Category: Health

Modest Expectations Septimus

Jeff Kennett recognised during a trip to New York that the colour yellow stood out in the visual spectrum. He had seen the New York taxis were all yellow and they stood out somewhat better than the various muted colours of the taxis in Melbourne at that time. So he decreed the yellow taxi for Melbourne.

Clive Palmer has recognised his party’s colour stands out like wattle in springtime.

Mr Palmer is a clever man. The hoarding owners know that and make him produce the cash before they agree to display his message.

On the hoardings Mr Palmer’s image appears to be photo-shopped so he looks much lighter and younger than he actually is – he is a very heavy gentleman and sometimes when he was captured asleep in Parliament, I wondered whether he had Pickwickian Syndrome named after the fat boy in that Dickens novel who was always falling asleep.

But while the heavyweight Mr Palmer is barely on view in person in this campaign, his messages are there: “Fast Trains”, “More Wages”, “Cheaper Energy”, “Free Cake” and they have apparently resonated with some in the electorate. Clive has perceived the end stage of the information revolution; photo-shopped images and two word policies. “Clive Palmer” itself is a policy.

Mr Palmer has been underestimated. His Chinese partners have found that out. His nickel workers have found that out – shimmering generosity followed by real famine. It is now up to the Australian electorate not to overestimate Mr Palmer.

And remember! Yellow is also the colour used for biohazard warnings.

The Psychopathology of Politics

I once toyed with going to Yale to undertake a doctorate in the psychopathology of politics. It was the early 1970s and I had come under the influence of Alan Davies, the then Professor of Politics at the University of Melbourne. “Foo”, as he was affectionately called, continued to influence much of my thinking in this area, and enabled me to write about it, getting some currency in the 1970s when I was considered to be “someone of promise”.

I didn’t go to Yale, but my interest in politics remained. I have two aphorisms that have stood the test of time: “all politicians proceed from a basis of low self-esteem” and “politics is the systematic organisation of hatreds”. The first is attributed to Harold Lasswell, a major American political theorist, and the second to one of that political Adams family which yielded two American Presidents.

However in the potpourri of personal politics where the pathology lurks, it is the ability to see yourself through the eyes of the viewer, which is a saving grace. Jacinda Ardern has that skill. She is an art gallery of images; so many images she is able to project and yet remain that singular woman I described in an earlier blog.

On the other hand, one thing about Bill Shorten is that he doesn’t have the intuitive sense of image that Ardern has. If I were his adviser, every time I saw him jogging I would tell him to jog away from the media lens. Or if he insists in exercising to find a medium in which he does not look like a duck, paddling along, paradoxically without a bill. Watching him jogging, it’s hard not to expect him to quack. But then again when you’ve got a critic like Murdoch, who presumably was not called “Boof” for nothing at Geelong Grammar, then your jogging gait is only a small irritant.

Morrison understands this image aspect of politics much better than Shorten. Whether his “aw shucks” approach has worked, we will find out in about a week’s time if the independents don’t cruel the pitch. Morrison abandons images that don’t work, like his “happy clapper” church routine. He is the ultimate pragmatist. Research obviously is telling him that the baseball cap is working. Remember Turnbull venturing into Queensland with his brand new Akubra? He was referred to as “that tent peg” – wide hat thin body.

You don’t want your audience laughing at you; only with you. This is another aphorism and one of perspicacity in being able to tell the difference.

Of Australian politicians, Penny Wong is wonderfully deft in a way that is not Ardern, yet from the same school; those who can stand outside themselves and see their image as others do. Her minimalist approach to herself is extremely effective. 

Dental Benefits

Stephen Duckett, well remembered in a past life as the Raider of the Lost Cookie Jar, has instigated a discussion on one of the most neglected areas of Australian politics – establishing a national dental health scheme. There was a somewhat insipid yet positive response from Shorten but as far as I can see nothing from the Liberal Coalition.

The paper is timely and whether you agree with the detail or not, it is important. However, it is 67 pages long and I don’t intend to critique it – rather it is useful to emphasise a few points and place the accent on different areas.

First of all, let us say that the advocacy for a dental benefits scheme, along with a medical and pharmaceutical scheme, has never had a champion in the Australian parliament. In fact I cannot establish whether there has ever been a dentist in the Australian Parliament.

After the Constitutional amendment in the 1946 referendum, the ubiquitous Earle Page, (a rural medical practitioner in his own right) championed the adoption of a national medical scheme, which was established in 1953, and massively updated following the Nimmo Report in 1969 with first Medibank and then Medicare.

