Australian Medical Association Archives

Modest Expectations – Boning up

Dr Tanveer Ahmed is a University of Sydney graduate, who is in psychiatric practice with an alphabet list of specialities from addictive disorders to transcultural psychiatry. Nowhere among the list is a claim that he knows anything about Medicare. In fact, what he wrote in AFR some weeks ago contains a particular passage of arrant nonsense replete with non-sequiters. (sic)

But as all relevant stakeholders agree, the Medicare system was dreamt up at a very different time. Half a century ago, the challenges were around infectious disease, infant mortality and work-related injuries in a manufacturing-based economy. The medical profession was about large hospitals and alpha male consultants.

First, Dr Ahmed, Medicare is a payment system of Federally-funded patient benefits, a Constitutional head of power granted to the Commonwealth in the 1946 Referendum. Earle Page, in 1953, was the first to try and harness this head of power for the benefit of the patient, particularly in setting up the Pharmaceutical Benefits Schedule. Still in operation today, Dr Ahmed.

Now, progressing this nonsensical proposition that Medicare was the results of some reverie: the genesis for Medicare was the Nimmo Inquiry, set up by a Coalition Government and reporting in 1969. The Report was the platform, which enabled John Deeble and Dick Scotton to outline their plan for a universal health system. This was adopted first by the Whitlam Government (Medibank) and in its second iteration, Medicare, when Hawke was in power. Patient medical benefits have been at the heart of system. The throwaway line of medicine 50 years ago reflects the arrogance of ignorance. Unlike today, infectious disease was not perceived a major problem. It was the decade before AIDS; and Infant mortality was not a major discussion point, but abortion was. In 1972, yes, the mortality rate per 1000 live births was about 16; today it is closer to three. The figure for Aboriginal infant mortality is closer to 13.

Entering into a discussion about what was relevant 50 years ago demonstrates the resilience of the payment system and how it has coped with distortions. In other words, can that resilience continue?

A major challenge is that there is no recurrent mechanism for adjusting the fees for Medicare benefits. What happens now periodically is the Commonwealth sets up an inquiry into medical benefits – or more specifically one or two sections of the Schedule – and while the Inquiry proceeds Government uses it as an excuse to freeze Medicare rebates. So different from changes initiated by the Nimmo Inquiry 54 years ago.

Secondly, a serious distortion is the practice of public hospitals to double dip by “privatising’ their outpatient facilities, diagnostic imaging and pathology. Public hospitals are supposed to be funded through the State/ Commonwealth agreements. However, there were some State governments that diverted such funding for other uses and have been shamed. Politicians are very good at building monuments to themselves and hospitals can issue very useful media releases, especially if the number of dazzling gizmos blinds the population to the lack of staff and services.

Yet Dr Ahmed said the medical profession is all about large hospitals. Where does that comment get us? Hospitals are about staff and being able to provide an optimal 24/7 service. The solution lies in the management of the hospitals and when Dr Ahmed was in swaddling clothes, I was involved in a hospital management plan which worked because it encouraged participation by the medical work force in management – in other words not leaving the decision making in the health care system to others. But what has his statement to do with the current plight of the health system.

The recently constituted Review commissioned for two PSM awardees who probably know “where the bodies are buried” should be able to produce a “fearless review” report, unless both of them are among the grave diggers. The cynical view is that by commissioning the Review from the “Yes Minister” crowd, at best we may get a sample of the soil where the bodies are buried rather than a complete exhumation.

The third challenge is the growth of medical practice being treated as just another business commodity. The hedge funds, the private equity investors, the conglomerates based overseas mostly saw Medicare as a “Eureka” moment. A government ATM! The doctors become salaried ciphers, as they get a guaranteed stipend while the patient benefit money flowed offshore into tax havens. Ahmed mentions this but does not make the connection between this distortion and Medicare.

The fourth is that the co-payment becomes the major patient cost as the value of the benefits decreases relatively. Given that medical specialists charges are increasingly detached from the medical benefit, then Medicare becomes more and more strangled – and in time irrelevant if no remedial action is taken. Two forces are contributing to this strangulation – (a) funding the NDIS – it is difficult to believe that significant funding that would otherwise be directed to Medicare has not been diverted to the NDIS, and (b) the asymmetry of information undertaken. between patient and provider. The consumer is at a disadvantage in that when confronted with a diagnosis he or she is completely at the mercy of the information fed by the providers.

These are the real reasons Medicare has lost its effectiveness. A salaried profession is coming to general practice by stealth, coupled with an absence of regular review of the value of the patient benefits. In the past, George Repin assured that the AMA’s contribution was in Joint Inquiries, regular engagement with the Commonwealth that assured the value of the patient benefits. I fear today that the AMA in such updated reviews would be protecting the profits of overseas investors.

Introduction of capitation across Australia raises the question of why? The Constitution provides a particular way to go which has been remarkably robust, despite the attempt of Fraser’s Government in particular to sabotage it in its infancy before Medicare’s introduction consolidated the system under Hawke, with the guidance of his exceptional Minister for Health, Neal Blewett.

I have dealt previously with this idea that the health professionals naturally come together and work co-operatively. To accomplish this requires people with very special skills and not authoritarian personalities – perhaps Dr Ahmed’s feared alpha male consultants rampaging through Medicare. Still, I do not know what a reference to the alpha male medical consultant has to do with the value of the Medicare Benefit.

No, Dr Ahmed, the scheme was not dreamed up; and God knows why the AFR printed this shallow piece where simply put, the Commonwealth government, a Labor Government, is just starving the scheme into bureaucratic marasmus.

Meanwhile, the AMA sends out media releases printed on warm lettuce leaves.

Herding Goats

In an earlier blog, I wrote about my Uncle Frank Egan, who kept a flock of sheep in his backyard in Avoca, a settlement nestled in the Victorian Pyrenees. He fed his sheep by a judicious use of the Long Paddock for miles around, which earned its title as Egan’s Paddocks. It kept the flock intact, while he had very little actual land.

It struck me after driving through the extensive gorse lining the roadway between Zeehan and Strahan, after reading about the various forms of gorse eradication, that goats would seem to be the best way to solve the problem, as long as the relevant local government is patient as it may take a few years to fully accomplish.

Likewise, after the extensive rains, with the prolific growth of grasses alongside the roads, goats could be used to trim the verges. However, goats without a goatherd may prefer a diet of wheat shoots or canola rather than just stick to the roadside. Thus, goats need supervision. The concept of local government employing a goatherd should not be too difficult with a migrant community where the goat is an essential part of family life.

Goats are such versatile animals. Angora goats are known for their hair; others species for the quality of their meat, and further others as milking goats. The assessment of goats in relation to their weed clearing capacity, especially relating to gorse, suggest Boer goats may be the best.

