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25 Years in Orthopaedic Politics – Perspectives and PredictionsTue, 03 Nov 2015

By Stephen Milgate
National Coordinator – ASOS

After 25 years of working in health policy, it has been my pleasure to witness first-hand the passing parade of self-appointed gurus, health policy ‘experts’, and academic advisers who have served up a conveyer belt of taxpayer funded ideas that don’t work “to fix health”.  Some are well meaning, most are well paid.

Rarely do they face any negative consequences when their interventions fail (the agency problem).  Iatrogenic injury from naïve intervention is by no means confined to the practice of medicine.

To gain insight, one must first ask the right questions.

Australian healthcare – is it sustainable?  Is it evidence-based?  Is it patient-focussed or provider-focussed?  – interesting questions. 

But here is a more interesting question.

Why is Australian medicine so good?

Why are you such an outstanding success?

Why do Australians want more and more of what you do?

According to the co-author of the CareTrack Australia Study (examining evidence based care of common conditions), Professor Jeffrey Braithwaite,

“The most remarkable thing about modern healthcare is not what goes wrong, or how much money is wasted but how successful we usually are.  The more we understand what helps us get healthcare right, the better the prescription for our health system in the future.”

“Our doctors, nurses, administrators and support staff are intuitively nearly always right.  Yet we don’t invest in research to tell us how these millions of encounters work effectively; that is, when the system is performing at its resilient best, flexing to accommodate the unexpected.”

I believe his observations are correct. 

Not only do you get it right most of the time, but we, the patients of Australia know that you get it right.  What you do works for us. 

And because we know it works for us, and because we know what you can do for us, we push you to the boundaries of your performance with our demands for better, quicker and more effective medical interventions.

In doing so we ignite debates among you about what interventions work best, in what context and with what outcomes. And we love these debates because we say the results will help us get more and better interventions to improve our health and happiness.

Recently the CEO and Chairman of NIB Health Insurance Mr Mark Fitzgibbon, told a Centre for Independent Studies Forum on health innovation, “most people are clueless, you just go with what the doctor says.” 

He is wrong and he is right.

He is wrong about people being clueless but he is right about the fact that most times we will go with what the doctor says.

We go with what the doctor says because we know from experience that most of the time what our doctors have told us throughout our lives has been helpful and correct.  

They get it right most of the time. 

And because we know from experience, and we learn from our experience, and the experience of others (our friends, our family, those we care about, those we talk to) – we are not clueless.  

And we reject any notion that our personal experience is invalid or that the collective experience of the doctors we trust to treat us is invalid because we know as the ancients knew that both reasoning and experience are powerful ways of acquiring knowledge. 

We do not need health fund executives or health bureaucrats to manage our health decision making. 

Concerns of our vulnerability to a rapacious medical profession due to information asymmetry have been greatly exaggerated.  We want our doctors to know more about medicine than we do, that’s why we go to them.

The expectation of medical ethics, accountability before the law, our choice of doctor, our right to a second and third opinion, the importance of professional reputation, and regulation that only recognises the highest standards of medical training are our traditional and important safeguards. 

But there’s more.  In the age of the internet, we the patient can access a vast array of high quality information on all aspects of our healthcare.  We can share our medical experiences and opinions.  Far from being clueless, our information problem is more likely to be that we are over informed with the wrong information.  Only our doctors can help us overcome this problem.

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So why is healthcare such a hot political issue when by any measurement, we are so much better off than our forebears would ever dream of? 

Because the central issue is not what you get, but who pays. 

Playing to the insecurity we share with all other mortals, and our joy at spending other people’s money on ourselves, actors in our competitive political process worked out that promises of universal, high quality healthcare, financed by debt and taxation at no cost to the user could give them a competitive edge.   And they were right.

However, despite Solon’s warning of 600BC that when the future looks too good there is trouble coming, what was suppressed in the policy debate (and is still denied by some) is the growing and hidden liabilities (costs) (not shown in federal or state government budgets) for a health and welfare system that is dependent on (1) ever increasing economic growth and taxation revenue and (2) an increasing and cooperative supply of self-sacrificing younger taxpayers.

As reality bites, and the dream fades, the competitive political process we so much admire and enjoy, is working 24/7 to create the ‘narrative’ that will give it sufficient cover, to lower the appetite of all Australians (and parts of the health sector) for universal ‘other people funded’ healthcare. 

For the moment, Tony and Joe’s ‘up the guts’ approach to curbing government healthcare spending has been rejected in favour of a more sophisticated and indirect approach, that can disguise spending cuts as quality assurance measures and better management of the system.  

Regardless of the outcomes of these manoeuvres, the warning signs for Australian medicine are clear.  Business models reliant on government funding or government subsidised health funds are fragile. 

The enduring relationship between doctors and patients over the centuries shows that our model of medical care and medical ethics can survive and thrive, even in the most difficult circumstances. 

Faced with an uncertain future, we the patients will look to our doctors and in turn, if they remain our doctors (not government doctors or health fund doctors) we will find a way to reward them for the incredible benefits they deliver.

Stephen Milgate
National Coordinator, ASOS

AOA Medico-Legal Society (AOA ASM)
Brisbane Convention Centre
12 October 2015

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