Yet government policy has been silent on a universal dental policy. First of all, organised dentistry was opposed to it as they saw it as unnecessary government intervention in affairs of the mouth.

However, there are a number of matters that need to be addressed before the detailed question of coverage and affordability can be considered.

The first is the matter of fluoridation. Australia has a vocal fringe group opposed to fluoridation of water. To these people, it is yet another of the many tentacles of the Giant Conspiracy. There are many rural local government areas, particularly in Queensland, that do not have fluoridated water.

It is not only the Conspiracy Theorists, but also some Big Business that wishes to thwart fluoridation. I experienced this side of the debate where a community, in a public meeting, supported fluoridation without dissent, but the largest industry in the town – Murray Goulburn, which was not present at the meeting – went direct to government to say it would not put fluoridated water in the milk products. The reason given was that the Asian market rejected fluoride in milk products.

The community decision was ignored. Business triumphed over public health. Until a separate water pipe bringing unfluoridated water was provided at taxpayers’ cost to Murray Goulburn, the children of the Victorian township of Cobram unnecessarily forwent fluoridated water for nearly a decade after the community decision.

The point is that any universal dental scheme must take into consideration the requirement for universal fluoridation in the water (with the only exemption being those communities that have the recommended level already naturally present in the water supply), and not to be prisoner to the vagaries of some local governments. This whole question of national fluoridation needs to be addressed before benefits are paid for dental treatment.

The second consideration is the Australian Constitution and the question of “what are ‘dental benefits’?” If the dentists had encouraged the provision of a dental benefit scheme from the outset, then the definition of “dental” would have been clear. However, there are a number of health professions that have “dental” in their title. Not are the least of which are “dental hygienists”. These professions with dental in their title could argue that their services should be eligible for benefits under the Australian Constitution. Unlike “medical” which has been defined, any profession with “dental” in its title could be recognised as an independent profession. For instance, the Australian Health Practitioner Regulation Agency (AHPRA) lists dental hygienist, dental therapist and dental prosthetist.

I am a great supporter of a universal dental scheme, but I am also opposed to shovelling out money without consideration of the consequences. This will be a recurrent theme as my blogs keep piling up.

A Child Care Parable

There once was a young post-graduate student, who was pregnant. She had graduated in medicine and then there were restrictions on pregnant women being interns in hospital. Some reasons had a trace of validity, but most were the consequence of male prejudice in a male dominated profession. Her husband was newly graduated in medicine but the annual wage for an 80-100 hour week was about 1,000 pounds including his board, but not hers. She remembered escaping being machine-gunned by a low flying American plane in the war. Although a small child in the street in Ljubljana, and the plane was so low she saw the face of the pilot, who aborted his strafing run when he saw that it was a child. He was black.

She was thus of migrant parents who had been refugees from central Europe. So her upward progress had been though determination and sheer hard work. She wanted a career, but she also wanted her child to be looked after in a safe environment in which she had a role in assisting. So she started a group with friends, who initially raised funds by serving coffee and biscuits at the university theatre. Eventually she secured a premise in an old Jewish school in the inner city near the university.

Then the battle for recognition and viability started – making ends meet and battling a government department headed by conservative male bureaucrats and complicit older women, whose model was the wartime nursery. These were set up so that women were freed to work in the factories and elsewhere. After the war, it was assumed women would know their place and retire behind the white picket fence. Those who wanted careers could resort to parents or nannies.

A fire had occurred six years before in a childcare centre, in which a number of children had died. Regulations were tightened, some justified, others less so. For instance, there needed to be a dining room with spatial dimensions of ten square feet for the first ten children and then eight square feet per child after that, presumably on the basis that the more children there were the smaller they became. Really?

Attitudes hardened and the idea of providing for parents to run a co-operative was resisted. However the co-operative was formed with parents as directors and the government reluctantly provided funds to renovate and equip a centre in accord with their strict regulations.

Parents paying fixed term fees from one to five days a week solved the question of financial certainty and hence assured financial viability.

The Centre had a trained registered nurse with child and midwifery qualifications as the executive officer and a kindergarten teacher, and others trained to various skill levels, both full time and part time, meeting the requirement for one staff member per five children for infants and one for fifteen when they were at kindergarten level. I use the word “skill” because education here requires in-service training, more males, and adequate salaries. Of these aspirations, she never enticed a male onto staff. Otherwise she was very successful.

She was adamant that all the staff be trained and cared for by the executive. The turnover rate as a result was low.

She had two sons, one who went into care at six weeks. They are now in their fifties, successful in different fields, each with a working spouse and each with three children.