In support of the above, a Dandenong Valley horticulturist, Colin Arnold has said; “Angled onion is a major problem along the Dandenong Creek. The goats love the flowers and eat the foliage too at certain times. They also eat other local weeds: privet, English ivy, pittosporums, blackberries, hawthorn and even prickly gorse. Gorse has seed that is viable for 25 years, but goats will find those seedlings and eat them, too. In areas where there are larger bushes, such as blackberries and tree regrowth, I put bigger goats.”

He added that young goats preferentially target weeds rather than eat the native vegetation. I would like to see the evidence, but generally the local councils should know where their native vegetation needs protection.

Arnold does use Boer goats for the task. They are also good meat goats – so in drought times, the flocks can be reduced. Others use an electrified corral where they can leave the goats to munch. The goats are resilient to being outside, if given a modicum of care. Nevertheless, the employment of goatherds by government could standardise the responsibilities of such a person.

To me, it is a no brainer for the use of goats to be introduced and trained goat herders should be recruited to establish an industry that becomes no different from any other local government responsibility.

It is a pity that Uncle Frank never developed a business called “The Long Paddock Munch” – the family fortune could have been, founded in the mouth of the goat.

Pity about the lack of goats then, and the spectacle of Uncle Frank as a goatherder is just too fanciful, but the profession should not be discarded as a thought bubble today with so much exotic invasive weed needing removal – and hopefully also to fuel reduction in the bush.

Snug in the Huon Valley

Where would you find settlements called Snug and Flowerpot and Eggs and Bacon Bay? Then there is Cygnet, just down the road. Has a certain ring about it, if under a different spell.

You drive along the winding road South from Hobart into the Land of the Scarecrows. It is a picturesque drive through small villages and past farms. There is a collage of primary produce outlets and markets along the way. Fruit and vegetables are fresh; the taste tells me so. Tomatoes straight off the vine; wonderfully variegated beetroot and radishes; home to stone fruit and once where apple orchards and hop field dominated, now there are cherry trees covered in netting, and at the end of summer the trees are showing exhaustion after bountiful crops. This is the Huon Valley.

As we look out over the garden of our friends, there is the scenic D’Entrecasteaux Channel, which separates the Huon Valley from Bruny Island. On the Channel there is always a sloop or a ketch to complete the picture of summer serenity.

But if you look in the other direction covering the hillside are the brooding forests of eucalypt and blackwood.

On 7 February 1967 Southern Tasmania was engulfed in fires, an event which came to be known as the Black Tuesday bushfires. They were the most deadly bushfires that Tasmania has ever experienced, leaving 62 people dead, 900 injured and over seven thousand homeless. The fires were particularly linked with Snug, which was almost completely razed. This occurred after a very rainy year in 1966, and there was plenty of bush to burn – as it did when the temperature rose, the wind came from the north-west and the humidity was low.

As we were driving on a hot day a week or so ago, we stopped at a roadside stall near New Norfolk and while we were buying his youngberries, the farmer looked up and said that the wind had shifted west, and had it done so in the morning that would have been a perfect scenario for bushfires to break out. Fortunately it did not occur.

Our friends have taken precautions against bushfire – a mandated reservoir of water, extensive clearance of vegetation including tree removal. Nevertheless, there is only one narrow road out of the Valley and despite the increase in fire trails, the bushfire danger to the Huon Valley remains, as it does to Hobart, as happened in 1967.

Fire management plans are available, but brochures are easy to write and their recommendations are often expensive to enforce. With the current doctrine of allowing everyone to do what they like, as a side product of decades of neoliberalism where trust in individual responsibility will suffice on the grounds that we all live in a rational world. Naïve, comes the cry!

After the Black Sunday bushfire in 2009 in Victoria, a curious journalist interviewed people implicated in deliberately lighting fires and found that “a criminal profile for bushfire arson {which} is fairly well defined, but to my way of thinking, unsatisfyingly clinical. We know arsonists are usually men at an average age of 26, with a disconcerting number volunteering with the country’s firefighting agencies. They also tend to be disconnected from friends and family and live with depression or {other defined} mental illness.”

In fact, the man convicted of some of the Black Sunday bushfires received 17 years imprisonment. The severity of the penalty was linked to 173 people who died; 2029 houses were lost. In contrast to the Snug bushfire, the Black Sunday bushfire took over a month to extinguish.

The Black Sunday arsonist was 39 years old at the time of the offence and a former volunteer in the Country Fire Brigade. Nevertheless, that fire’s common causes are three: fallen powerlines, lightning strikes and arson. To that can be added the discarded cigarette butts and sparks from industrial equipment. Nothing much you can do about lightning unless the site of the strike can be immediately identified – a forlorn hope. Thus, reliance on community efficiency in preparation for bushfires may help; but I am not sanguine with climate change. Tasmania will become more and more like Victoria. This would be tragic, the signs of 1967 are not evident now in the Huon Valley. But for how long?

Picklefad?

I used to play squash twice a week in the sixties. Australia at the time had the world’s best men’s and particularly women’s squash players. Heather McKay won 16 consecutive British Opens from 1962 to 1977. Squash courts were not cheap to build and as the popularity of squash waned, so did the number of squash courts. This has been ultimately the fate of indoor racquet ball sports; popularity is important to maintain their costly capital expenditure. There are a variety of these, now niche sports; moreover, table tennis without the table would be a little difficult for the ocular challenged. Badminton, once battledore and shuttlecock, is not a game for the concrete red-meat Americans. Royal tennis for the elite. The problem with croquet is that it needs a big lawn whereas tennis, once its companion sport, has proved adaptable to a variety of surfaces.

And now pickleball, tennis when one is not playing tennis – the conundrum is how long will it last before it becomes “pickled ball.”

By the way the name, according to trusty Wikipedia, as mentioned in the body of the following article, came about because in the summer of 1965, pickleball was founded by three guys fooling around on Bainbridge Island, Washington. Within days, it was called “pickle ball”, a reference to the leftover non-starters in the “pickle boat” of crew races – an American term. Note the date of invention and the time it has become popular. The rule of thumb between time of invention and time of general adoption is 18 years.

I am indebted to the Boston Globe for this edited version of how the new phenomenon has become a sensation, if not an addiction.

Karine Marino played pickleball from 8 until midnight on a recent Monday night, drove 11 minutes home to Bedford, took a quick shower, set her alarm for 5 a.m., and drove back to the same indoor courts for her 6:30 a.m. game.

“But I just do that once or twice a week,” Marino, 58, said. “It’s not all the time.”

No, no, of course not. She usually plays a mere three hours a day, unless she’s in a tournament, or she’s coaching a friend from her club, Life Time in Burlington, or …

Pickleball, as you may have heard, and heard and heard and heard, has become the “fastest growing” sport in the United States, per the Sports & Fitness Industry Association.

But it’s one thing to read that nearly 5 million people played last year — an increase of nearly 40 percent over 2020, according to the sports association — and another to watch a loved one get sucked into the game’s gravitational pull. Flying to pickleball camps, joining multiple pickleball leagues, eying a $145 designer pickleball dress, and playing through the pain of pickleball elbow.

