Medicare Archives - The Best Mouse Tap

Modest Expectations – Beagle spelt within a M

A brief note of mixed disgust and incredulity. Tasering a 95 year old woman suffering from dementia, slowly wandering around with a steak knife in one hand and holding onto a walking frame, in the early hours of the morning.

Who called the police? What training had this staff member had to relieve the demons circulating in this fragile lady’s failing mind.

Then we have a police force which cannot relieve the underlying anxiety of an old, confused lady sufficiently to take the knife away. God knows what was going through the old lady’s mind. God knows what was going through the police officer’s mind. Tasering the old lady twice – not once.

As I was writing this piece earlier this week, I expressed the view that the shame should move right to the top of the nursing home and the police. I still hold that view. I also still maintain the view that the Police Commissioner’s response was pathetic and her lack of empathy lamentable. I remember one of my old Professors, who said sometimes Jedburgh Justice was the best way. Hang them first; and then try them.

I had written more. However, now Mrs Nowland has died and serious charges have been laid against the police officer, with likely more to follow. Nothing more should be said other than policies, procedures and training in both nursing homes and for police responding to situations in these places need to be reviewed immediately – as should that of a Commissioner whose reaction in plain sight fails in so many ways. But that relates to a far wider problem of how such a person has reached the top braid.

In a Town in Nova Scotia

From the 1980s onwards, I have spent various periods in Canada; in fact I include Newfoundland in the places visited. Among the places I have been to in Canada was Sydney, Nova Scotia. There are a few places named Sydney around the world, including a whistle stop in North Dakota and across in Montana a bigger spot on the map called Sidney.

However, I was curious to visit Sydney Nova Scotia. Why? Because it was there and I happened to be in Nova Scotia for some other reason. It was early April, bitterly cold, and the Atlantic Ocean on the shore was still frozen as if it were an ice sculpture. The first reminder that this province was still in winter emphasised by the “hairy” night time landing in Halifax en route. While I am not a white-knuckle flyer, there is something eerie about descending through a yellow stained cloud, and not seeing the ground until it appeared just before touchdown. The plane then sat on the tarmac; and we waited for about an hour before resuming the last leg to Sydney.

Sydney was a very unprepossessing coal town on Cape Breton Island, tucked away on the Sydney River. The town was founded after the American War of Independence by Colonel Joseph DesBarres and named in honour of Thomas Townshend, 1st Viscount Sydney, who was then the Home Secretary in the British cabinet. Lord Sydney appointed DesBarres as lieutenant-governor of the new colony of Cape Breton Island. It was a busy time for Lord Sydney as, after the loss of the American colonies, there was a need to retain the Canadian loyalists and find another place to dump convicts. Sydney was a busy Boy. Nevertheless, after having the Cape Breton settlement named after himself, he also had the new settlement in New Holland named after him by Arthur Philip, the naval officer he sent to establish the convict settlement, and in what Philip descriptively named New South Wales.

DesBarres headed a group of loyalists and soldiers who set up the town of Sydney in the Spring. Amongst the first matter of business was to build a church for people and soldiers to pray in. British engineers from the 33rd Regiment of Foot, under Lieutenant-Colonel Yorke, with the help of masons, built the St George church. King George III supplied £500 in 1787 and DesBarres added Caen stone from ruins of the Fortress Louisbourg This finely cut stone was used specifically as “finish stones at the corners of the building and around the windows and doorway”. The building was completed in 1791. Somewhat different priorities to the Rum Corps.

I was invited to meet the local council when they found I had come from Sydney Australia, and it being 1986, a year after their bicentenary, they showered me with the leftovers of the celebrations, bunting, souvenirs, including a tartan scarf which has long since been consumed by silverfish. The one reminder I still have is a plastic cameo brooch of DesBarres.

Cape Breton Island, beautiful even in mid autumn, concealed the fact that it had long been a coal mining area from the late 17^th century when the original French colonists had discovered it and then it was continuously mined to the mid-1970s and episodically since, hence the description of Sydney as “Coaltown” – and the major reason for its current population of about 30,000. There have been desultory attempts to re-open the mines, and so-called “bootleg mining” since. When I was there, it was defining what would replace the traditional major industry.

Tourism is always one solution, and the Cabot trail around the Island showed the disparity of these fishing villages dotting the coast as one such attraction. There would be a predominantly Scottish village and then the next one an Acadian village. In the latter, the reaction to mention of the “Quebecquois” was somewhat amusing. One of these Acadian French dismissed them “nouveaux” – they even changed a perfectly good word “patates” to “pommes de terre”, he said. Unfortunately, it was too early for the traditional feasts of lobster and rock crab, but one cannot have it all.

When we landed, I noted an advertisement at the airport for Air Pierre. The French have a penchant for holding onto their colonial empire, having been early into North America unlike most of their acquisitions elsewhere In Africa and the South Pacific. The only remnant of their Northern American colonial possessions are two tiny islands in the St Lawrence, called St Pierre and Miquelon. When I was a child, I remember I had stamps from these places. The islands achieved notoriety during Prohibition, being a major centre for smuggling French grog, still wine, champagne, vermouth and other spirits into the United States. Unfortunately, I was not able to go there because the weather was foul and during my stay Air Pierre was grounded.

I intended to go to the Louisburg Fortress. The morning was cold and I woke with a very strange feeling of foreboding. I felt that my close friend Alister Brass had passed away. Before I had left Australia, I knew that Alister was very sick with AIDS. Nevertheless, there was no question that I thought he would not be alive when I got back to Australia. I went out to the Fortress, which had been built by the French, and was said to be worth visiting. It had been snowing, and the Fortress had been closed for winter. It was only when I got back to the hotel later that I received the news that Alister had died. Given the time difference, there were only hours between my premonition and his actual death. This coincidence or whatever has haunted me for the rest of my life. My poem to Alister published in a recent blog attests to this.

Berlin; Not Irving

I came across a couple of reviews of two recent books entitled Berlin: Life and Death in the City at the Center of the World and The Undercurrents: A Study of Berlin. I was there in 2002 to attend those International Conferences about the effect of technology on the quality of health care. You know, the normal talkfest, where the opening day is always well attended, the conference dinner is an opportunity to be photographed inevitably smiling with a glass of wine in one hand and the other hand, since the demise of the cigarette, a dangling appendage.