Her advice even now could help a government intent on bringing in a childcare scheme, free of rorts. Subsidising the for-profit sector without demonstrable parent involvement is not the right business model.

The Centre she set up is still going strong.

Mouse Whisper

Experienced at the lunch table at the Magill winery in the suburbs of Adelaide when asked whether she preferred to be called “woman” or “lady” the young waitperson responded: “established female”.

Modest Expectations Fathom

This question may be seen as a bit odd for those who don’t have a father who was a young man in the 1930s, and I say father not mother – not to be disrespectful to women – but as a sign of the times in the 1930s.

“Which side were you on during the Spanish Civil War?” Did you back the republican government or Franco? It is a double-barrelled question, because that war can be interpreted as a battle between fascism and communism for two reasons. Hitler was testing out his military might, not only on the Republican army but also the Spanish citizens and Stalin was making sure, in the guise of supporting the Republican cause that he sacrificed socialists and anarchists to his form of authoritarianism, laughingly described as communism. However, the Republic was the legitimate government.

The Spanish Roman Catholic Church supported the Franco insurgency as also did the Church in Ireland. An Irish brigade was formed to fight for Franco. It was so ill-disciplined that Franco sent them home. However, the Irish connection is a recurring theme.

Most of those men from other democratic countries, including Australia, who went to fight were on the Republic side. The only recorded Australian who actually went to fight for Franco had a change of mind and he was killed while flying for the RAF in 1940.

However, it is a textured question. The cloth for the Spanish Civil War was woven years before. The Italian Futurist movement, which glorified war and dismissed history as bunk, was hidden beneath its paintings and poetry that provided the warp for the rise of Mussolini. Disaffection and perceived decay of the Weimar republic among other factors led to the rise of Hitler in Germany.

This was manifest not only in Australia, but as the New York Times noted this week in an editorial: In the 1930s and the 1940s, The Times was largely silent as anti-Semitism rose up and bathed the world in blood. That failure still haunts this newspaper.

A young Sydneysider, Phillip Morey, experienced its rise in the early 1930s, when he recognised the Fascists with that expressive word “rodomontade”. Below is taken from a memoir written about Philip’s experience:

He loathed the fascist New Guard that had been cavorting around New South Wales at the time. He considered the rhetoric of Eric Campbell, its leader, to be a “bombastic rodomontade”.

Philip remembered Campbell from two years before when the antics of Captain De Groot on Saturday 19 March in 1932 had initiated a confrontation with the Lang Government. Not that Philip had much sympathy with Jack Lang …

Francis De Groot was an Irish fascist who lived on his own bravado. Campbell was the populist Fascist — organiser of clandestine training for his New Guard for whom Mussolini in Italy and this new fellow Hitler in Germany seemed to have some answers to the world disorder.

Philip was determined that he was not going back to this world where the colour of the shirt seem to dominate — whether they were “black shirts” or “ white shirts” — Philip had thought Campbell’s posturing all very puerile — playing soldiers with his band of followers in various parts of Sydney. He had heard just before he’d left that they had been drilling in Killara, further up on the North Shore. Campbell had even issued a directive on street fighting — how to march with fixed bayonets and how to clear buildings with grenade, tear gas and rifle.

The text rings true when you see the antics of the extreme right today. The current mob has the ethnic hatred of Eric Campbell and later Eric Butler with his League of Rights. Then the target were Jews, and there is still residual anti-Semitism, but Muslims are now the prime target, and unlike the pathetic followers of Eric Campbell, their spiritual descendants have access to murderous weaponry.

How more insidious are the inheritors of Bartholemew Augustine Santamaria, in the 1930s, a rising intellectual within the Labour movement and protégé of Archbishop Mannix, once an avowed member of Sinn Fein? Santamaria was an avowed admirer of Franco, the only difference between Franco and Mussolini was that Franco stayed neutral during World War II and died in bed.

The Santamaria playbook mimicked his perceived communist foe in the union movement. He created industrial “Groups” within trade unions, backed by a secretive “Movement” designed to plant Catholic operatives in key positions throughout the Australian Labor Party – only now they are embedded in the Liberal Party.

But back to the question of 1936, how many of those who now support the heir to the Movement in the Sydney Institute would have voted Franco if they had been in the time of my father? However, I do not want to limit that question only to that select few – anybody can answer.

And the relevance? Franco was a tyrant who clothed himself in the Roman Catholic Church – currently in the western world, we would have one would-be tyrant, who clothes himself in fundamentalist creationism and another in the Orthodox Church. They are most prominent but not potentially the only ones. Franco is their shroud.