A woman attorney recently figured out that her boyfriend was graciously giving her son a ride to school — under the guise of being helpful — in part because it is next to pickleball courts.

“He has a whole new social life with retired ladies,” she said.

Pickleball was invented by three dads, who were looking for family-friendly entertainment. From there it famously jumped to retirement communities, and periodically word would come out of Florida or Arizona about some goofy-sounding game in which grandparents were engaged. If people talked of it at all, it was mainly to mock.

But in a makeover even people who eat plant-based diets (nee vegans) might envy, pickleball has come so far that not only is there such a thing as Major League Pickleball, investing in a team has become the hottest financial move since crypto, though ideally with fewer crashes and indictments.

“Naomi Osaka and Patrick Mahomes Join Wave of Celebrities Investing in Pickleball,” Forbes headlined in December. “LeBron James is a pickleball fan,” a 2022 CNBC headline read, “and now he’s buying a team.”

Pickleball has a reputation for being a friendly sport, and that’s accurate — unless you try to get between a pickleballer and their lifeblood, aka more pickleball courts.

“You are always hunting,” said Erin McHugh, a woman who sees empty parking lots as potential courts and author of “Pickleball is life: The Complete Guide to Feeding Your Obsession.”

There are an estimated 35,000 courts in the United States, more than double the number from five years ago. But it’s not enough.

At a South Boston indoor pickleball parlour, where courts rent for as much as $100 per hour, aspiring players need to act fast. Those who don’t grab a slot within seconds after the online sign-ups begin are unlikely to get a court at the time they want, said owner Brian Weller. “It’s like trying to get Taylor Swift tickets.”

As the sport grows so does the drama. Pickleballers are battling both tennis players for court space and court-side neighbours who are fed up with the loud thwack-thwack-thwack of the hard plastic ball hitting the paddle (and also the boisterous and sometimes drunken chatter from spectators).

Tension flared. In Marblehead {a coastal Massachusetts town} recently when pickleballers complained about the winter closure of pickleball courts, according to the Marblehead Current, “There’s a {Chinese} balloon flying over the Carolinas, but we’re worried about pickleball nets,” a member of the Recreation and Parks Commission said. “I’m at my wit’s end with pickleball chatter.” The Commission compromised by agreeing to reopen six courts for players who can bring their own nets.

Why is pickleball so seductive? Its relatively small court means there’s less ground to cover than in tennis. You could spend a lifetime working on your game, but you can also have fun right away. You can socialize and exercise at the same time, usually outside, and for that reason it became a pandemic darling.

But a sport doesn’t get this big without a sprinkling of magic. Perhaps Marino, a retired engineer and aspiring pickleball “evangelist,” captured it best.

“The majority of people say it takes them back to their childhood,” she said. “To that carelessness. You play in a way that you are disconnected from your reality.”

Mouse Whisper

This was sent by My Mouse on the Wye. It has been seen more than 20,000 times on Facebook, but still makes me chuckle.

There was this well-dressed man on the bus in Cardiff. He was the quintessential English gentleman, with the cultured arrogance as he directed a rebuke to the woman in the hijab talking to her teenage son for speaking a foreign language not English.

An elderly lady on hearing this turned around from where she was sitting, and said to yon knight, “She’s speaking Welsh.”

Modest Expectations – Swansea

For the next two weeks, we are cruising the waters of Vietnam. Commencing in Ho Chi Minh City, we have just pulled out into the Saigon River as I write this continually changing blog. It is Tuesday just after seven am, four hours behind Sydney time, on a day when the Treasurer will empty his pot of gold or whatever over the Australian people. Past cranes, moored tramp steamers, the container barges, the tugboats, house boats and small craft, it is raining and for a working port, it is strangely silent. Clumps of water hyacinth, a skerrick of Mother Nature, defiantly float down the heavily industrialised river. We await the delivery of our breakfast. It is four hours to the sea.

Once Miss Saigon Now Don’t Miss Ho Chi Minh City

We landed in Ho Chi Minh City, which we all once knew as Saigon. Here in a city of about 10 million people, most seem to live on motor bikes and scooters. This is the inescapable impression one gets of this city as you drive from the airport. Gone are the days of wandering the city. My images are those of a man encased in a vehicle being driven hither and thither. The city I knew as Saigon shows little signs of what they call “The American War”. Our guide drives us past the War Remnants Museum where, we were told, the detritus of the War abandoned by the Americans as they retreated from Vietnam in 1975 is on show. To the people it is there to serve as a reminder; and it is in a distinct space away from the Military Museum, where the success of the Vietnamese people is remembered. Its forecourt is littered with planes, helicopters and tanks, mostly Russian. We did not go in.

My experience of the Vietnam War was examining those young men whose birthdays came up in the lottery, drafted if classified as medically fit. These young men were 19 years old; and now these ageing veterans are beset by the demons of having experienced war in a land that they hardly knew for a cause disgracefully misrepresented by the politicians of the time. I well remember the Federal election of 1966 when Harold Holt won in a landslide victory, interpreted then as a ringing endorsement of the War.

Unlike the Second World War, where Australia was threatened briefly with invasion, this was a War concocted by a few men, some of whom should have known better. It then descended into an obsession, a delusion, and the young people rebelled. After all, it was a war for the Americans to save face “by soundly defeating a third world country with third world socialist ideals with third rate communists like Ho Chi Minh and Võ Nguyên Giáp”. How so very wrong were these assumptions. Lyndon Johnson found that out when he poured over 500,000 troops into battle with over 58,000 casualties. Australia, his “all-the-way” fellow traveller, committed 60,000 army, naval and air force personnel for 521 deaths and over 3,000 wounded.

For what? I am no longer the young doctor who examined conscripts, but someone being driven around a bustling metropolis. We stop at the Presidential Palace where a North Vietnamese tank crashed through the gates on 30 April 1975 effectively ending the War. Now the grounds are a place for families to walk around, children to play, and there is only one small reminder when a uniformed man officiously challenged my wife while she was photographing, but did not prevent her from doing so, once reassured she was not trying to evade payment for entry into the grounds by crashing the gate. He nevertheless made her stand behind a mythical white line he had drawn with his finger.

Being a young doctor in the 1960s, the money for recruit examination came in handy as I was living on a meagre post-graduate scholarship and had a family. It gave me a perspective on the young men who had been called up. Only once was I confronted by a young man in beard and the uniform of the Woodstock set. He refused to be examined; I and a young fellow doctor whom I knew well were left as the night went on trying to induce him to be examined. A bloody martyr. Save us the histrionics, I thought at the time.

There was no way we were going to pass him, but we stupidly thought we could save him from being arrested if he would consent to be examined. We watched and he watched back. Eventually, the other young doctor calmly explained that eventually we could just leave him and then what may happen would be beyond our control; we were not infringing on his rights any more than any other doctor except that we could not explicitly say anything to him about what we found. While he was in this room he was totally under our control; we just had a job to do – and the word repeated several times struck a chord.