It also gave me the opportunity to see Berlin, 57 years after it had been reduced to rubble and being a city isolated from the West by being lodged in the middle of the Russian zone. The Russians with their year-long blockade of West Berlin failed in 1948-49; as did ultimately the Berlin Wall, even though it lasted for 28 years before it was pulled down.

The first book, written by Sinclair McKay, concentrates on the period from the end of WWI to 1989; the second, authored by Kirsty Bell, who has lived in Berlin since 2001, starts when she finds her new apartment has been built on “sandy, watery subsoil”. Berlin’s name is derived from brlo, a Slavic word for “swamp”.

When I visited, there was a surprising number of reminders of the “bad old days”, but the first impression – or at least the memory that has remained as one of the first places where I had something to eat and drink coffee – was in the Tiergarten Park, which covers over 200 hectares un the centre of Berlin. It was a sunny day when I lunched under the shades of trees. Contrast with the comment made in Berlin that at the end of WWII, only 700 trees of a pre-war estimate of 200,000 remained. Given the destruction and the failure of the Communist DDR to do much in the way of renovation of the city, by 2002 the whole city was returning to its mixture of the stylish and the tawdry.

One of those was Christopher Isherwood, who wrote Goodbye to Berlin, the underlying libretto for Cabaret. Isherwood lived in Berlin between 1929 and 1933, and I went to visit where he lived in Nollendorfstrasse 17, now a Turkish district alongside advertisements for sado-masochistic “entertainment” clubs.

My visit coincided with the FIFA Cup in 2002, when Turkey was being very successful reaching the semi-finals before being beaten by Brazil, and then winning the playoff for third place against South Korea. It was one of the successes during this period when the streets of Berlin were smothered in celebrating Turks and its national red flags with the white crescent being waved everywhere. The Turks constitute seven per cent of the Berlin population.

The other person whose tumultuous life I associated with Berlin was the Polish-born Rosa Luxemburg, whose inherent strength in her beliefs, although being a communist and being a founder of the Spartacist Group, was a genuine believer in a better world, one of the women I have always admired. She believed in democracy in the face of the Russian Soviet. She was murdered by members of the Freicorp, precursor to the Nazis. Apparently, according to Kirsty Bell, on the bank of the Landwehr Canal there is a bronze plaque where her body was recovered from the canal – a somewhat macabre memento mori. I was unaware of this. Otherwise, I would have paid my respects.

The River Spree runs through Berlin and, as with the Brandenburg gate, it is a divide between the West and East sides of Berlin. But the most striking reminder was the remnant of the Berlin wall, and alongside the remains of the Gestapo headquarters, with its subterranean horror show of the Nazi inhumanity. Holocaust is the common word to describe this whole dark period, which has left an indelible stain on those of us who were born into that era, but thankfully in a far-off country.

When you emerge into the summer light, it is not refreshing, rather a sense of concentrated disbelief. I take a deep breath and turn towards an adjacent handsome building. This is Gropius-Brau, its classical Italianate style, (reminiscent of a signature building designed by my great-uncle in Melbourne when it was awash with gold), so popular in the late 19^th century. Unlike many other buildings it had been restored because it was still pockmarked by bullets. Yet it had survived, been renovated and was still in use. I remember there was a post office in the building, which is now an exhibition centre. Martin Gropius was the architect, and he was uncle to the much more famous, Waler Gropius, who was one of the founders of the Bauhaus movement, so influential in the modernisation of architecture of which his uncle was so adept at designing in Classical style.

Crossing into the former East Berlin was a more emotional experience, and Berlin must have more museums and galleries than in any city of similar size – as the blurb put it: Berlin is one of the coolest destinations in Europe. With 300 art galleries, 170 museums, 3 opera houses, and 150 theatres. Museum Island with its plethora of museums needed more than the few days I had to spare. On and on, wandering through this formidable city.

The problem with visiting Berlin and getting a flavour of what has seen the very basest and very highest of human endeavour takes more time than I had. I have always intended to go back – but never have.

Pity. I’ll read these books.

The Bulk Billing Epic or the Mystery of how much Deloittes Received – Not Earned

Seven months ago, the SMH headlines shouted “Revealed: $8b Medicare scandal”. The accompanying editorial stated baldly: “Nearly four decades later, the concept of universal healthcare in Australia is at serious risk. Medicare – the bedrock of Australia’s health system and a core element of this country’s social fabric – is sick, and could soon be placed on life support.”.

This investigative report elicited a response from the Federal Government in commissioning an Independent Review of Medicare Integrity and Compliance by Pradeep Philip, a former health bureaucrat with economic degrees and now working in the lucrative field of consulting.

Philip would have been a knowledgeable bystander if not directly complicit in the cost shifting that the States have employed in undermining Medicare. The States were assigned certain responsibility under health agreements, but then became bureaucratic buccaneers in looting Medicare – euphemistically called cost shifting, the ruthless privatisation of their public hospital outpatient clinics. His Report does not help; it is poorly organised and thus embodies the criticism of consultants “that they only read the commissioning agent’s watch”.

The only concrete fact of relevance is that all the allegations of overuse and fraud are not backed by data. As one critic has said of his comment “While simplification and system changes are required as articulated in this review, there must also be a commitment by all stakeholders to change which will bolster the integrity and compliance of the MBS”, how can there be commitment to change in the absence of detail.

And what was behind Philip’s lavish praise of Dr Faux on the first page of his Review, when later the Report discounts her allegations, which were allegedly the reason behind this whole boondoggle.

After all, the previous Government had made a huge financial commitment in Bruce Robinson’s interminably Tolstoyesque Inquiry, which seems to have elicited a few changes around the edges of Medicare; and has been seemingly downplayed by the incoming government.

The government is concentrated on the apparent dearth of general practitioners, both absolute and relative. Hence, its fiddling with patient benefits for general practitioner care, including setting the benefit at 100 per cent, which destroys one important incentive built into Medicare, is destined for failure as an incentive.

The fault in medical training starts with the entry requirements, which has incidentally occurred with the feminisation of the work force. At the same time, the universities seem to have forgotten that the prime aim of the medical course is to turn out practising doctors and not researchers. The obsession for a primary science science degree so that graduates graduate with a sham post-graduate degree, a so-called “Doctor of Medicine” coupled with filling up the course with mature age students does not help. Added to that is the importation of a raft of overseas medical graduates which provides a toxic brew if the aim is to get a useful relevant graduate medical workforce.

