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May 4, 2014

Verdict on the National Commission of Audit: it lost the plot on health

The National Commission of Audit's recommendations for health reform are based on ideology, not evidence, according to Dr Andrew Weatherall, an anaesthetist, prehospital doctor and blog

Melissa Sweet — Health journalist and <a href=Croakey co-ordinator" class="author__portrait">

Melissa Sweet

Health journalist and Croakey co-ordinator

The National Commission of Audit’s recommendations for health reform are based on ideology, not evidence, according to Dr Andrew Weatherall, an anaesthetist, prehospital doctor and blogger.

And he warns the Federal Government that there will be some predictable kickback if it follows the Commission’s suggestions for an ideologically-driven, short-term fix, rather than an evidence-based plan for the long-term.


Andrew Weatherall writes:

It’s said there are seven basic plot lines that any story can follow. This is probably why it can be pretty hard to genuinely surprise an audience. Sometimes such familiarity has all the warmth of your most loved slippers. Sometimes it’s just boring.

The release of the Commission of Audit recommendations should be just such a familiar show. The new government comes in freshly minted in the regalia of office and commissions a bunch of ‘distinguished people’ to review all the horribly wasteful things the last bunch were doing.

They then produce a report with a range of suggestions that would make a Dickensian orphanage master quiver in fear. The government adopts a small proportion of them to a much lesser degree.

The grateful villagers throw their hats in the air with joy having been granted a much easier tightening of the belts and merry dancing in the streets commences. And fade to a message from our sponsors.

So why all the wailing and gnashing of teeth this time, particularly on the health front?

The underlying assumption appears to be that while the suggestions won’t be followed chapter and verse, they do reflect a good deal of the philosophy of the government.

The commission has suggested a range of measures that seem designed to significantly alter the fairly universal health system that Australians and particularly those working in health cherish.

Assault on Medicare

The narrative leaked so far has built an impression that an assault on Medicare was imminent. Now more of the script has leaked, and people are ready to pounce in anticipation of the real announcements in the budget.

Perhaps underlying the angst is a broader sense that the document is one driven by ideology and not evidence, that the audit looked for plot lines they liked and made recommendations to match.

The two key components that look like an assault on Medicare are the idea of a GP co-payment of $15 and the push to have higher income earners kicked away from Medicare entirely.

Removing universal access and asking the patient to pay more of the share sounds a bit like a move to “Americanise” the system and that makes many nervous.

You could only really be keen on that if you’d been convinced by one too many episodes of Grey’s Anatomy that the US is best when it comes to fancy pants medical care.

Maybe they’re enamoured of the heroic work of Dr McDreamy. Maybe they find tales of junior doctors who accept marriage proposals from the patient whose heart assistance device they’ve just sabotaged such an exciting diversion (or discussion-worthy) that they’re looking to reproduce that magic.

Perhaps the stardust is enough to obscure the evidence of astonishing and wildly variable health costs, lower life expectancy and slightly increased risk of death created by inequality.

Why is moving people away from universal access to health care a self-evident good? Viewing health policy only through the prism of the budget lets you skate over all these issues.

To be fair, the head of the auditors, Tony Shepherd, did mention that we don’t want an US-style system.

Of course, he also casually asserted that Australians go to the GP an average of 11 times a year, which doesn’t really seem to match the available information from the National Health Performance Authority at the My Healthy Communities site (thanks Dr Tim Senior for the link), which suggests the real number doesn’t even reach 8 visits. Wait, that looks suspiciously like actual evidence and might suggest that Australians are not sniveling hypochondriacs. Disregard.

When it comes to the co-payment, let’s put aside the confusion created by saying a price signal would make people think twice about whether they really needed to go to the doctor, while telling a Senate Committee the next day that it wouldn’t change whether or not people attended and would therefore raise money.

Let’s even try and leave for later any attempts to reconcile the merit in arguing that a co-payment is sensible price signaling to modify behaviour, while a price on carbon to address an issue listed by the World Health Organisation as our greatest public health challenge represents a cost of living apocalypse.

What evidence there is (covered well here) suggests that co-payments are most likely to deter those on lower income from seeking primary care (who just happen to be the most vulnerable members of the health community) and that patients aren’t the best judges of whether they should go to see the doctor.

Not only that, but what does it mean for remote and Indigenous health? Co-payments seem likely to have longer term cost implications as it weakens the relationship between patients and their GPs, which is why the AMA don’t seem peachy keen. That doesn’t fit the narrative though.

This is health policy created to address a budget “emergency” that is a sideshow confection, by adding a payment to everyone to prevent a problem of some patients turning up to the doctor too often that doesn’t seem to exist.

Ideology, not evidence.

There is no doubt that health costs need to be addressed and most in the area would be disappointed if health is anything other than a major topic of discussion in May.

The problem is with creating policy blueprints over a timetable of a few months to address costs rising over the course of decades without actually looking at widely available evidence.

That’s what has people so jumpy. Evidence is not just something the team from CSI look for on sweaty hotel sheets with a weird blue light. It’s accumulated by the combined efforts of lots of people doing hard work and closely examining data collected in the real world.

If the budget looks like an ideologically apt short-term fix rather than an evidence-based plan, the response is likely to be even bigger.

• Dr Andrew Weatherall is an anaesthetist and prehospital doctor who writes in his spare time. His blog, The Flying PhD, is a finalist in the Best Australian Blogs 2014 Competition.


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