It did not take us long to find a reason for failure to pass his medical examination. He had the loudest machinery murmur that either of us had ever heard, indicative of a septal defect in the heart. The only further requirement for us then was to ascertain whether he was symptomatic, which he wasn’t. As this was going on, the defiant demeanour had given way to the fearful request asking if anything was wrong. We could only respond to by saying he should go and see his local doctor as soon as possible. He did not have a local doctor – “only the sick had doctors” – we shrugged and told him to get dressed and find a doctor anyway; that was all.

Given the buggery he had caused, which just meant we got home about eleven in the evening, we had a wry laugh about it. Reflecting on that episode now from a distance in time, it was just an example of bureaucratic anomie we had to tolerate to get and maintain our employment; and rationalise that there were three groups of examining doctors – one looking to fail and one with the zeal to pass them. The third group who were those encased in their pure objectivity. Of course, you knew in which group my friend and I lay.

All these memories came back as we were driven around this city, where the French influence is still evident in the wide boulevards lined with tall resin trees. The Notre Dame Cathedral Basilica is encased in scaffolding and is temporarily closed. Yet you see it is derivative from the Paris Cathedral of the same name, except that the Saigon version is built of Toulouse bricks, which have retained their bright red colour even after so many years. The French were here in Indochina from 1858 until 1954 when its army was crushed at the Battle of Dien Bien Phu, a defeat which should have alerted the Americans to the robust strategic combativeness of the North Vietnamese – and their courage.

Today is near the end of the rainy season, and while the hotel is ablaze with Singapore orchids and hydrangeas, the streets are beige and grey, there was frangipani in leaf but yet to flower. Shop fronts cluster – cafés, a motor bicycle repair shop, bánh mì outlets, craft shops. Then we drive into the street lined by the likes of Hermes, the flash Takashimaya and all the other suspects for the wealthy shopper.

We stayed at the Hyatt, an excellent hotel where the standard of Vietnamese cuisine raises the bar for their cousins in Australia. As I gaze around this spacious hotel with its people, obligingly going out their way to cater for me, I thought, how pointless the aptly renamed American War was. Unfortunately, there are those in power who cover their eyes and create memorials to those who so unnecessarily died or were so crippled not only physically but emotionally that they are the legacy for a fruitless war. Yet the raided bluster still goes on, even if the aim is the destruction of a War Memorial rather than Vietnam.

Medicare Lost

There are a number of elements in the Australian Health system which are both misunderstood and misrepresented. The 1946 Referendum granted the Federal Government the power of providing a financial benefit for medical, dental, pharmaceutical and hospital services. The benefit goes to the patient; it is not a fee charged by practitioner or institution. It is the amount of funding to be paid as a “benefit” to the patient for a particular item of medical service. A dental scheme has never been enacted.

In 1974, optometrists gained limited access to benefits on the grounds that they were deemed “medical”. It was a propitious time for that profession because of the number at that time who were members of parliament. It helps. The consequence of this generosity was the potential for this to cascade to every health professional being able to be deemed “medical”.

That has yet to happen, even though it is every central agency’s nightmare, given that Medicare is one of few expenditure line items not to be capped, although from afar, it is evident that capping is being undertaken by subterfuge. This generates its own problems for patients as the gaps between medical benefit and actual fee charged inevitably widens.

Finally, doctors are free to charge what they believe fair and reasonable. The Federal Government has no control over prices and incomes, last tested by the Referendum result at the end of 1973. The States do have the ability to fix prices, but in this day and age that would be politically suicidal – even if a Government tried to isolate one group of professionals.

When Medibank and Medicare were being brought into being, both Bill Hayden and Neil Blewett, as Ministers of the Crown were very knowledgeable and spoke the language of “health” fluently. So did Michael Wooldridge on the Coalition side later. All three were effective. From the commencement of my graduation in medicine at the end of 1963 to the present, there have been 22 Australian Health Ministers. Bill Hayden in fact was never Minister of Health, but as the Minister responsible for the introduction of Medibank, he may as well have been. Most of the others are in the same basket as is the current incumbent, Mark Butler. They neither speak “Health” nor know much about it. Thus, they are very susceptible to those influencers, whether these are in fact knowledgeable or not. Health has its fair share of the evangelical, the biased, the bigoted and the just plain stupid. Imagine you are standing in a marketplace where everybody is speaking a different language that you barely understand, but you are the newly appointed consul from Rome and everyone is speaking Arsacid Pahlavi.

All three mentioned above had very good bureaucratic backup; people knowledgeable and able to speak “Health.” The problem is that a Head of the Department over a 12 years’ reign who does not really understand her portfolio, save as being very good at keeping her Minister on side irrespective of party has been accompanied by the decline in the quality of health policy. This modus operandi essentially ensures that nothing of importance gets done; especially if you use the ruse of shuffling everybody every few months which is a recipe for destroying the corporate memory.

There are a number of bureaucrats who believe that bureaucratic management can be content free. The late John Paterson clearly believed this, but he was not alone. This theory does not work in health. Having been around longer than most in health policy and politics, I remember well the axiom that it takes 18 years for any reform to be sustained; and that is what has been lacking. John Deeble and Dick Scotton were working on the reform of medical financing from the mid 1960s, with important input into the influential Nimmo Inquiry in 1969. The culmination of their work was the passage of the Medicare legislation in 1983. That sounds about the expected time, and the scheme was successful. But over time, with the loss of these two especially, when dysfunctions in the ongoing implementation emerge, remedies are not found.

Corporate memory is shown to be in short supply. Since Medicare from the start provided the right balance between government funder, health provider and patient, it nevertheless was susceptible to gaming. First there were the State governments who, once the Federal Government allowed them access to Medicare payments, privatised a substantial amount of their services or, in the case of Victoria, just diverted health payments to other parts of the State budget. So, the first impediments were rogue State governments compounded by a weak Federal response.

The second element in maintaining stability which was very important were the periodic Inquiries into the Fees Schedule between the AMA and Government, the last being in 1984. The value of these Inquiries was that they made both sides produce data, however imperfect, instead of opinion. As such, these data could be examined objectively and a negotiated position agreed. After these Inquiries finished, which were essentially exercises in cost accounting, the consultancy which Robert Wilson and I were involved in looked at in depth into several of these exercises, quasi-inquiries between government and specific segments of the medical profession. There is no doubt that the Fees Inquiries were not conducted with the level of complexity now required in costing medical services and practice arrangements.

However, it is fair to say that costing radiation oncology practice in the 1980s approached this level of complexity. There were a number of lessons which still can be learned from this exercise. The first was that when the professional relativities were being developed, most of the radiation oncologists were employed in the public sector. Hence the only reference point to Medicare benefits was the salary they earned from the particular State-run facility.