Women make very good doctors. There is no doubt of that. I have watched the increase in female medical graduates, and I have perceived even at firsthand the difficulties the female medical graduate has in controlling the domestic scene as well as pregnancy. The problem is that the first leads to limited hours of practice and the second to time out of practice.

When my first wife was pregnant, she had to give up working as an hospital intern at three months, and even though in those days registration meant that one could practice immediately after graduation – it severely constrained her ability to work. Even though the prejudices of the 1960s have by and large gone and child minding is now considered an acceptable adjunct to family life, it means that instead of a commitment to a practice where patient treatment is the centre point, the centre point is now being able to balance home and career (so-called lifestyle). In other words, there is now an income and lifestyle target to be reached rather than a medical workforce being available to cover the national community health requirement 24/7 (excluding fully-staffed hospitals).

This lifestyle then results in male medical graduates expecting to enjoy a similar lifestyle (why not?). Coupled with the demise of the single doctor practice and the added effects of corporatisation of medical practice, the effective pool of medical practitioners has reduced, especially to those “perceived hardship posts”. Nobody gets paid for administration of a practice and the worries of running a business when the doctor also has a home to run. Hence the “progress” of changes in medicine where practices initially being run by entrepreneurial doctors, eventually succumb to the incursion of corporatised medicine, then the hedge fund that views health care as just another commodity, where profit is largely dependent on how much can be extracted from Medicare and how much can the employees be squeezed. Medicare is one of the open-ended government schemes limited by the value of the patient benefits, once very succulent but now, in reality, its total available funding is constrained by having to share with the NDIS (itself not immune from rorts that are now being systematically uncovered).

The problem is that leadership is lacking among the medical profession. I have tried to provide that leadership, but I have failed in the transferability factor of my expertise. I have banged on for decades about the challenges faced in rural regions – social dislocation, professional isolation, community tolerance and succession planning. These are challenges, even before money enters the consideration. To his everlasting credit, Chris Brook gave me my head in instituting a successful Victorian program – The Murray to Mountains Intern Training Program. Luckily, I had a great number of people associated in this program, who supported me, because I may have been the leader but never the boss of the program. This executive responsibility resided with a group of innovative rural health service chief executive officers, whom I was luckily to work for, plus one Shane Boyer. They should be listened to by the Minister.

The problem is that there is also no national leadership in this area. An opportunity indeed lost.

Was that Metternich who flashed by on the RAAF plane?

Monsieur Le Secretary-General – in front of my modest office

It is estimated that Australian taxpayers chipped in at least a million bucks to support the bid of former Liberal finance minister, Mathias Cormann, to become Secretary-General of the Paris-based Organisation for Economic Cooperation and Development. Judith Sloan in The Spectator

As the solemn group of important people trundled up to the Hiroshima Monument – these very important leaders of the Western World bearing wreaths – I espied on the wing position, a familiar figure. It was Mathias Cormann.

No longer one of Julie Bishop’s “swinging dicks”, no longer a cigar chomping accomplice of Joe Hockey in the construction of one of the most heartless Federal Budgets ever, no longer the unsmiling host of Prime Minister Morrison at a football match in Perth where the whole crowd booed them mercilessly, not the architect of the near obliteration of the Western Australian Liberal Party, and finally not forgetting his $23,000 jaunt to Broome in 2017.

No, this is the New Mathias Cormann, Secretary-General of the OECD, now a centrist Bureaucrat. He is seen “hob-nobbing” with everybody that he can possibly rope in for a photo opportunity. Given that the Australian Government underwriting him to traipse around the OECD countries in an ultimately successful attempt to escape the Morrison Titanic, he seemed to have thrived. Not for him the sleaze of the ex-politician misusing his former professional life to provide a luxury living. No, this is Mathias Cormann, the confidante of the Heads of State, a bon viveur fluent in at least four languages, now far away from the opprobrium of his former political life. He should rest secure in the knowledge that his deeply unpopular predecessor was in the post for fifteen years.

Mathias holds this notable hardship post with a tax-free salary of about Euros 250,000 annually plus a bagatelle of meagre benefits, such as 30 days annual leave, plus French public holidays and the one week the organisation closes each year. He is reported to have a grace-and-favour apartment, said to be relatively modest, where his wife and two daughters have just joined him for the initial five-year stint. I am sure Cormann with his track record of frugality has redefined “modest”.

But there seem to be no photos of him with Prime Minister Albanese. Listening to Cormann, with the polished accented voice re-iterating the deep meaning of life in honed cliches, our Prime Minister should be proud. I thus was surprised that these notables had not sought one another out for a “yak”. But there seems to be no record of them meeting at the recent G7 meeting. Have I missed something on the Crowded Sidelines of this Conference? Or is Cormann worried that the Prime Minister is going to serve him with an invoice for his Election Campaign payable in 30 days – heavens no, nor will he be served with an inaugural subpoena to appear before the newly formed National Anti– Corruption Commission (NACC), surely. Now when will the two meet – or not?

Mouse Whisper

You know, we mice when we meet, are called a nest; but rats are called a mischief or a plague. I, being a solitary nest, recently have had to share space in the house with this family of ring-tailed possums, whom I see through the window climbing down the bars from their drey in the roof to go nightclubbing in the nearby pittosporum. Three pairs of red eyes momentarily peering through the window – jill possum and her two joeys. The jack possum not surprisingly is nowhere around; so not sure whether she is getting the single jill possum allowance. The collective noun for ringtail possums? No, not an Edna but a Nesting – in general possums in a group are called a passel.

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 – We’ll drink champagne in Udine

Look, I’m not one for a Grudge …

To him, been just given the Nudge

I shall not, I will not, deliberately Fudge

Nor will I Budge

Yes, he said I did robotically Bludge

Then pushed me back into the poverty Sludge

Who? You guessed it, he was known as Alan Pakenham Tudge

Yes, some say he has left quite a Smudge

But whom am I to constructively Judge

As broken, defeated I onwardly Trudge

The Little Red Citroen

This is one prime example of the unexpected consequence. For years, when we have come to Tasmania, we hired a car. But with COVID and even before that, hiring cars was becoming prohibitively expensive in Tasmania, and at busy times of the years, the car hire companies introduced limits on the free kilometres.

