AUSTRALIA'S MEDI-MESS -- CONTINUED

Four new reports below

Rudd flailing at the air over health

State health ministers have been ordered to design ways to admit fewer people [That's a great start!] to hospital and release patients only when they are ready to leave, in exchange for incentive payments to be rolled out by the Rudd Government. Federal Health Minister Nicola Roxon is preparing for a meeting with her state counterparts on January 31 in Melbourne to discuss how to implement the Government's $2 billion plan to fix the problems in the nation's health system over the next four years. The Rudd Government has warned it will consider a commonwealth takeover of public hospitals [Do the Feds REALLY want that monkey on their backs?] if the states have not begun implementing reforms by the middle of next year.

Ms Roxon's move came as retired appeals court judge Geoff Davies - who headed the 2005 commission of inquiry into Queensland health, prompted by the Jayant Patel malpractice scandal - called on governments to consider rationing services or restricting access to ensure safety and quality.

After health ministers and treasurers met in Brisbane on Monday to discuss the distribution of $150 million for an elective surgery blitz - a tiny proportion of Australia's $80billion-plus annual health spending - Mr Davies has used the opinion pages of The Australian today to criticise previous reform efforts. "It is possible that, in the end, the only realistic choice may be between, on the one hand, a system which 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, one which can provide a safe and adequate system but not to all categories of people or not of all services presently promised," he writes. "But the possibility of that choice is one which politicians have, so far, refused to confront ... because they have assured us that we are all entitled to free healthcare, whatever that may mean."

Australian Health Policy Institute director Stephen Leeder questioned whether Mr Davies had been exposed to the "dark side of health" for too long, saying most patients were satisfied with the level and quality of care received in public hospitals. Professor Leeder said the public system had for more than a decade struggled to provide more essential operations with less funding, "relatively speaking", and that it was time for governments to respond. He said surveys had shown Australians were willing to pay more to improve the system, although not in the form of co-payments or direct funding, but "the people reluctant to do anything about it are the politicians".

But Jeremy Sammut, from the Centre for Independent Studies, said health costs would continue to rise and governments should look at more radical funding options. "If we shift to a self-funded model, we'll have more chance of having a sustainable health system in the long-term," Dr Sammut said. He said such models should go beyond the private health insurance reforms embraced by the Howard government and instead replicate the superannuation reforms of the early 1990s.

But Australian Healthcare Reform Alliance chair John Dwyer said he did not believe the public health system was unsustainable. "I do believe that a quality public health service, in which people will get quality of care in a timely manner based on need, not their own personal situation, is entirely achievable," he said.

Ms Roxon told The Australian there was an awareness that change was required. "We do understand that there is a legitimate claim for more money for hospital services, but we also need to be much smarter about how we provide a range of other services that could keep people out of hospital, that could make their transition in and out of hospital better." She said there was "a significant amount of sifting going on" of good ideas, not just within the federal Health Department and the states. "I'm asking the states and territories to give us some ideas. I'm absolutely adamant that we have to get both the entry and the exit end of the hospital working properly. "So we have to look at managing inappropriate and preventable hospital presentations and admissions, and we have to look at having proper discharge processes so that people who are frail or chronically ill don't leave hospital with everybody knowing they'll be back in two weeks."

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Patients risk death in Australia's sick hospitals

We've all heard about the worrying inadequacies of our public hospitals. Shortages of hospital beds, shortages of doctors and shortages of experienced nurses are among the most serious. At least in one hospital, Bundaberg, these inadequacies have caused serious injury and death. Their revelation has caused public outrage. But such inadequacies are by no means confined to one hospital, or even to one state. On the contrary, there is convincing evidence that they are widespread throughout Australia. Public hospitals, generally, are not delivering all of the services promised by governments to all of the people to whom they are promised, at a level that ensures adequate patient health and safety.

Until recently, the solution of this problem has been mired in political point scoring and mutual criticism between the commonwealth and state governments. Because direct responsibility for health has been that of the states, the commonwealth health minister chose simply to blame the states for these inadequacies; and state leaders responded by blaming the commonwealth for failing to fund the education and training of sufficient doctors and, more generally, for failing to provide sufficient funds to enable the states to deliver adequate patient health and safety to all of those who sought it free of charge.