The technical staff were salaried – the radiographers, the scientists and all the others essential for treatment. Capital expenditures by States was on machines – when funds were available new equipment would be purchased – with no thought given to amortising the cost of these facilities. At the same time technology was improving with development of linear accelerators, the most commonly used treatment machines, and there were calls for such machines to be funded.

Essentially then we had to construct a cost effective model, taking into account all of the above three elements for private radiation oncology practice, which we did in association with the Federal Department of Health, involving delineation of the professional, technical and capital components. Along the way, we determined that three linear accelerators were the most efficient deployment of facilities. There were subsequently a number of Inquiries into Radiation Oncology trying to disprove our findings. Eventually politics triumphed – single treatment machine facilities were installed with all the staffing problems that entailed and the Federal government allowed the States to have access to the capital component despite the costings being based on private facilities. This decision has bedevilled the health system ever since; not only States privatising but also “double-dipping”.

The other change has been the extensive corporatisation of medical practice with both Australian and in recent years international finance company owners, and since the sustainability of the business model is profit not patient outcome, then the gaming of Medicare items becomes an essential component underpinning such a model. Nothing has been done to change this effect on Medicare. As a consequence further Medicare funding is repatriated overseas.

Finally, there are the doctors themselves. Even among the medical profession before corporatisation, some had already embarked on determining the best methodology to game the system. Medical practice loses its credibility if the objectives are all financial. With seemingly endless differentiation of the specialties and the chopping and changing of item descriptors, the number of items expand and their descriptors have expanded. With volume comes complexity, and therefore some doctors have been known to employ people specifically to work out the optimal profitability by manipulating the value of various items of service, whilst maintaining the broad lines which the Health Department has established, such as for general practitioners the 80/20 rules (seeing more than 80 patients for 20 or more billing days a year) and more recently a similar rule for consultant physicians and paediatricians in relation to telehealth.

Extravagant lifestyle becomes one driver to charge well beyond the benefit. If there were regular Inquiries, it could focus everybody’s need to have an affordable health system. If the proceduralists have good results, then the patient is inclined to accept the cost. I suspect that is why some ophthalmologists are able to charge exorbitant fees – cataract removal and lens implant gives back eyesight, in skilled hands it is swift, with little fear of complication. Moreover, we only have two eyes so there is a limit on the number able to be done on the one person! Personal willingness to pay a premium has always been an important vector. For most ophthalmologists, attention to the items of service remains an important vector for profitable gaming if one believes the recent claim that injection for macular degeneration is being overused; and here there may be more than two bites at the cherry. This illustrates how narrow is the walkway between gaming and outright fraud.

Item descriptors are the basis of relativity, the different value of one specialty against the another. The relativities were set in the early 1970s when each of the then specialties was asked to value its professional expertise, but over time, changes in medical practice should have been factored into medical practice and altered these relativities. The benefit when conceived was set based on the professional component. It assumed the cost of the technical component would be paid by the hospital or facility where the operation takes place, which led in the 1980s to recognition of stand-alone day surgery centres. The problem of capital expenditure in terms of prostheses has never been satisfactorily sorted out, and if it is not absorbed into a global benefit for a particular item of service, it will continue in a limbo state of chaos.

Now that the Government intends to place consulting firms on a strict diet, the Department should beef up its expertise in medical knowledge and cost accounting by constructing a long term Medicare Branch directly responsible to the Minister, based on the model Robert Wilson and I conceived which was successful and transparent until the content-free big consulting firms took over.

The areas to be examined should expect the AMA to develop a similar expertise and be less concerned with vapid reactive media releases. However, it also needs to be recognised that with greater complexity in medicine one organisation can no longer claim expertise across the entire medical spectrum and therefore this process inevitably involves the assistance of specialist organisations.

Then the effects of the following can be objectively examined

(a) gaming, and when gaming becomes fraud

(b) corporatisation

(d) the structure of items and their descriptors to incorporate the three components

(e) the future of relativities

(f) the re-institution of regular Health Department – AMA Inquiries

I have also not included so-called aesthetic surgery – lifestyle masquerading as health. It requires a separate line item.

As an addendum, some may say that the recent MBS Review carried out some of these tasks and, with its latest hand-picked committee, it will deal with the relevant issues. However, I don’t see all the above issues on its agenda. The MBS Review was a massive undertaking that had many critics, especially in relation to the perception of hand-picked participants and pre-conceived outcomes.

The recent media attention on a PhD about the use of Medicare items and perceptions of overuse adds another dimension. I have yet to read the 400 or so pages of the thesis, but there is clearly disagreement about what conclusions were actually reached and their accuracy; the mainstream media, as always, does its bit of headline grabbing without too much concern for the nuance. Unhelpful when the rot is widespread and entrenched.

The Throwback

Just a thought about the antics of Vladimir Putin when I heard that many of the young educated, the basis of a middle class which Russia has always found difficult to maintain, have left the country. They are those who have the funds to do it, and in a country which is essentially socially corrupt, “who you know” is paramount to achieving one’s goal.

The fool Yeltsin, who facilitated the transition of Russia to a kleptocracy enabled a large number of the financially adept without any apparent morality to carve Russian resources up into fabulously wealthy satraps. Putin’s rise from being an obscure KGB agent showed the value of contacts, in fact becoming a form of padrone, and then realising the fallibility and foibles of Yeltsin, he nestled like a cuckoo, not making himself a large target in order to be underestimated by potential rivals as he threw them out of the nest.

Putin was a shrewd, intelligent man, who yet has always carried a mystical belief in Mother Russia. Whether Putin was religious or not, he recognised that in post-Communist Russia, the Russian Orthodox Church could be an ally. After all, while the Church looms large within the framework of Orthodoxy, Moscow is not numbered among the original five Patriarchies.

Feelings of inferiority drive most political behaviour and Putin is no different. The Russian Soviet Empire in which he was born had been stripped of its Asian states and most of its European hegemony. The disdain of the freed Baltic states would have infuriated him. Khrushchev, having ceded Crimea to the Ukrainian Soviet in a fit of pique, meant Crimea also need to be recovered in this post-Soviet world.

Putin still had influence in two satellite European countries – Belarus and Ukraine. Elsewhere in the Caucasus and in its former Asian empire, it has been able to ensure that what Russia determines, these states will obey, and he showed what happens with disobedience when he defeated any Georgian aspirations in 2008 and carved pieces off the country to reinforce the point.

Putin repeated the process in Ukraine by occupying the Russian speaking border areas and carrying out a bloodless annexation of Crimea, in so doing humiliating Ukraine, sending elements of the Ukrainian navy based in Sebastopol packing, as Russia assumed control of the Black Sea naval base.

Now it is a different Ukraine, Putin’s corrupt Ukrainian marionettes having been banished by a young man – Zelensky, a true knight errant. And Ukraine has significant resources and a population of over 44 million people (cf Georgia 10 million).