Thus because of both this and increasingly wanting to stay longer in Tasmania at any one time, we made the decision to take the car ferry, the Spirit of Tasmania. Let’s say, that its disabled passenger cabin is excellent, even though it is a long corridor away from the lift, but the crew are solicitous, and one seems always at hand. On this occasion, travelling across from Melbourne to Devonport was uneventful, and we went down the West Coast to our property at Strahan.

When we decided to return, the rain had come to Northern Tasmania – flooding rains but some of the major roads remained open, even though much of the countryside was completely under water. However, the major unexpected consequence was that the level of the Mersey River at Devonport rose, floating the Spirit of Tasmania upwards, such that it was impossible to load cars and trucks. Therefore, with several cancelled ferries, and no confirmation of a new departure date for at least 48 hours, and a departure date delayed for effectively at least four days, we saw the uncertainty that bad weather introduces.

As we were due to go to Vietnam at the end of the week, we had no choice but to leave the car in Tasmania. Fortunately, we have good friends south of Hobart with space in their yard for a car. So we drove the car down from the North to their place, where we left the car and flew back to Sydney.

Fast forward a couple of weeks. Back in Sydney, preparing to travel to Tasmania to pick up the car. Then we were both laid low by a very nasty respiratory virus, not COVID, but may as well have been – how sick we both were. The upshot was that the car was marooned in Tasmania for another month.

Then “the cavalry” came to our rescue. Number two son said he was prepared to go and pick it up and bring it back to Melbourne – flight to Hobart, pick up the car our friends had conveniently left at the Hobart airport, then drive it to Devonport, overnight to the new Victorian Spirit of Tasmania destination, Geelong; thence up the Princes Highway and home.

By this time we were fit to travel, and as we had business in Albury, another friend offered to bring our car to Albury and meet us there. Number one son picked up the car, re-fuelled it and dropped it to our friend’s place. One-way hire of a modest sedan from Sydney to Albury cost about $1,000. Our friend having dropped our car returned to Melbourne by train, a trip which enabled him to read a book and which cost $20.

The exercise would have not been possible without this chain of friends and family. It makes us realise we are not alone on this planet – and we thank you all.

Medicare and the Constitution

Australia is consumed to a greater or lesser degree by the prospect of incorporating recognition of the Aboriginal people into the Constitution in a nebulous concept known as the Voice.

Meanwhile, the Government is flailing around wondering how to make Medicare work.

Medicare is made possible, because it is based on providing a range of patient benefits for a number of defined responsibilities.

In 1946 the following was passed in a referendum of the Australian people, an amendment to Section 51, namely:

(xxiiiA.) The provision of maternity allowances, widows’ pensions, child endowment, unemployment, pharmaceutical, sickness and hospital benefits, medical and dental services (but not so as to authorize any form of civil conscription), benefits to students and family allowances:

The Commonwealth does not have any constitutional power to regulate prices and incomes; and that is the greatest misunderstanding of how Medicare works. Hence doctors can charge what they believe is fair and reasonable; and only individual States can determine otherwise. Thus, of all health professionals, only doctors and dentists are able to receive Commonwealth funded patient benefits for their professional services. When the amendment was passed in 1946, the explosion of other health profession numbers had yet to occur, plus these professions being deemed to be in private practice. Patient benefits can only accrue to doctors working in private practice, although this has been systematically undermined by public hospitals “privatising” some of their clinics – in essence promoting double-dipping. Here the Commonwealth has been weak in its response.

In 1974, optometrists were given access to a limited patient benefits scheme where the profession accepted the benefit in effect as full payment; and they were deemed “medical” – a sleight of hand because at that time there was an unusually large number of optometrists as members of parliament. The other means of providing patient benefits is to provide a medically supervised patient benefit for a health professional group. In areas such as diagnostic imaging, radiotherapy and pathology, there has been a long term recognition that the benefit contains not only a professional component for the medical service but also the payment for technicians and scientists essential for the delivery of the services which are incorporated in the technical component of the medical benefit. The other component is the capital component, which acknowledges the level of capital expenditure to deliver the medical service. This last is a vexed question because it has not been universally agreed, and for instance, there is a separate list, from which prostheses are costed.

Recently, there is a clamour by various health professional groups for direct access to patient benefits, but despite the above stratagem, it should be ruled to be unconstitutional. As reported in the Persons with Disability and the Australian Constitution monograph, that:

In 1944, The {Pharmaceutical Benefits} Act was challenged by members of the Medical Society of Victoria with the support of the Attorney-General of that state. Publicly, the society objected to its members being co-opted into the scheme and having their professional judgment limited to only prescribing the free drugs from the Commonwealth scheme. The challenge before the High Court rested on two points. The first was whether the scheme that required doctors and chemists to act in accordance with the regulation was authorised by a legislative head of power in the Constitution. In short, did the Commonwealth have the power to regulate medical services? The second point was whether the Commonwealth scheme was in fact merely the appropriation and spending of funds authorised by the Parliament, and thus supported by the incidental powers under the Constitution.

The challenge was upheld by the High Court, but indirectly led to the future constitutional amendment in 1946. Effectively by adjudging the distribution of £30 million for the provision by the Commonwealth of free drugs to be unlawful constitutionally, it provided ammunition for that future constitutional amendment.

As a parenthetic comment, pharmaceutical benefits are directed towards providing a benefit to pay for medicines, and these are contained in the Pharmaceutical Benefits Schedule, not for pharmacists to provide independent professional services, however defined. This is a major pressure point, but it effectively confuses two roles. The pharmacist often knows more about the drug; the doctor, the reasons behind the prescription. Currently a pharmacist may provide health advice, for which there is no patient benefit. The doctor provides health advice for which there is patient benefit.

The pharmacists receive a patient benefit for dispensing medicines, their administration and the potential side-effects but not for dispensing health advice.

2023 – Prime Minister Albanese – who knows …

The Commonwealth Government has different means of handling this. Already it is strangling Medicare and effectively passing the funding as sickness benefits under the NDIS system. The Constitutional amendment by including “sickness benefits” codified Commonwealth funding in the disability sector. It is unfortunate but the AMA has been asleep at the wheel for decades, as the value of Medicare benefits to the patient has been eroded. In response, specialists have just raised their fees, devaluing in effect the value of the medical benefit. Increasingly, GPs have abandoned bulk billing and are charging fees that leave patients with significant co-payments over and above the patient Medicare benefit.