So it was heartening that then-Opposition leader Kevin Rudd not so long ago acknowledged - the first time by a commonwealth leader - that public health is not just a state problem, but one that must be solved co-operatively by the commonwealth and the states. And that acknowledgement has now resulted in commonwealth funding to ease elective surgery waiting lists. But it is one thing to recognise this; it is quite another to recognise and acknowledge the nature and extent of the problem; and yet another to solve it.

In consequence of the report of my commission of inquiry into Bundaberg and other public hospitals in Queensland, the Queensland Government acted promptly to attempt to remedy the inadequacies disclosed in that report. But it was hampered in what it could achieve by the terms of the Australian healthcare agreement, which it had made with the commonwealth, as had all other states.

By that agreement, the state was committed to continue to provide, at no cost to all who sought them, all of the services which it promised at the commencement of the agreement, whether or not it was capable of providing them adequately. And when the then premier, Peter Beattie, raised the possibility of co-payments for some services, the health minister, Tony Abbott, threatened legal action for breach of the agreement. The result was, and remains, that states, endeavouring to improve the quality of free hospital care, are confined to do that within the existing framework, whether or not that framework is capable of delivering adequate patient health and safety to all who seek it free of charge.

The Australian healthcare agreements are based on the assumption that all Australians, irrespective of their 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.

Can Australia afford to provide all of those services, free, to all Australians while maintaining an adequate standard of medical and hospital care and safety? For if there is one thing that we should never compromise, but unfortunately have, it is an adequate standard of care and safety. Unless that standard is achieved, there remains a serious risk that patients will continue to suffer both delay in treatment and inadequate treatment, either of which substantially increases the risk of injury or even death.

It is possible that, in the end, the only realistic choice may be between, on the one hand, a system that 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, one which can provide a safe and adequate system but not to all categories of people or not of all services presently promised. But the possibility of that choice is one that politicians have, so far, refused to confront. Politicians have refused to confront this possibility because they have assured us that we are all entitled to free health care, whatever that may mean. To admit that they cannot provide, safely and adequately to all Australians, all of the services presently promised might risk public disapproval, even anger.

But Australian governments must together consider whether, in order to deliver a safe and adequate free public hospital system within realistic budget constraints, they must make a choice: either limit the services presently promised by that system or limit the categories of persons to whom they are presently promised.

Two realities compel this consideration. The first is that, without either such limitation, governments have consistently failed to provide a safe and adequate free public hospital system. And the second is that Australia's national real healthcare spending has been growing faster than the Australian economy every year since 1990. Taken together, these show that the possibility of public hospitals providing all of the services promised to all of the people to whom they are promised, at no cost and at a safe and adequate level, is becoming increasingly remote. Thus the first challenge for co-operative federalism in health: what kind of free hospital system can Australia realistically deliver without, in any way, compromising patient health or safety?

There is a second challenge. Who should deliver that system? Should it be delivered solely by public hospitals or should some part of it be delivered by the private sector under contract with government? The latter is already occurring in some states. And if universities in this country commence providing specialist surgical training, and to that end establish teaching hospitals, greater surgical expertise may, in the future, at least in some specialties, exist in those hospitals than in public hospitals.

Consequently, better quality surgical care and treatment may be obtained in some areas by using the private sector, funded by government, to provide it, rather than by providing it within government-run hospitals.

I do not presume to know the answers to these questions. My concern is to ensure that any reconsideration of the provision of free health care in Australia is not confined by the way in which it has been delivered so far. For if there is one certainty about the existing system, it is that it remains inadequate. A little safer now than it was, but still worryingly inadequate.

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Ambulance absurdities in Victoria

Surprise! Something that is "free" will be abused

MELBOURNE'S $16 million-a-year ambulance dispatch system is forcing paramedics to race through streets to treat nose bleeds, apply sticking plaster and tend to compulsive hand-washers. Ambulance officers say a computer dispatch program that fails to distinguish between a heart attack and a stubbed toe sends them on thousands of unnecessary high-speed runs each year.