Putin came to office over 30 years ago with all the novelty of youth unknown; now at 70 and over 30 years later, he exists in his braggadocio shell, which threatens and threatens. The problem is that his oligarch mates have not devised the business model for a nuclear war outcome by which they can loot without having to worry about radioactive caviar and vodka laced with just a tincture of polonium. After all, the latter has been favoured Putin method of eliminating his individual adversaries.

Toilets all at Sea

I recall the anecdote about Frank Lloyd Wright who once said to his son-in-law, Winston Peters; “Wes, sit down will you. You are ruining the scale of my architecture.” Frank Lloyd Wright was a small man, and Wes had been helping in the construction of this extraordinary house, Fallingwater, built over a creek. Whenever anybody mentions Wright’s name, Fallingwater is the first of his many buildings that people associate with him. Fallingwater is located at Bear Run near Pittsburgh in Pennsylvania.

I remember shaking Winston Peters’ hand, when we were serendipitously at Taliesin West in Scottsdale, Arizona at the same time as he was. Given that Wright built homes from the perspective of his short stature, with many of the low ceilings his houses could be described as “snug”. Winston Peters was lean and rangy. I was struck by his quiet manner and in the “old money” he was nearly six foot five inches tall. Wright was feisty. Peters was not, and he would have done what he was told and sat down.

The reason that I thought of that exchange is that it is probably best not to have airlines run by the vertically challenged. I have not travelled by air for some time, but my level of disability is gradually increasing, the price of increasing age. However, in the airplane toilets, you cannot swing a leprechaun – and manoeuvring in such a confined space, where I suspect that the partial pressure of oxygen is much compromised, I have great difficulty using a facility the size of a small wardrobe. The senior airline executives may find cleaning their backsides in an airline toilet a breeze. I do not. For the disabled of normal size in such a confined space, especially with doors that may open out on a very narrow passage space trying to orient oneself when using canes or crutches is a learned art. This problem has been aired recently in an international travel magazine by a wheelchair bound person who now, when about to travel on a plane, prepares by eating and drinking little in the 24 hours before the flight. Probably resembles the preparation regimen before a colonoscopy.

The danger of deprivation is dehydration, since the plane’s atmosphere desiccates the traveller, and therefore depriving oneself of fluids prior to flying is not very desirable. I just use a container discreetly, and my carer empties it. You must be able to adjust yourself and take your time; and have a very understanding carer.

There are rules about toilets depending on whether the plane has a single or double aisle; and all planes with a seating capacity of over 60 passengers are required to have a toilet. In these smaller planes, the level of difficulty is compounded; and I have been in some embarrassing positions in a Dash-8, where there is no water to wash your hands, and when the door is open, it blocks access to the cockpit and the toilet itself is constructed for a midget – and a small one at that.

I have been on long flights in small planes without toilets and have coped. Nevertheless, the convention of providing any receptacle requires knowing what it is like trying to empty your bladder when the plane is caught in even light turbulence. I am sure I am not the only one to have difficulties; but it is a topic which, like many in the shadows of disability, is not discussed very much – a taboo particularly in the board rooms of small people.

Mouse Whisper

A twitter more about men than mice.

A brilliant Merrie England twittertwist:

My son has lived through five chancellors, four home secretaries, three prime ministers and two monarchs. He’s four months old.

And as Larry the Cat would say, it’s just another new lodger at No. 10 …

Modest Expectations – Tura Beach V

Queen Elizabeth II

Her everlasting legacy. She did not linger. She died with dignity. She would have ensured that.

Celebrate her life; not mourn. She would not have wanted the clocks to stop.

Reflection

I reluctantly must accept that I have a form of long COVID-19. It is September; I reverted from a positive to negative RAT in second week in July. My condition is characterised by persistent productive cough, lack of sleep, a veil of depression. Some days are better; some I relapse.

In any event:

The window exists 

at the end of the room

A discoloured pane frames the tree 

Sallow maple leaves cling

Potted cymbidiums hang

From trunks

That gently swing

defiantly green

Striving to touch the cycadic spikes

Along the unseen cobblestone path 

The gate aubergine 

and fire-bricked wall

Brown-wooded letter box 

All separates me from the World

Nothing else? 

That’s right

Nothing else

Why bother?

I do not go out

Just lean back in my chair 

And realise that Winter has come.

I wrote the above which I called “Reflection”. It is this view which I see every day from my table, where I sit behind my computer. To my right is the television screen – images bouncing around as the sound is turned off. I love flowers and now on the table to the right of my direct gaze is a bunch of garnet-coloured dianthus (Sweet William) in a muted patterned rosé vase. It is framed by an arced spike of cymbidium flowers – carmine stigma and delicate red russet petals – cut from our garden – stuck in a Tall Poppy Vase, that someone gave me some years ago.

Yes, this past week was my Australia Day – September One – the start of seasonal regeneration and when the wattles are at their zenith. I will get out of my chair and go out. Maybe I shall improve, but it is draining me.

Fishing traps

Rain is a myth haunting the arid places
And clouds are the dry eyelashes of the sun and moon. . ..
Its only protest is dust and the rivers drying
And the horrid gaping sores of a dying race – Maria Reay, Poem from Brewarrina (1946).

I was reminded of one of my visits to Brewarrina by my son meeting “Dean from Brewarrina”, in the Tasmanian Highlands for God’s sake. We are a literary family, but predominantly in the lifestyle area of writing. Maybe I stray when I comment about the fish traps on the Barwon River at Brewarrina, a very old manifestation of Australian Aboriginal identity and industry.

The poet, Mary Gilmore, grew up in the Riverina and moved around NSW as a child. Her father if not a sundowner, was certainly a wanderer. Mary Gilmore herself moved around and was one of a group which followed William Lane to Paraguay in 1893 to found the settlement of New Australia to pursue a socialist ideal. Hers was a short lived emigration; nevertheless, she lived her life back in Australia with her exquisite literary ability used to promote her socialist ideals.

In 1933, when she was 56, she wrote about the fishing traps in an article in the Sydney Morning Herald, the following of which is an extract:

That the aborigines made fish-traps and fish-balks (as we used to call them when we came across them) is a fact. That they used natural barriers as Mr David G Stead writes is also a fact. Sixty years ago there were many of the smaller balks in existence, and white people knew them and made use of them for other purposes than those intended by the aborigines. The larger fish-traps were made for the great gatherings, and were invariably based on a running reef or natural outcrop of rock. There were a number of these places of gathering known to my people, and I often heard them spoken of. One of these was on the Clarence, one at Brewarrina, one on the Upper Murray, and one down near Hay or Narrandera – it was near the swamps between these two places, the swamps being sanctuaries.

When you view the fishing traps on the Barwon River at Brewarrina, there is a necklace of rocks meandering down the river, and when Gilmore was writing her articles, she was responding to opinion which tended to dismiss these traps as manmade. Gilmore concedes in this paragraph that the local indigenous people used natural rock formations upon which to fashion their fish traps. The reason that few have survived is attributed to whitefella dismantling the structures; but another reason is that all the structures as described, particularly those made of wood and reeds, would have been susceptible to the periodic flooding of the Murray-Darling Basin.