This solution is not that easy for general practitioners. They have been fooled because every time the Commonwealth initiates a review into Medicare, it just puts the whole question of increasing patient benefits on hold. Stratagems such as reducing time with patients, so the doctors time spent is little more than a greeting, a cursory look and then dismissal has been one response. As one wag jokingly said, in some practices, one doctor spent so little time with the patients that they had to be fit because they were required to jog through the surgery to sign the benefit form at the exit.

The central agencies shudder when they hear suggestions that all health professional services should attract a patient benefit – essentially an unlimited payment scheme only constrained by the Commonwealth’s willingness to ascribe a benefit. Currently, the Constitution stands in the way, but if judged by the legal challenge against pharmaceutical subsidy back in 1944, a referendum to change all that would surely be in the gunny sack of every populist Australian politician.

Ironically, amid this agitation, under the Constitution a dental benefits scheme could have been set up long ago. None has ever occurred, despite the concern over the dental health of the nation. Why? The dentists traditionally have not wanted it. This says something about the “influencer”.

Parramatta 1973

Back in September of that year there was a byelection. This was the first under the Whitlam Government and was caused by the resignation of the local member. This local member was Nigel Bowen who, after the 1972 election, had lost the leadership election of the parliamentary Liberal Party to Billy Snedden by one vote. In 1973, Bowen was appointed as Chief Judge in Equity in the Supreme Court of New South Wales. This meant his resignation from Parliament, thus precipitating a byelection. Nigel Bowen in 1964 was elected to Parliament to succeed Garfield Barwick, then on his way to be Chief Justice of the High Court of Australia. The Parramatta electorate at that time was “the Menzies gift”, as though he was propelling distinguished jurists into Federal parliament to emulate himself. It did not work out, although as Attorney General, Bowen produced some enlightened proposals, but not enough to be drafted in as Opposition leader.

As a distinguished jurist, facing years in Opposition, he decided to resume his career, not unexpectedly, especially as he was 61 years of age at the time. Snedden was fifteen years younger. For the Parramatta byelection, the Liberal Party preselected a young Liberal, direct from conservative casting, his father was a State MP, Philip Ruddock. Philip always danced from one end of the Party to other, but he had a certain resilience. He trounced his Labor Party challenger with a swing of nearly seven per cent. Ten other candidates, mostly independents, contested the seat.

This was the first Federal election in which eighteen-year-olds were eligible to vote, the voting age having been lowered from twenty-one earlier in the year.

As was expected Bowen did not involve himself in the campaign. Snedden did, and although he was a poor public speaker, he was a good grass roots politician. Whitlam on the other hand made a declamatory speech which canvassed the forthcoming prices and income referendum to be held later in the year. As with the by-election, this referendum was soundly defeated. It had been a triumph for Snedden and helped to consolidate his shaky hold on the Party, especially in NSW at that time.

Peter Dutton, the acclaimed Leader of the Liberal Party, is now faced with a by-election in the first year of a Labor Party government, as was Snedden. The recently retired member, Alan Tudge has been a conspicuously poor performer involved deeply in the Robodebt imbroglio. Let us say, he is hardly the person Nigel Bowen was. In 1973, Snedden was campaigning in NSW whereas his natural base was Victoria. Likewise, Dutton will be campaigning in Victoria, where his normal habitat is Queensland.

Nominally both Parramatta in 1973 and Aston in 2023 were and are safe Liberal seats. The expectation would be that the Opposition Party would achieve a swing as this is the expected outcome after the election, thus strengthening the hold on such electorates. In Parramatta in 1973, Ruddock achieved this swing, and had no need to go to preferences.

Dutton wants a female candidate. He’d better choose wisely, because I hate to see a dead bird floating among sheets of unread Murdoch papers – lose the byelection and you are a dead duck paddling, mate! It will be interesting to see if a wild duck, disguised as a teal is pre-selected. And what of the Labor Party? Can’t lose many feathers contesting; and as a bonus gives an idea of whether it has made inroads into the teal vote.

Thus, what of Aston, where, despite a swing against him at the 2022 election, Tudge held the seat comfortably. Can Dutton emulate Snedden?

ChatGPT – So you want to Cheat; go right ahead

Lawrence Shapiro is a professor of philosophy at the University of Wisconsin-Madison. He is coy about his age, but he received his PhD from the University of Pennsylvania in 1992, so he must be cognitively still vital.

He writes very calmly in the Washington Post about this artificial intelligence tool which has been heralded as a means of writing essays and assignments without even thinking about it – albeit a means of cheating.

This opinion piece is a very clear appraisal of the tool. He seems very relaxed. After all, he has recently published a second edition of his book Embodied Cognition which a reviewer has hailed as an outstanding introduction for those unfamiliar with but who would like to explore this movement. As the reviewer continues: It clarifies the very idea of embodiment, elaborates the central themes of embodied cognition, and evaluates theories of embodied cognition against standard cognitive science.

I think I will stick with this general appraisal.

ChatGPT has many of my university colleagues shaking in their Birkenstocks. This artificial-intelligence tool excels at producing grammatical and even insightful essays — just what we’re hoping to see from our undergraduates. How good is it, really? A friend asked ChatGPT to write an essay about “multiple realization.” This is an important topic in the course I teach on the philosophy of mind, having to do with the possibility that minds might be constructed in ways other than our own brains. The essay ran shorter than the assigned word count, but I would have given it an A grade. Apparently ChatGPT is good enough to create an A-level paper on a topic that’s hardly mainstream.

Universities are treating the threat as more dire than an epidemic or even a budget reduction. The most obvious response, and one that I suspect many professors will pursue, involves replacing the standard five-page paper assignment with an in-class exam. Others expect to continue with the papers but have suggested that the assigned topics should be revised to focus on lesser-known works or ideas about which a chatbot might not “know” too much.