The “textured” metaphor is apt.

And my father? I believe he would have voted for the Republic, but then I never asked and he was unpredictable.

Fanfare for the Common Man – A Reflection on Anzac Day

Across the water from the small township of Lubec, Maine is Campobello Island in Canada. I have crossed the bridge to the island. Campobello Island is synonymous with Franklin Delano Roosevelt. Roosevelt smiled. Roosevelt exuded optimism. He was also a cripple, struck down by poliomyelitis one morning on this most beautiful of islands. Yet he strove for independence.

Until the ghastly event in Christchurch, I thought I came from a country where to “bare arms” is to get down to work with my fellow citizens. Yet I live a country where our major commemoration is a World War One disaster at Gallipoli and our national day is called by some “Invasion Day,” when Great Britain dumped a bunch of their unwanted – convicts and marines – in a desolate place called Botany Bay in 1788. Despite its apparent vigour, Australia is a country rooted in pessimism.

By contrast, the USA national day celebrates something more than putting a British foot on a distant shore.

Australia has a dirge for a national anthem. That of the USA was forged as the smoke from the British bombardment of Fort McHenry cleared and the American flag was still flying. Francis Scott Key was inspired to write the words of “The Star-Spangled Banner.” Today Fort McHenry is one of two places in the United States where the fifteen-star flag still flies. The other is at the end of the Oregon Trail.

I have seen much of Australia.

But then I have been privileged to roam the United States too. I have sponsored two musk oxen called Amethyst and Pixie Stix in Alaska. I have sat in the South San Franciscan courtyard of Genentech just after it had started listening to the late Bob Swanson’s aspirations and then writing about it. I have eaten king salmon in Salem, Oregon, and crab in Sabine Pass, Texas – both sublime experiences. I have stood at the door of that miracle of Minnesota, Mayo. I have gazed at Mount Rushmore and know now why those four presidents were carved. I have wept at Shiloh. I have stood in the wheel ruts of the Oregon Trail in Douglas, Wyoming. I have joined in a march to the San Francisco Tenderloin on January 15 to honour Martin Luther King. And oh, so much more!

The United States in all its diversity has been my energiser from the first time I ever went. Even in adversity, this country has always exuded optimism, irrespective of Trump.

“Make America great again!”

What rubbish! America remains great so long as it never lose its Smile, it never loses its Optimism; but above all it never loses July the Fourth and its Constitution.

If we want to replace January 26 as Australia Day…

“The first celebration of Wattle Day was held on 1 September 1910 in Sydney, Melbourne and Adelaide. Plans in 1913 to proclaim the wattle as a national emblem and to celebrate Wattle Day nationally were interrupted by World War I, but wattle remained a strong symbol of patriotism during the war years.”

This Google entry sums up Wattle Day succinctly.

One can only be struck by the colours of the Australian countryside in early spring. The yellow displayed is not only because of the wattle but also because of the canola in the broad acres and broom along the roads – there are so many yellow wildflowers but elsewhere it is the yellow of the prickly gorse scourge. So every symbol has its downside.

Intermingled with these patches of yellow is the eucalyptus green countryside – the wattles themselves, the gum trees and then there are the green pastures and cereal crops yet to ripen.

And when the land is so green and yellow should this be the time to remember our country with a national day? After all, the Argentinians, whose national day is May 25 say you can look up into the sky and see their flag. In September we would have the option of both looking up to see the Southern Cross but also to see our national colours across the land.

Even D.H. Lawrence in his rather dismissive novel about Australia, Kangaroo, wrote: In spring, the most delicate feathery yellow of plumes and plumes and plumes and trees and bushes of wattle, as if angels had flown right down out of the softest gold regions of heaven to settle here, in the Australian bush.

And what a time of the year! September is the gateway to the football finals; the cricketers are emerging from their chrysalides; and the festival finishes on the first Tuesday in November. A September 1 Australia Day would be a time of rebirth and not one stained by the metaphors surrounding colonisation and invasion.

Leave January 26 to New South Wales to work through those first years of the Rum Rebellion – and with climate change the temperature will probably be the same in September as it is now in January.

The Doctors’ Dilemma

In 1946 the Australian Constitution was amended to include the provision of health benefits for medical treatment, dental treatment, hospital and pharmaceutical benefits. Very specifically defined. In 1946 when this question was asked of the people of Australia, there was not the diversity of health professionals operating outside an institutional framework.