The reason for the survival of the Brewarrina fish traps was the fact that Brewarrina was beyond the navigability of the river paddle steamers. However, the structures are simple and could have been easily reconstructed by tribal groups after every river catastrophe, because the river is susceptible to spreading across the floodplains. Brewarrina may have these rapids, where rocks are suitable for re-arrangement, but it emphasised the importance of Brewarrina as a gathering place for Aboriginal tribes. These corroborees required some preparation to ensure sufficient food was available. Hence the importance of ensuring the fish traps were in good condition; but the converse may be true. For a hunter gatherer society where the corroboree was a regular convocation of the local tribes, it was essential to hold them in a place where food was plentiful.

One of the observations about the necklace of rocks defining the fish traps was that each fish trap is said to have one family responsible for its trap. Given the nature of Aboriginal society, I find it unusual that, in this instance, each of the fish traps was singled out as a single family’s responsibility, implying that the fish traps conferred de facto property rights.

Depiction of fish traps, in ochre on sandstone

Brewarrina has an Aboriginal Cultural Museum recessed into a hill, and one day when driving between Bourke and Walgett, we dropped by. I remember this day well. I had no intention of purchasing anything – after all it was a museum. Nevertheless, there was one item for sale and that was a slab of sandstone upon which a depiction of the Brewarrina fishing traps was painted in ochre. The cost was $250. We bought it.

It was a very heavy piece. We transported it back to Sydney, where it sits on its mulga wood stand. We also picked up a large rock, which sat at the intersection of two sandy tracks just outside the Tilpa pub. The rock squats incongruously in the front garden, a desert souvenir in a sub-tropical mess of bromeliads. Both remain as treasured memorabilia from the Outback.

The fish trap painting was something special – whether the fish traps were nature’s work, manmade or shared between both, it does not matter. What is not debated is that Brewarrina has been a place of significance to the Aboriginal people, even now the site of the annual Baiame’s Ngunnhu Festival, belying the misery implicit in the words of dispossession written by Maria Rey nearly 80 years ago.

Utopia

Now

We seek constitutional reforms to empower our people and take a rightful place in our own country. When we have power over our destiny our children will flourish. They will walk in two worlds and their culture will be a gift to their country – Uluru Statement 2017

Then

The objectives of ATSIC are:

to ensure maximum participation of Aboriginal and Torres Strait Islander people in government policy formulation and implementation
to promote indigenous self-management and self-sufficiency
to further indigenous economic, social and cultural development, and
to ensure co-ordination of Commonwealth, state, territory and local government policy affecting indigenous people. – Section 3 of the Aboriginal and Torres Strait Islander Commission Act 1989.

By way of

“Where a clan or group has continued to acknowledge the laws and (so far as practicable) to observe the customs based on the traditions of that clan or group, whereby their traditional connection with the land has been substantially maintained, the traditional community title of that clan or group can be said to remain in existence.” – Attachment by certain High Court Judges to the Mabo decision

Once I was invited to address a bunch of Aboriginal elders at Utopia. This settlement is home to both the Alyerrerre and Anmatyerre people. It lies 350 kilometres north-west of Alice Springs on the Sandover Highway, an unmade road which runs across the Northern Territory spinifex and black soil plains until it eventually joins the Camooweal-Urandangi Road just over the Queensland border.

Utopia had even earned a reputation as a centre for Aboriginal art, being where Emily Kame Kngwarreye lived and painted. When we visited, she had passed away three years before. She was one of a number of Utopia artists, notably Minnie Pwerle, Barbara Weir and Gloria Petyarre.

The distinctive style of Utopia painter Minnie Pwerle

As I was undertaking work for the Commonwealth Government, the Aboriginal elders, an all-male group, invited me to tell them why I was there. They had moved to a roofed, open concrete area, and then they squatted in a semi-circular area. A whitefella, to whom I had not been introduced hung onto a pole on the fringe.

Even though the Aboriginal elders had seemingly sat in a non-hierarchial arc it was not difficult to work out who was the boss. As I started to talk, I started to experience this extraordinary energy of the gathering. I had never felt this level of non- verbal communication, despite their expressions being impassive, as I glanced down and around the group.

In retrospect, I likened it to the same pressure I had felt at school, when you had to speak for two minutes, without saying “um” or “ah” – or repeat yourself. The pressure was constant during the 15 minutes I spoke. When I finished, the man whom I had already identified as the leading elder stood up and said, half to the meeting in general and half to me. “Very good meeting. Let’s go have a cup of tea.” That was that.

I had felt the communication during my time talking; it had been intense, continuous but not hostile. Over the mug of tea, the discussion was general. One indication of whether you, the whitefella, was acceptable was the ability to chat. Aboriginal people can be silent; and if they believe it to be irrelevant, they simply don’t turn up for a meeting. I have been snubbed several times; “sorry business” takes precedence.

This time the two women in the party then joined us for tea. The centre of attention was the young kid with a charred kangaroo head which he gnawed at distractedly. It is amazing how small instances stick in one’s memory when other parts of that weekend passed in a blur.

The women went off with the women elders for “women’s business”. I have no idea what went on, even though one of the women was my wife. So, I can say no more; but if you are a woman reader, then you can find out if you wanted to do so.

But what is then the “Voice” in Canberra whitefella terms?

This was just one of my experiences with Aboriginal people. These were essentially desert people, and a significant group. It emphasised to me something that I had come to realise – the level of non-verbal communication among Aboriginal people. There was no indication of how well the two tribes intersected. In modern settlements where tribes have been forced together, such as Doomadgee in the Gulf Country. This product of the mission supervision and education led to displacement from traditional lands. Doomadgee is now a cauldron of various tribal groups forced together. Unsurprisingly, they are often in physical conflict.

Therefore, the concept of Voice has different connotations.

William Buckley escaped from a failed white settlement in Victoria in 1802 and lived for over 30 years with the Aboriginals who inhabited the land around Port Phillip Bay and thence into the hinterland where Colac and the shallow Western district lakes are located. When he emerged from the bush at the time Batman came from Tasmania to settle Melbourne, he had lost the ability to speak English.

Nevertheless, he had a unique perspective on what constituted communication. “Voice” in terms of a continuous Aboriginal traditional means of communication has always had a huge component of the non-verbal but also the song lines.

Buckley quickly regained his use of the English language, and in his memoirs, he describes his original exposure to a corrobborree (sic). These seemed to be where tribes could meet in harmony or for a celebratory purpose. When he was picked up by the Wathaurong tribe, as white was associated with death, he was thought of being a re-incarnated relative. So his “initiation” into the tribe was the reason for a corrobborree (sic) where there were hours of dancing and singing and beating of sticks and improvised drumming by the women on their skin rugs which they had removed and tightened between their knees to resemble a primitive tympanum. This gave meaning to the Voice?

