Institute for Healthcare Improvement which describes the aims of a health system as improving the health of the population, while simultaneously improving the patient outcome and experience and controlling per capita cost for the benefit of communities.


  2. Dr George Margelis says:

    Health policy is far too important to be left purely to politicians.

    The consequences of the changes they implement need to be properly understood, and recognise that often short term savings lead to long term complications that increase costs, decrease quality of life, and tie the hands of future governments.

    Jo Sutherland’s link to the Institute for Healthcare Improvement points to the need for our healthcare system to have a goal. We first need to define that goal for Australia, and then start a real discussion about how we obtain it. That can’t be done in sound bites, it needs us to develop a skill set in health policy and relevant solutions amongst those involved.

  3. George Hamor says:

    The truth is that universal healthcare is simply unaffordable unless a serious discussion is held with the public about what the health system should fund and what proportion should perhaps be means tested.

    Then there is the cost of maintaining state and federal health bureaucracies with no impact on health care outcomes.

    The costs of maintaining existence with expensive ICU admissions in situations where there is no hope of improving quality of life is just one area where all involved in healthcare have failed to engage meaningfully.

    Unless people with the standing of Prof Leeder and others have serious discussions with politicians who can then engage the population, there will continue to be tinkering at the edges.

  4. Michael Gliksman says:

    Well said Steve, as always. Is the Government listening?

  5. q402681@amamember says:

    To discuss Health Care Policy (either micro or macro) in total isolation of Health Cost is simply impossible. However, I can only agree with Peter Baume’s cynical comments. Unfortunately for the Socalist world altruists, the Harvard School of Business totally trumped the Harvard School of Medicine in the late 1970s at the time when Health Care cost were rapidly exceeding the growth in the GDP of all developed countries and economic rationalist govenments held sway. Thus accountants and MBA bureaucrats hjacked all policy decisions and financial control from the wider medical community. He who controls the finances/treasury benches controls the business/government.

    Unfotunate fact: We lve in world where Socialised Medicine can only ever be adequately funded by a coexisting expansionary capitalist system that actually generates suffcient taxes to pay for it. Unfortunately for the Socialist Left, the 20th century showed very clearly that command economies all fail sooner or later. We, as a largely socialist welfare state, are at a tipping point. What has not happened in Australia is any recognition by the wider community or politicians up until now of the need to fully recognise and engage, as a distinct and important group the shrinking proportion of individual PAYG tax payers (<20% of the total) who actually pay more in taxes than they receive in government benefits and are being asked to constantly to fund more and more social welfare initiatives. (See Europe). To fail to recognise and confront this evolving dilemma will inevitably lead to a weakening of any meaningful expression of a “social contract” within our society.

  6. Michele Grandolfo says:

    About 30% of resources dedicated to health service maintainment are wasted  because of overdiagnosis and overtreatment. Wasted interests of professionals are implyed, these destroy the professionality. Corruption is the instrument to sustain wasted interests, with a devastating combination of interests of drugs and medical devices producers and academy. Modern biotechnologies increase the exploitation with alleged false hopes.

    Directive paternalism drives professionals behaviour instead of the perspective offered by the milestone Ottawa Chart on health promotion ( promotion of autonomous control of persons an communities on their health status). Directive paternalism is essential to promote the medicalisation of life. Consequently health literacy is promoted too. The alternative is Public health literacy as defined in:

    1. Freedman DA, Bess KD, Tucker HA, Boyd DL, Tuchman AM, Wallston KA. Public health literacy defined. Am J Prev Med 2009 May; 36 (5): 446-51.

    the control of  overdiagnosis and overtreatment through continuous evaluation process using adeguate process, result and outcome indicators must involve professionals, administrators, politicians as well as community. Only in this way it is possible sustain a universal public health system. that, without alternative, guarantees more health for the better off as well the worst off. Health is a common good.

  7. Jo Sutherland says:

    David De Leacy is right- Harvard Business school was, and continues to be influential in the health policy space. Their highest profile “activist” currently is Prof Michael Porter- world-reknowned microeconomist. He has turned his attention to health reform, and frames the discussion around achieving “Value” for healthcare spending. The equation is simple: Value=Outcome/Cost. In order to measure value, we need to know what outcomes we are aiming for, and achieving. Porter says some ways to improve value of healthcare spending are to bundle payments, organise care in integrated practice units, and establish universal outcome measurements for every patient.


  8. Margo Saunders says:

    We have 2 converging problems putting the squeeze on ‘people-based health policy’ and person-centred health care: the virtually unfettered power of corporations to promote products which drive preventable diseases and conditions; and an absence of a coordinated national approach to improving health literacy.

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