Therefore whenever any other professional group (apart from the dentists) wants access to Medicare, they have been blocked by the Constitution. Except that there have been a number of instances where the Constitution has been sidestepped, notably in the 1970s when optometrist benefits were introduced. It so happened that at that time there were a number of optometrists who were politicians on both sides of the House – and bingo, benefits were introduced because optometrists in the provision of these services were deemed “medical”.

In fact, many areas of medicine could not operate without the inclusion of the cost of the nurses, technicians and scientists, as occurs in pathology, radiotherapy and diagnostic imaging. The fee for Medicare benefit can incorporate a professional component (the doctor moiety) the technical moiety (including the non-medical staff) and a capital component (for the machinery). This is best exemplified in the structure of radiotherapy benefits.

However with the expansion of the Medicare Benefits Schedule after 2000, payments were made to a whole variety of health professionals through the Medicare Benefits Schedule but all were contained within or linked to medical care.

This interplay with doctors is shown by the midwife eligibility criteria:

A collaborative arrangement is an arrangement between an eligible midwife and a specified medical practitioner that must provide for:

(a)  consultation with an obstetric specified medical practitioner;

(b)  referral of a patient to a specified medical practitioner; and

(c)  transfer of the patient’s care to an obstetric specified medical practitioner, as clinically relevant to ensure safe, high quality maternity care.

There is no independent set of benefits. “Collaborative” is the closest the government legal advice has allowed given that “deeming” would be a red rag to the bull for the present generation.

However, this cute sidestepping trying to avoid the Constitutional restrictions only survives unless there is a High Court challenge.

Currently this manoeuvring does not threaten the doctor’s livelihood, but once the threat of another health professional group threatening general practice incomes then it is not only the politicians who will hit the fan.

Obviously if your basic income is government guaranteed who would not want that? The AMA is reported as being opposed to nurse practitioners obtaining Medicare benefits for their patients as with the independent stream of allied health professionals. If the government were to do so, would nursing be deemed “medical” or would the Government have to put nursing benefits as a Constitutional amendment to a referendum? With the backing of powerful nursing unions in an atmosphere ignited by the MeToo movement, any referendum would be a forgone conclusion.

Getting an amendment into the Constitution would be one achievement; it would then be a case of setting the scale of benefits. All the arguments about relativity would explode both between professions and within the nursing profession and each of the other professions included in the Constitutional amendment.

Talk about Pandora’s Box. In amongst this mayhem the central agency boffins would be tearing their hair out over the fiscal consequences of all this.

And compounding all this political noise is the proposal put forward by Shorten to set up a universal dental scheme – I shall deal with that in my next blog. Ah, the joys of policy formulation.

Mouse Whisper

The owner of the Dry Dock pub on the Finke River was heard to say to the customer in white:

“Son, when are six feet eighteen hands? Not too difficult to fathom the answer.”

Modest Expectations Fore

Golf puzzles me. However, I do enjoy fluttering around the Masters Golf Course in Augusta on the YouTube bird. A floral pilgrim arboretum with quaint names like Amen Corner and Flowering Crab apple; kaolin coloured bunkers; water courses and ponds interwoven with trees and bushes which seemed to be groomed rather than planted. The spring flowering dogwood, azaleas and magnolias provide a regimented colouration – red, pink yellow and white. The annual Master’s tournament is testimony to that Brownian movement which is America. The winner this year – an epithet for Trumpian America – tiger woods.

In contrast, every time I pass the Rosebery golf course on the West coast of Tasmania, against the mountainside away from the local zinc mine there are abundant green fairways dotted with a mixture of exotic and native trees – just varieties of green. Perfectly groomed but lacking bunkers. Never have I seen anybody playing golf there – not even a Tasmanian devil stirring – it seems a golfing Marie Celeste -an epithet for Canberra at election time.

Lessons from the Memorial Sloan-Kettering Malfeasance

The whole political spectrum is awash with promises of funding for cancer but it is nigh impossible to predict the expected outcome from the actual outcome. The ALP seems to want to provide money for patients whereas the commitment on the Coalition side seems to favour research.

Except for certain localised cancers, mainly of the skin, the cancer patient become a statistic in the survival rate – in other words the cancer patient always hopes to be at the far end of the survival curve. Increased research funding is equated to increased survival.

The current Australian election campaign is awash with promises to tackle cancer. The time-honoured political response is to promise more money for research – however it is dressed up. Politicians have always seen cancer funding as a vote winner – they can provide funding without strings and bask in the immediate kudos.