Then one Aboriginal fellow, whose family were from Queensland, demonstrated that in his tribe there were clicks in his language. At least there is one Aboriginal voice, known as Lardil, where the clicks express a certain meaning. He demonstrated the clicks.

I had experienced a click language before, in Namibia among those from the Kalahari Desert people. In fact, where we were once in Namibia I asked one of the women serving us to read out the menu in her language. A wondrous experience – words mingled with clicks. I regret that I did not record her recitation.

Above I mentioned songlines. I remember the small group of Aboriginals, whom we once encountered on the banks of the Murray River near Mildura. They had come from the Pitjantjatjara Lands to get away from the “troubles” as they said. These people live in the northern part of South Australia, but they have a number of what I thought were songlines which they can follow across “country”. After all, I had also met a group of Pitjantjatjara men in Ceduna on the Southern Australian Coast, an eight day walk across the desert from Amata, one of the Pitjantjatjara settlements. It was suggested that this small group on the Murray River may have followed other songlines, as one Aboriginal man later suggested. Unlikely, but then these people do travel – and it is their land as they would have it.

Songlines are events where fact merges with myth interpreted through storytelling, rock art, songs and dance. As one Aboriginal elder has said: “Aboriginal people use songlines as a means of navigation, following all the landmarks they sing about. You may not have been there, but the songs give you enough information to find your way. Our people learn hundreds of songs.”

Thus, there are many interpretations of “Voice”; the Aboriginal people have so many languages and so many different totems and taboos to augment the various voices.

Given that, I have no idea what the Voice means. Is it just a forum for the articulate Aboriginal, given that there have been a number of these manifestations?

The sorry history of the Aboriginal and Torres Islander organisation (ATSIC) failed the Voice test. ATSIC was defunded nearly 20 years ago; and the former Chair is still facing 380 fraud charges. This miserable outcome of ATSIC is being used by opponents of enshrining a Voice. What has changed?

My vote in any referendum is contingent that its interpretation does not enshrine an Indigenous elite. Not the shrill Voice of self-importance. Secondly, nor should the Voice be a nod to tokenism.

The dulled Voice of dispossession continued.

Jobs and Skills Summit

We hardly need to labour the importance of the AMA’s core purpose—fighting for doctors’ interests—amid the chaos COVID continues to inflict on a health system that was stretched and inefficient to begin with. It is true that doctors’ interests have rarely, if ever, perfectly aligned with the public interest. Nonetheless, the debate over the future of healthcare in Australia stands to benefit from coherent and unified advocacy on behalf of the medical profession. The AMA still has political clout, but it needs a renewed clarity of purpose to more convincingly argue that doctor knows best

Thus concluded an editorial that appeared in the Sydney Morning Herald in July bemoaning the lack of engagement and the fall in the influence of a once powerful Australian Medical Association. In 1983 I attended the Hawke summit as part of the invited Association delegation, where the AMA President spoke.

It is important to reflect on how important the Hawke Government Summit was. It was summarised thus:

The Hawke Labor Government has not been conspicuous for its reforming pro-labour initiatives. With the exception of Medicare (itself quite a limited initiative) little has been done to improve the position of the least well off members of the population. This is not to say that the Labor Government has done nothing and is not interested in reform. It is just a question of the reforms they have introduced: assets tests, the deregulation of banking, entry of foreign banks, abolition of exchange controls and the floating of the Australian dollar.

The “relevance symbolism” of AMA involvement was not lost on some of the more assertive members of the AMA, but the following years were full of fighting for doctors’ interests. Whether the SMH editorial writer above was referring to the rise of Bruce Shepherd and his protégé, Brendan Nelson in the late 1980s I’m not sure. Certainly, the last bilateral Inquiry into Fees for Medicare Benefit occurred in 1984. Thereafter relations between government and the AMA dissolved into conflict.

Influence has faded once the strategists, who facilitated the AMA presence at that 1983 Summit, moved on and it lost its strategic direction under the populist Shepherd and his acolytes. Shepherd may have won a few battles, but an association where office holders are ephemeral loses continuity, (especially when they pursue personal agendas rather than those of the Association) – and may I say clout.

The AMA was not invited by Albanese’s crew to the recent summit. In fact, there appear to be only three invitees associated with health – Annie Butler; Federal secretary of the Australian Nursing and Midwife Association; Carmel Monaghan, CEO Ramsay Health; and Christine Nixon, Chair of the Australian College of General Practitioners.

One was a health professional, Annie Butler, heading 290,000 nurses – an experienced nurse; one businesswoman heading a successful private health group and an ex-copper who has had her fair share of controversy. Given the politics of general practice, as distinct from the practice of general practice, who knows what her grasp of the health sector is apart from the petty intrigue which has dogged the RACGP for years.

The effect of the pandemic on employment seems to be ignored in the lack of AMA representation at the Summit last week. Although the AMA had made plenty of comment, it failed to have a leading role. In fact, it was one of the failures of organised medicine that it assumed a passive role and at no stage attempted to co-ordinate resources and advice outside government during 2020-2022.

Such intervention would have shown relevance and helped quell extreme opinions. A very small but vocal minority in the community seized the agenda; and the politicians had no defence except enforced social isolation. This was an important incentive for vaccination when it had become available, but once the lock downs were revoked, there was no other incentive to maintain the level of vaccination, which had been further complicated by the different times of the approval for administration to the various age groups. Their public health experts were silenced.

Medical associations now have lay administrators. Their loyalty is to their career. They have no ongoing professional stake in maintaining the professional relevance with government.

As one who has led a number of campaigns, notably the campaign against the French nuclear tests in the South Pacific in the 1990s, I eschewed the self-aggrandisement for action. We had a plan. Irrespective of its effect, France has long since stopped the nuclear tests. The lesson was that when the interests of the medical profession coincide with those of the public as it did then, it is a powerful combination.

An AMA which exists with its office-bearers counting the number of the media releases and their appearance on Tik Tok or whatever – but in effect doing nothing or as one person said using the phrase “looking good in their suits” to define inactivity. That unfortunately is the AMA, a sound bite expressing concern or saying why doesn’t the government do something is in itself a recipe for irrelevance.

It is not surprising that Annie Butler has the ear of Government. She is an experienced nurse. She does not have to look good in a suit.

Mouse Whisper

Overheard in a lunch bar

Sandwich maker: What would you like in your salad roll?”

She: Everything except onion, please.

He, in American accent (next in line): That is a very Australian way of ordering.

She: Is it? Never really thought about it. Still, better than saying tomato… and a slice of beetroot … carrot … lettuce yes… jalapeño… perhaps jack cheese… at least with using “except” I’ve avoided the list sliding into infinity!

He: I get your meaning. So different from us Americans.

Whisper: The efficient quiet Australian!