Ambulances have been sent to people with in-grown toenails and sprained ankles - at $860 a trip. Call-outs have jumped more than 25,000 in the past year but paramedics say that up to half of the code one jobs - the highest priority response - are for cuts and scratches, or less. Their union says ambulances are sent to most jobs to eliminate the risk of litigation. "I can't tell you how many Band-Aids I've put on this year," one paramedic said. "It's costing a massive amount of resources. "We can't get the response times down because we're going to everything."

Another said: "Everything's an emergency. Some of them are things that, when I was a kid, your mum would look after." Other "emergency" jobs include: a patient whose lip had been cut on a pizza crust, a man with a paper cut and a boy with a grazed knee.

Ambulance Employees Union secretary Steve McGhie said paramedics did not need the burden of treating minor complaints. "It is an American system based on (fear of) being sued. It's causing huge concerns for paramedics," Mr McGhie said. "It will get worse before it gets better."

MAS chief executive officer Greg Sassella said the same dispatch system was used around Australia and the world. Mr Sassella said it was "conservative" in rating the degree of emergency, but there was no better system. Victoria had tried to improve the system by introducing referrals to doctors or nurses, he said, weeding out more than 26,000 calls last year. Mr Sassella said referrals, which cost $61, will be expanded in coming years. "We've done more than any other service in Australia to reduce over-response," he said.

Paramedics believe some people call ambulances to avoid waiting at medical clinics. "They think they'll be seen quicker at a hospital (arriving by ambulance). There's a percentage ... who know how to play the game," Mr McGhie said.

The MAS annual report says the "community's expectation of ready access to health care" is a reason for a 9 per cent rise in call-outs in the past year. But one officer said the figure was misleading. "I can tell you, the number of sick people in Melbourne has not gone up 9 per cent in the past year," he said. "There is a proportion of society which uses us as a taxi service ... every day, you do an inappropriate job. We are being flogged, absolutely flogged." The officer said Victoria should run a public awareness campaign on when it was appropriate to seek emergency help, similar to one in the UK.

The MAS report said the increasing number of call-outs was partly due to reduced access to medical services and patients discharged early from hospital. An ageing population, greater rates of complex and chronic illness and more people living alone are also cited as factors. Ms Sassella said ambulance resuscitation rates for cardiac arrest had risen from 5 per cent to 55 per cent in the past decade.

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Ambulance absurdities in Queensland

Surprise! Something that is "free" will be abused

The State Government will consider on-the-spot fines for Queenslanders misusing the Ambulance Service as paramedics become fed up with frivolous call-outs. Emergency Services Minister Neil Roberts will meet with his department next week to consider the introduction of infringement notices as the Ambulance Service shoulders a call-out rate 30 per cent above the national average. Paramedics have told The Courier-Mail of instances in which "patients" have faked injury to ensure a free ride to hospitals including:

* A man who faked an ankle injury to receive transport to the Gold Coast Hospital, where he was later seen walking freely. He then admitted to paramedics he had needed a lift to see his girlfriend in the maternity ward.

* A man complained of back pain but when the ambulance arrived he said he did not have money for a taxi and wanted a lift to a methadone clinic.

* A Gold Coast woman claimed she was sick and needed transport to hospital. When she arrived, she left the ambulance and headed for the shops. A paramedic said there was nothing they could do to stop the woman. "That happens all the time," the paramedic said. "They basically say we pay our ambulance community cover so shut up and take us. "We're absolutely flogged and everybody's sick of it. "Most of us are ready to give it away."

The ambulance service receives funding from an annual levy on Queenslanders of $97.99, collected through electricity bills. An audit into the service, ordered by Premier Anna Bligh, last month recommended the scrapping of the levy and reintroduction of the old subscriber/user pays system, or a retention of the levy and a new user co-payment regime. But Ms Bligh said a levy and co-payment system was "untenable" and the subscription system had previously resulted in people making a financial decision not to call an ambulance.

There is a provision in the Ambulance Service Act for fines of $3750 for people making "false calls" but acting Emergency Services Minister Andrew Fraser said "these offences must be dealt with summarily through the court and it has been rarely used". "The Government will examine enforcement and consider the introduction of infringement notices," Mr Fraser said. Queensland Ambulance Union State Organiser Jason Dutton said the union welcomed the fines and other steps being taken by the Government.

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