Therefore, the recent Memorial Sloan Kettering Institute disclosure is something to make everyone pause. This institute is prestigious, shorthand for “above reproach”. I have actually visited this sprawling but unremarkable bastion of cancer treatment and research on the East Side of Manhattan.

The New York Times has been progressively reporting what one may describe as “malfeasance” – corruption seeping through the upper echelons of the Institute.

The heart of the matter as reported by the NYT is that fact that “scrutiny of researchers’ stakes in start-ups has intensified at a time when venture capitalists are betting millions of dollars on the next potential cure for cancer and when expensive treatments like immunotherapy have fueled public concern over rising drug prices.”

As reported in the NYT, a review, conducted by the law firm Debevoise & Plimpton presented a week or so ago concluded: “that officials frequently violated or skirted their own policies; that hospital leaders’ ties to companies were likely considered on an ad hoc basis rather than through rigorous vetting; and that researchers were often unaware that some senior executives had financial stakes in the outcomes of their studies”.

There has been a great amount of public soul searching, but it seems that despite the list of questionable activities at the Institute most if not all those with fingers in pie have survived and the cosmetic changes and promises to do better have not been matched by deeds. The excuse is that culture change takes time, but when the direction of research becomes a branch of a hedge fund, then in the long term the effect is that of a “warm lettuce leaf” sanction.

However, when the scandal emerges in a leading institution in USA, it is reasonable to assume it is not an isolated example. The problem is that anything to do with health is now a business and health is just one commodity on the sprawling profit and loss sheet. Aiming to save lives in the most effective manner – an incidental – is met with guffaws by this coterie. So let the policy makers shed the faux Pollyanna approach to research funding, knowing how difficult it is to remove emotion from any decisions – hence this is an area where any policy makers worth their salt should follow the money trail – and hopefully not end up finding a Memorial Sloane Kettering Institute at the end of the trail.

Howard Florey, our greatest Australian, the man who gave penicillin to the world would have shaken his head in disbelief. He never benefited from the discovery; never made a buck out of a drug which saved millions of lives but ironically changed the fortunes of the pharmaceutical companies who picked up the patent.

After all, infectious diseases were the cancer equivalent of the day. Lest we forget. 

The Out-of-Pocket Expenses

Cancer is multifactorial; it is an expression of everyone’s mortality.

We, the patients have to bear the brunt; and given the mortality surrounding cancer that brunt is so often deadly.

Pancreatic cancer in particular has a five-year survival rate of 7-8 per cent; and that is survival not quality of life.

Some unfortunate people get multiple cancers – just not metastatic spread. Many cancers are terminal. Treatment is surgical, radiation, or chemotherapy – cut, irradiate, poison. There is nothing pleasant about cancer; and if you emerge from this experience and are presented with a huge bill then it adds to the unpleasantness.

One approach to alleviating the burden of cancer is to improve the funding of the actual care, and that seems to be at the heart of Shorten’s stance. Minimise or eliminate the out-of-pocket expenses. However, apart from waving a few figures around, the implementation is just that – short on detail.

There are number of matters which need to be balanced – the Medicare benefit the government is prepared to pay and the fee the doctors charge. The figure of $150 has been mentioned as some extra payment. What does that mean?

Inevitably as one grows older, one is faced with the prospect of surgery. As a privately insured patient, I always ask what will the whole business arrangement known as “operation” cost.

What is the price? How much will that vary from (a) the MBS benefit (b) the amount guaranteed by my level of health insurance? The surgeon is responsible for the whole episode including post-operative management no matter to whom he or she may delegate it.

There is the anaesthetist – the person who suddenly appears before the operation at the behest of the surgeon. Since the surgeon hires the anaesthetist, it is reasonable for his or her price to be disclosed.

Then there is the surgical assistant – often a supernumerary – but who has to be costed in and someone the patient probably never sees. “Is that person necessary?” is the obvious question.

The same occurs with pathology – the pathologist is rarely seen – and diagnostic imaging, where the patient may see somebody vaguely resembling a radiologist.

Then there is always the matter of complications to be factored in and therefore the total cost before anything else needs to be agreed. The patient should not have to bear all the risks.

Similarly there needs to be a price put on the radiotherapy or chemotherapy, with may occur in association with surgery or independently.

Then there is the unknown – the cost of palliative care. Unless, you the patient are demonstratively terminal, it is not something the average cancer patient wants to think about. But nevertheless it entails a price; dying from cancer is not cheap.

When you buy a house, you don’t buy it room by room. Therefore, for that purchase knowing what you do, what your entitlements are and then negotiating from a solid basis breeds a degree of certainty. If you as the buyer feel this task is all too daunting you get someone you trust with the appropriate knowledge to do it for you.