Good luck with that. If ChatGPT can pen a solid essay on multiple realization, an issue on which I happen to be a world authority in good part thanks to lack of company, I doubt it would have difficulty constructing essays about lesser-known Shakespearean sonnets or unremarkable soldiers who fought for the Union Army. Besides, if we’re going to demand deep thought from our students, shouldn’t it be about the more important stuff?

Here’s what I plan to do about chatbots in my classes: pretty much nothing. Let me say first that as much as I value the substance of what I teach, realistically my students will not spend more than a semester thinking about it. It’s unlikely that Goldman Sachs or Leakey’s Plumbing or wherever my students end up will expect their employees to have a solid background in philosophy of mind. Far more likely is that the employees will be required to write a letter or an analysis or a white paper, and to do this they will need to know how to write effectively in the first place. This is the skill that I most hope to cultivate in my students, and I spend a lot of time reading their essays and providing them with comments that really do lead to improvements on subsequent assignments. In-class exams — the ChatGPT-induced alternative to writing assignments — are worthless when it comes to learning how to write, because no professor expects to see polished prose in such time-limited contexts.

I should emphasize just how desperately my students need formal instruction in writing. My wife confirms that I’m noticeably crankier than when I first started teaching 30 years ago. Everything today seems worse than it was back then: traffic, TV news, macaroni and cheese. But I don’t believe that the deterioration in writing quality that I see is a consequence of age-tinted glasses. I read too many papers from upperclassmen, from students who have taken other writing-intensive courses, in which only one sentence out of five is not grammatically or stylistically defective. I would be failing these students if I let ChatGPT discourage me from teaching them what might be the most essential competence they can gain from me.

But what about the cheaters, the students who let a chatbot do their writing for them? I say, who cares? In my normal class of about 28 students, I encounter one every few semesters whom I suspect of plagiarism. Let’s now say that the temptation to use chatbots for nefarious ends increases the number of cheaters to an (unrealistic) 20 percent. It makes no sense to me that I should deprive 22 students who can richly benefit from having to write papers only to prevent the other six from cheating (some of whom might have cheated even without the help of a chatbot).

Here’s an idea for extracting something positive from the inevitable prominence that chatbots will achieve in coming years. My students and I can spend some class time critically appraising a chatbot-generated essay, revealing its shortcomings and deconstructing its strengths. This exercise would bring a couple of rewards. First, analytical writing, like any skill, benefits from seeing examples of what works and what does not. While students might reasonably object to having their own essays made a target of public inspection, chatbots couldn’t possibly care. Second, given that chatbots are not going to fade away, my students might as well learn how to refine their products for whatever uses the future holds.

I urge my colleagues not to abandon writing assignments for fear that some students will let artificial intelligence do their work for them. Instead, let’s devise ways to make chatbots work for all of us. Truly, the cheaters are only hurting themselves — unless we respond to them by removing writing assignments from the syllabus.

Mouse Whisper

He has been reading this book The Amur River which relates to Colin Thubron’s recent travel from Mongolia, reaching towards and eventually along the Amur River which divides Russia from China to its mouth. Fascinating book, he announced to all and sundry, and me. He could not refrain from telling us about Kim-Jong-Il, the original poisonous North Korean puffball. Kim-Jong-Il was not born in some celestial nursery but in a tiny Russian village near the Amur River and was swept up in fighting the Japanese. But Thubron recounted this description of this high born North Korean dictator – his tastes I doubt were developed along the Amur. How, I ask you do such nutters get these gigs – no mouse would ever be allowed to indulge in such a display? {Sic}

Despite his propaganda, he was mundanely earthbound, and frightened of flying. He travelled only in a luxury carriage of his own armoured train. On a secret journey to Moscow, his Soviet escort described him eating fresh lobsters airlifted in every day, with roast donkey and champagne, while his people starved.

Modest Expectations – Ted Greatorex

For a couple of years in the 1980s, we spent Christmas at the Savoy Hotel in a suite which enabled us to look straight down the Thames and Christmas lunch was in the Savoy Grill. One of the offspring who had taken a year off to fence in Paris and Budapest (he was actually based in the latter but had a great many contacts in the stylishly named Racing club in Paris) came over to London to have lunch with us. The food was excellent; the wine flowed; the jollification found him taking off his jacket. The Christmas cracker, suitably extravagant, yielded a parachuting man. Never mind that the son draped the parachute, to which a tiny figurine was attached, on his head so that the figurine was dangling over his nose. One of the waiters sidled up to him and murmured: “It appears that Sir’s jacket has slipped from Sir’s shoulders. Perhaps I could help Sir to put Sir’s jacket back on.”

Ah, the good old days, when Mr Pickwick stalked the land, but the offspring did not reply to the waiter “You jest, good sir. Be of good cheer.” He obeyed and put on his jacket, and Grill etiquette was restored. The parachute remained on his head for the duration.

Yuletide Greetings Everyone.

Ernie Toshack

When I see Scott Boland bowl, with his very understated approach behind a line of more famous fast bowlers, I was reminded of Ernie Toshack, whose nickname was the “Black Prince”. He was born in Cobar and during WW11 worked in the munitions factory at Lithgow. When he was not working, he tried his hand at cricket. The man who became a member of Bradman’s Invincibles in 1948, started in the Marrickville 4^th in 1941. He was initially rejected by Petersham. His progression during the war years to his first test, being against New Zealand in 1946 at the age of 32, was spectacular. Even given that the number playing competitive cricket would have been thinned by the War, nevertheless his progression to Test status was impressive. In fact he had only two years at Test level, before chronic arthritis in his knees forced his retirement. Lindwall, Miller, and perhaps Bill Johnston were the fast bowlers our generation venerates, but Toshack? He was no batsman and therefore it was his bowling for which he was selected.

He was a left arm medium pace bowler who was very accurate. It is said Bradman would walk down the pitch and put a sixpence on the pitch, point to it and say to Ernie that was where he wanted him to put the ball. Ernie would respond, which made him not only a very economical bowler but also underrated because he lacked an explosive delivery.

Toshack had an exotic genealogy. He was not of Aboriginal descent as Boland is. It is said that his ancestor was John Randall, believed to be originally a slave from the United States and a soldier who fought for the British in the American War of Independence. He arrived in Sydney with the First Fleet in January 1788. Skilled in musket use, Randall was soon employed as a hunter, sourcing wild game for the British officers.

