Guest Column with Peter Brooks

February 11 / 53

Peter Brooks, AM MD FRACP FAFRM FAFPHM, is Director of the Australian Health Workforce Institute at the University of Melbourne. Professor Brooks has recently joined the Faculty of Medicine, Dentistry and Health Sciences to direct the Australian Health Workforce Institute. This group is developing an evidence base for health workforce policy and involves researchers from the University, the University of Queensland, University of Adelaide and University of Auckland. Professor Brooks has held posts as Executive Dean of Health Sciences at the University of Queensland (1998- 2009)  Professor of Medicine at St Vincent’s Hospital Sydney (UNSW, 1991-1998) and Professor of Rheumatology University of Sydney (Royal North Shore Hospital, 1983-1991). He has published widely on musculoskeletal medicine, health workforce and epidemiology and burden of musculoskeletal diseases. In this editorial he raises issues which relate to the health workforce as we enter the second decade of the new millennium.

The health and social welfare sector is now the largest part of the Australian workforce (14 per cent and around 1.3 million) and the most rapidly expanding. Ageing and chronic disease, along with the ability to provide many more health services are going to drive this agenda and the costs of health care to unsustainable levels. The health budget is the most rapidly expanding part of the financial responsibility of any Government, with predictions of reaching 20 per cent of the GDP by 2020. With these rising costs we will see increasing inequality of access and affordability to health services, whether it is an increasing ‘gap ‘ payment between what a doctor charges and what Medicare or private health insurance provides as  reimbursement. Within the health profession, (medicine in particular) significant disparities are arising between generalist (General Practitioner and non-proceduralist) salaries and those of specialists – particularly those carrying out procedures.

Inequalities have always been part of society, but they are now growing significantly, and were highlighted recently by an excellent book – The Spirit Level – Why Equality is Better for Everyone – by Richard Wilkinson and Kate Pickett (Penguin) and a companion piece by the late Tony Judt – Ill Fares the Land (Penguin). Tony Judt also provided an excellent essay and an article published in the New York Review of Books (29 April 2010) in which he develops the philosophical basis to this dilemma.

The Spirit Level provides data showing that if you take almost any societal parameter you like to think of, be it the number of criminals in prison, the level of nonviolent or  violent crime in a community, literacy, obesity, life expectancy, infant death, social mobility – there is a correlation  with income disparity – the higher the inequality, the greater the problem. Why do we need to understand this? Because we (Australia) are up there with the US in the inequality stakes, along with New Zealand, United Kingdom, Portugal and Singapore. The percentage of the Australian population which controls 80 per cent of the finances has decreased significantly during the last few years while the number of people on incomes below the poverty line has increased significantly, and in 2010, some 1 million Australians had to access food support.

The uncapped fee for the service system which operates in Australia for health funding, with its significant bias towards procedures, is driving these inequalities, is not encouraging good practice among health professionals (for example, there is an incentive to do something rather than take some preventive action) and is unlikely to be financially sustainable in the long term. Some review of the financial incentives driving the Australian health system – albeit politically hard to achieve-will have to be part of health reform required to put sustainability back into the equation for health care. 

An extended version of this article appeared on the health blog Croakey: the planet’s health) to ransom?

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