Buying a property and assuring health are no different in needing a broker than any other commodity.

Now try and translate that into what the political parties are suggesting as health policy. This area is complicated by the current review of the Medicare Benefits Schedule, which has been going along for four years but with an end point in creating a new MBS schedule without putting any value on any of the items. Alice may well be asking where is the tea party.

Yet the ALP has a proposal putting finite values on patient reimbursements and injecting them into health care financing. Pluck a figure from the policy teapot to give to the patient as an added benefit, and the market may absorb that benefit and the price for the service commensurately rises.

The current state of affairs is not the best situation in which this policy initiative is being put forward – private insurers put up their premiums, doctors charge what they believe their services are worth or what they think the market will bear, the central agencies of government hover to squeeze the value of the benefits.

Let us set out a premise. Once diagnosed, cancer treatment in our affluent society should be cost free to all. Having made this statement it is tempting to think that premise too fanciful. However that is the challenge and just throwing a consultation benefit or subsidising one piece of equipment to the exclusion of others does nothing to solve the problem.

It would be useful if the patient could choose a one-year or five year survival package with named participating doctors, health facilities and health insurers who would accept the package based on the mean expected survival. The actual projected expectations should balance out the assumptions underpinning the package. The assumptions should be made clear. Work on the basis that whatever figure, however fair and reasonable will be inevitably wrong; so err on the side of generosity.

This is not fanciful – there are arrangements where surgeons label them selves as “no gap” when linked to particular hospitals with arrangements with health insurance, but it is patchwork – sometimes quite attractive patchwork.

However, it does not absolve government, and when politicians enter funding for cancer, there should be a plan to give the cancer sufferer a non-transferable amount of funding either in a one or five year package according to the expected price of such service – realising that currently MBS benefits provide a de facto floor price – the public hospital provides a guaranteed government funded place. Private hospital insurance premiums and the AMA list of recommended fees provide the other end of the price spectrum. Work between those two limits and determine the fund holder. In the end if information were symmetrical it should be the patient and his or her family, however defined.

The resultant cost accounting exercise should not be beyond the wit of a smart bureaucracy. Absolve oneself from the clutches of the external consultants to do the work. Have a team dedicated to the task – not as happens all the time continually shift the bureaucrats around to destroy any continuity and thus disrupt the timetable.

Do not let the work of this well-intentioned attack on cancer meander for years. Have a very concise timetable – three to six months. There is enough information. It is a matter of distilling the options. Go to it.

Mouse Whisper

Overheard on Big Rat Island:

“Whose idea was it to change the Island’s name? Totally inappropriate! Kerr was not big.”

“But you forget the top hat, mate.”

Modest Expectations Hiru

“This is a serious horse, Mary Lou!”

These slightly reproachful words were uttered by a Spanish dressage instructor on a property west of Theodore in Queensland, where he was conducting a dressage training weekend. The owner had dared to turn away from watching him put her elegant black horse through its paces to chat to her friend. She should have been closely watching the intricacies of what the rider was doing, hence the sharpness of the tone. I was just an onlooker, but these words have entered my lexicon as words when you want to concentrate the mind.

I have followed Winx since her first win as a two year old in 2014. She has grown in stature since that time – a serious horse in every meaning of the word.

As she faces her last race, I note that the Liberal party are having difficulty pre-selecting candidates in some seats.

Just a silly thought to believe that you could put Winx on any of those ballot papers, now when politicians are so much on the nose. I would wager she would get more than just the “donkey” vote.

After all, the Emperor Caligula made his horse a consul. And they thought he was mad. However, I believe that horse won his election in a canter.

(Painting of Bowman and Winx by Garry Higgin)

The Protoplasm that is Politics

The Coalition Government in 1972 was a remarkable beast. It was caught up in Menzian aspic in a culture of internecine strife, which had been plated during the Holt days as Prime Minister. While John McEwen was around, this protoplasmic mess was controllable. However, he retired in 1971, and McMahon was let loose.

At the apogee of Australian civilisation as we knew it then was Prime Minister William McMahon, a prissy spiteful destabiliser, whose contest with the truth was in most cases found wanting. He had married late in life, and used his wife as a fashion plate accessory – remind one of someone? His government had difficulty in disentangling itself from the Vietnam War – and remember China was then indeed the Yellow Peril – a place for Australians to be quarantined against. Policy considerations were neglected by a Government exercised by whim and patronage spiced with payback.