The comparison between Boland and Toshack: they both had no whitefella heritage – one Aboriginal; the other in the parlance of our time, Afro-American. They were both very accurate medium fast bowlers, often but not always first change, came to Test cricket late – and their progression was unheralded, but their first test against England was memorable. In the first test against England in Brisbane in 1946, Toshack took 6/59; not quite the 6/7 that Boland claimed in his first test in Melbourne in 2021.

When you look at them more closely, there was not that close a comparison; I cannot see Boland affecting a bowler hat and a furled umbrella that the “Black Prince” would wear and carry. Nevertheless, when I first saw the understated Boland coming into bowl, I did think of Toshack.

Look good in a Suit

This response was prompted by the belated response to the antics of Shane Fitzsimmons, whose professional life was fenestrated by his leadership in time of disaster. This is the man who has been NSW Person of the year, and who this year at the CWA Conference said:

“I was broken during the fire season when we lost people. It was very challenging on some days: hoping for moisture, but all we got was lightning and more fires. But I was inspired by the tenacity of all the fire workers, by the tenacity of communities, by the outpouring of love and kindness of people in communities.

“My way of coping is talking openly to others about how I’m feeling,”

His speech is the type of avoidance that failure bestows upon its author. Read carefully and see no admission of accountability. This is a guy who has a formula for survival, which in the end was not enough. He was sacked last week from an organisation that did not have what its name implied – Resilience NSW.

But then he was not on his Pat Malone. Nevertheless, that is not an excuse for appointing people because they rise to the top in what are as closed an order as the Trappist monks, just different regalia.

We coined shorthand for the incompetent in high places: “looks good in a suit”.

However, let’s get to the mists of youth, a time of socialisation and when the young me became very sceptical of braid and the inherent sense of self-importance it brings.

My time in cadets at school introduced to me to a uniformed service. Being a cadet was important in my rebel socialisation. Membership of the cadet corps was virtually compulsory when I was at school, and I distinguished myself with being one of the few who went through the three years without being promoted, although I was entitled to crossed flags on my sleeves to signify that I had passed some test for the signal corps. My mate, who also was never promoted, not only had crossed flags but also crossed rifles on his sleeve to signify that he was a crack shot in the shooting team. It was a time when the school had a rifle range on the top floor of a then new building.

Perhaps it was our bringing alcohol into the cadet camp and having a brawl with senior NCOs who, in our other life, were just fellow students but with chevrons on their sleeve that gave them power in the environment of a cadet camp. Thus, when the fight broke out, I was rebelling against authority, and the fight was all the more vicious, terminated when I was hit by the butt of a rifle that night. I learnt to cop it, leave the dispute in the tent and not to complain. Any friendship I may have had within the class where there was no rank ended there and then.

Against that personal background, when I was President of the University of Melbourne Student Representative Council, I was faced with confrontation with the head of the Melbourne and Metropolitan Fire Brigade. It was the end of first term and the engineers and commerce students were having their annual “marbles match” on the lawn outside the Union building. The lawn was once a lake and therefore it took little rain to turn it into mud. The ‘marbles match” quickly degenerated, as it always did, into a form of the Eton wall game with all the combatants covered in mud. I never knew what the aim was, but I had a bird’s eye view from the SRC office.

The “mud match” was cracking on, and there was much student activity, when the inevitable happened. Somebody broke the fire alarm in the Union, and before long, with bells ringing, the fire cart arrived driving through the milling mob in front of the Union, where it stopped. Before the firemen could get out of their vehicle, some idiot student dumped a bucket of mud over them.

A few of us immediately went down, two of those accompanying me later became very senior judges – one of the Supreme Court and one of the Federal Court. With that amount of student firepower we were able to quieten the mob and isolate some very angry firemen covered in mud, issue an apology and offer to pay for the cleaning.

The University was a very different place, being the only one then in Victoria. Thus, it was very much a place of privilege and very much left to govern itself. At no stage did I remember police being on campus in response to any student activity, and such was the case here. A delegation, led by myself, later in the afternoon went down to Eastern Hill, where the firemen bosses were located. We were ushered in and the elderly fire chief was there glowering, surrounded by his lieutenants, all of whom affected a mixture of disdain and anger. There was no holding back as we were dressed down by this choleric elderly fire chief in his full braid. Any effort to apologise and to offer to pay for any damage was lost in a shouted invective, where top hat versus cloth cap confrontation was not far from the surface.

The newspapers were there to photograph us as we left the premises, and the incident was splashed across the front page of The Age. I do not remember being criticised by the Vice-Chancellor, with whom I met on a regular basis. It was my first introduction to a non-military uniformed service, but even at a young age I was not impressed by this braided bully, a standover merchant. OK, there are dopey students who do dopey things, but his response was completely over the top.

I was only 20, and at that age, we all move on, even if there was a post-riot hiccough, which was not related to the meeting with the fire chief. Several decades later, I was asked to review the NSW Ambulance Service. It was a time when what I knew as “ambulance driver” when I first graduated, was translating to a more professional workforce where the driver connotation had been transposed to “ambulance officer”. No longer the stretcher bearer, but a service where a cohort of newly-minted “paramedics” was being trained.

The problem was that the training was internal, there was no reciprocity between the States, and one of the teachers was reputed to have a baseball bat as allegedly one of his teaching aids. Then, within the NSW Ambulance Service, there was the “Brotherhood” – membership of which was said to be important for promotion. What was fact was that the Service had more levels of rank than the British Army. Trying to reform entrenched uniformed essential services is very difficult, even if the heads of the services are what you might call “look good in a suit”. They had risen through the services, knew all the buttons not only to polish but also to press to rid themselves of outside recommendations.

In this case, as with the hapless Fitzsimmons, it was the powers that wanted change. In our case reviewing the ambulance service, we avoided our recommendations being debated in the media. The most significant recommendation apart from reduction in the number of ranks, was to establish university-based paramedic training courses, which then led to reciprocity across the States – and at that time in the NSW Ambulance Service, an improved standard in leadership was implemented, and the ranks collapsed into a fewer number where competence trumped time in the service.

The NSW government has made a very definite and welcome decision to abolish Fitzsimmon’s empire. No worry, he’ll still look good in a suit with all those medals he gleaned as he floated to the top.

The New Health

The central objective of insurance – the removal of uncertainty – cannot be achieved through a cash reimbursement scheme unless the fees against which the benefits are paid are also predictable – R.B. Scotton 1969.

