What¹s the prescription for a healthy government?
Colin James's NZ Herald column for 17 July 2007
All health policymakers and administrators roast on this spit: "Free can't be the best, best can't be free." Voters in modern rich societies want the best for free.
They also want it along with tax cuts and despite any self-inflicted damage from eating, drinking and behaving badly.
Pete Hodgson rightly trumpets improvements huge heaps of money have bought since 1999 only to find a general public belief things are below par.
Why? Science keeps delivering expensive new "health" technologies faster than new lower-cost technologies for existing procedures. So the cost rises inexorably faster than national output (GDP). Ministers are doomed to fail amidst success.
There is no simple answer. Privatisation isn't it, United States experience tells us. Tens of millions there cannot afford treatment. And it is staggeringly expensive: treating real and imagined illness and fixing up damage in the United States takes about half as much again in GDP share terms as total private and public spending does of our skimpier GDP. Yet Americans' life expectancy is below ours.
Consequently, health services reform is a constant issue in both state and federal politics. Hillary Clinton failed spectacularly during her husband's presidency to fix the mess. Reformist state governors are struggling.
Moreover, a United States study found 15 per cent of doctors' diagnoses are wrong, due to the inexactness of medical science or inattention to the actual person in their care. Having seen different doctors differently diagnose and treat, with a resultant setback, a friend's condition here, I am tempted to give that figure some credence.
Hodgson's torture is that these personal mishaps and tragedies can readily morph into national "crisis". The smarter and more complex the technologies, the higher the expectations of infallibility.
Then there is churn. We train expensive thieves who accept large student subsidies then scarper overseas. We have to steal doctors trained in other countries to fill the holes. Hospitals hire locums at high cost.
Add in crony-ridden district "health" boards (DHBs), beset by disruptive unions trying to get nurses and others paid enough to stop them emigrating. Then there is Pharmac, which can't pay for all the wonder drugs lobby groups instantly demand on personal-tragedy/national-crisis criteria. (And, down the track, if the trans-Tasman therapeutics agency is scuppered, big companies might not bother to spend the time and money to register some drugs separately for our mini-market.)
Write your own stories. Or listen to National's Tony Ryall, ACT's Heather Roy and the Greens' Sue Kedgley telling you weekly how sickly the "health" system is.
Yet far more is done to enable far more people to live, live longer and live more nearly whole lives than 20 years ago. We should feel blessed. Instead we gripe, grumble and groan.
In 15 months or less, like as not, Ryall will get his turn to roast on the spit. Can he square this iron circle of expectations and delivery?
Ryall starts with a near blank sheet. "Health" was too hard for Don Brash so National's blink-and-you-missed-it policy last election is no guide.
Ryall has been developing a discussion paper, due originally in May but not now likely till September-October.
He starts with two guides: minimal restructuring -- it diverts professionals' attention from the real job; and a focus on consumer need, "personalised" and "closer to home".
So primary health organisations (PHOs) will stay -- "the vehicle is right," Ryall says. "There is a role for an organisation that works to improve and coordinate primary services." Any thoughts of "managed care" systems, which proved too daring for Bill English as Health Minister in 1998, are off the radar. There will be "no upheaval in funding". The GP subsidy will be "undisturbed".
Ryall will, however, "want to see how capacity can be improved".
He has yet to decide on the future of Pharmac.
DHBs will also stay. But Ryall wants smarter (including more) use of the private sector for "elective" -- meaning "waiting list" -- surgery. And he wants clinicians more prominent in directing resources.
His model is a system of clinical networks developed in New South Wales on which he has been making speeches over the past month. These are collaborative networks of clinicians which operate across hospital and primary-secondary boundaries to better manage resources, particularly for chronic illnesses.
They use a combination of diagnostic and health management "bundles", delegated funding, upskilling and information management. They have saved money and allegedly improved patient outcomes.
Management is not sidelined, Ryall says, but "incentivised to work closely with clinical staff". This, he argues, means the workforce is less likely to feel marginalised and demoralised and so leave.
Will that square the iron circle? For sure, no. But there is some fresh thinking. Which National's sickly health policy has badly needed.