Gough Whitlam by contrast provided an articulate alternative, offering Australia a new way. His election campaign was vigorous and enthusiastic. He had vanquished the Old Guard and promised so much – his clarion call being “It’s Time.”

Yet even with support of Rupert Murdoch, Whitlam ended up with a majority of only nine seats – and five of the ALP gains were in NSW.

Morrison – compared to McMahon? Time will tell. The Liberal party in 1972 had the DLP albatross, but now the continuing DLP cohort is embedded in the Falangist arm of the Liberal party. The Liberal party branches, once conceived to provide policy advice – “listening to the people mythology” – in reality are the vehicle for partisan pre-selection. It is thus unsurprising the so-called Liberal party has the crop of politicians it now has, seemingly out-of-step with the electorate.

That seemed so true in Victoria; but does it matter what candidates you have when one ignores the yearning for centrist politics where the art of negotiation is preferred to the strident megaphone?

In Victoria at last year’s State election, Daniel Andrews achieved an electoral landslide. In NSW Gladys Berejiklian has held the line for the Liberal party. Each has been pouring money into infrastructure, in a way that Whitlam promised to do in 1972 – into cities, regional centres, health and education. You can imagine Andrews and Berejiklian preferring the first way rather than yelling at one another, especially now they have both been re-elected for four years.

Morrison clings on, his hand on the megaphone. He should look at the 1972 and get some comfort, where in the end the overall swing was 2.5 per cent and even with McMahon, the Liberal Party still won four seats from the Labor party. At that time there were three Liberal and one National party premiers, including NSW, Victoria and Queensland. Today there are three Liberal party premiers in NSW, South Australia and Tasmania.

And Shorten is no Whitlam. He does not have the charisma. Unlike Whitlam, he has two strong lieutenants, Wong and Plibersek who, as the election nears, may become more prominent. However, with the media concentration on the two leaders, because the imagery of the prize fight is much more easy to convey in an election, emphasise the ‘may’. Therefore with all the talk about gender equality will these powerful women resonate – or be allowed to do so – in rural and regional Australia.

Even if the players are different, the scenario is reminiscent of 1972.

The long term lesson for what should follow as could have occurred from 1973 onwards? Defining and constructing the hard centre of politics, combatting this tiresome fearmongering, remembering what David Owen, the British politician, once said to me – never get caught in the soggy centre of politics. One might say that his is a re-interpretation of that familiar mantra – drain the swamp.

But that is only the start … hard… please define!

A few thoughts on the first salvos in health policy – Chris Brook comments

The budget and budget reply 2019 are now completed and no one could mistake that each was effectively a campaign launch for a Federal election – ending up as six weeks after the Budget.

Both have committed to expansion of funding for MRI and imaging more generally, (well done whoever lobbied this through both parties because there has been longstanding underinvestment in this technology). However, the ALP proposes to invest in greatly reducing out of pocket costs for cancer care, most of which is non-inpatient.

It seems ironic that the ALP is prepared to pay to repair a problem that is partly due to withdrawal by States of public oncology clinics. Thus, patients cannot access free care. The end result of the ALP’s plan hopefully will restore free care in public hospitals. It will be interesting to see if the Commonwealth chooses to claw back funding from the States for this, in effect exacting a punishment.

The Coalition has committed $450 million on chronic disease payments, especially for diabetes. Missing so far is the detail of what is new funding as opposed to just altering MBS descriptors.

The literature suggests such programs improve patient perception of care, which is a positive, but neither reduce cost nor hospitalisation rates.

Mental health funding is boosted in the Budget, though spending more on Headspace where its evaluation has given at best tepid endorsement. Nevertheless, any money directed to early psychosis is welcome.

Both sides promote their resumption of indexation for GP attendances, and not before time. It was always a cruel means to cut outlays.

The Coalition commitment to fund new drugs is welcome, though I note that the cost of the PBS is rapidly becoming the major cost driver in health , approaching $14 billion per annum. However, since “Big Pharma” makes a number of concessions and discounts from the list price, the real cost is closer to $9bn.

The rest is snippets and bits although the absolutely uninspired changes to Aged Care and Disability will have a strong indirect impact. If patients cannot access care, the putative expansion of care lends an air of unreality. By default the aged and infirm are forced to attend local general practitioner clinics or hospital emergency departments.

From my objective standpoint, the ALP wins this round, but it is early days in the campaign, so keep alert for further comment.

Mouse Whisper

Heard in the back of the Melbourne Club Caboose: “These three blokes born in December were given a portrait of Winx, each with Hugh Bowman atop. Why? Because a Sagittarius is half horse, half bowman.”