The common misapprehension about the Australian health system, whether it be called Medibank or Medicare, is that it sets the fees for doctors, because that is how the Federal Government intervention is interpreted.

The Grattan Institute is at it again. The Australian health system is built around providing a patient benefit for medical services, which are provided by doctors who are working in private practice. The Grattan Institute has a solution, so simple that the media can understand. I for one am bemused by the comment that “GPs should be able to choose a new funding model that supports team care and enables them to spend more time on complex cases, by combining appointment fees with a flexible budget for each patient based on their level of need.” Compare this confused thinking with succinctness of the late Dick Scotton above.

The Constitutional Amendment in 1946 enabled the Federal government to provide medical, dental, hospital and pharmaceutical benefits. No government has taken the opportunity to set up a universal dental system, (and that deserves a separate discussion), hospital benefits which are not at present available, instead the Federal government provides funding for the States, but the area of Federal-State relations unfortunately has become one area of significant double-dipping. The whole area of State-Commonwealth relations has been very fraught; the answer to double-dipping has been to look the other way and not proscribe this scam. Much of this playground developed in Victoria when Kennett was Premier.

Pharmaceutical benefits provide subsidised drugs on a schedule of benefits. That is the invariable, that is if the government sets a benefit it needs to provide a list of value of benefits. This has also been an area where special pleading for very expensive drugs has the form of a lottery, where who you know is of as much importance as proven efficacy of the drug.

Then there are medical benefits, which are the core of the health system, whether it be the initial Earle Page iteration or the post-Nimmo Inquiry, Medibank or Medicare, the architects of which were the late John Deeble and Dick Scotton.

The core of these later proposals was universality. Every Australian was entitled to free care – medical and hospital care; and for pensioners and other poor people identified, free drugs provided they were on a benefit schedule or made available through a hospital pharmacy. The government set a tax levy to cover the cost of Medicare.

When there is an open funding model coupled with changes in the technology to improve the efficiency, if these are not appropriately monitored, as has occurred, then the result can mean the funding model is now completely out of whack.

Any system which pays on the basis of benefits has a major subjective element. If you base it on the fair and reasonable fee that a medical practitioner charges, the value of the benefit is dependent on the particular segment of the profession being as objective as can be in the value of the treatment. In the initial establishment of the benefits, the ophthalmologists based their “fair and reasonable fee” on the highest charging colleague in the country, which produced an exaggerated benefit. This was 1971 and with time any improvement in technology that improved throughput made the benefit more lucrative. Nevertheless, it did not prevent most ophthalmologists currently charging far more than the patient benefit.

Despite an increasingly elaborate medical benefits schedule, a doctor can charge what he or she likes as long as it can said to be “fair and reasonable”. The benefits schedule was also constructed to provide a small incentive for bulk billing, for which swiftness and surety of government payments was the reward. The Schedule benefit for general practitioners has encouraged turnover and episodic treatment, and therefore the Schedule has become an object for gaming. This applies particularly to all consultations, pathology and imaging.

Procedural medicine is divided into diagnostic and curative/palliative. At the outset the benefits schedule was also constructed for professional services. One of the consequences of the increasing differentiation of medicine is the increase in the number of procedures which, in turn, has led to the increase in the size and complexity of the Schedule list, and consequently tracking benefits against the fees charged requires collection of data.

Yet an immense amount of time is spent determining the value of procedures, using varying levels of evidence, as if each item has a unique fee. That may be correct, but the government is concerned with providing a range of patient benefits commensurate with what the item of service is worth.

Once the benefits and the fees for procedures were more or less aligned, but that has changed. Over time there has been dislocation of the fee charged from the patient benefit accepted as full payment by the proceduralist. Those who cannot afford the added impost end up on a public health care waiting list. Added to this, the payment for prostheses has never been properly codified for benefit payment. There are resultant anomalies. Dressings for chronic skin infection are not covered by benefits – either Medicare or private health. The whole benefit for this area has never been satisfactorily confronted, while the number of prostheses continually increases.

Once general practices, imaging and pathology services were Australian owned – essentially cottage industries – but the profitability did not go unnoticed by business and gradually the multinationals have bought up the practices. Medicare funding thus is allegedly ending up in offshore funds. In other words, the Medicare system is providing a means exported profits. These hedge funds and other financial vehicles do not invest to lose money. In other words, Australian government funding is providing sustenance to those “altruistic entities” located in the Cayman Islands and its ilk.

The system needs re-structuring. Recently yet there has been a seemingly endless review headed by Bruce Robinson, which seems to have become arcane groups of specialists debating the equivalent of angels on pinheads. It was supposed to review the health system and hopefully repair the system. Like so many of the reviews since Nimmo and after the last AMA-Government Inquiry in 1984, money is funnelled into the big consultancy firms, many of which are peopled by former public servants, for little result in terms of improved health care.

The central agency nightmare is if the Benefits system is extended to the whole raft of health professionals, other than those as specified in the constitutional amendment. However, a “weasel clause” came in 1974 with the extension of a limited patient benefit to optometry, by “deeming optometry services medical”. The inclusion of health professionals since then has been based on them being undertaken under “medical supervision”.

These professions wish to have independent access to items that generate patient Medicare benefits, and many would object to the “deemed medical” rubric as infringing on each individual skill set. However, to my mind any such benefit systems could be challenged on constitutional grounds. The community indignation which would ensue would likely be such that a resultant constitutional amendment put to referendum would be overwhelmingly passed and the resultant floodgate of expenditure would provide the Federal government with potentially massive expenditure – and headache.

There are exclusions from Medicare benefits – in other words, government can exclude procedures or anything they deem ineligible, as has been done with most cosmetic surgery. Limitations on the number of courses of IVF treatment are imposed. This can be a blunt object, and with every inclusion or exclusion there inevitably are grey areas – and controversy.

My view, after many years of being involved with Medicare, is that the construction of the benefits list is all important, and patient benefits need to be clearly differentiated for the purpose of calculation into four components. The three traditional components are professional, technical and capital, to which I would add the educational component to boost the value of the benefit for consultative medicine. Technical and capital component can be calculated based on actual cost, providing that the ratio between actual use and capacity does not allow windfall gain. Professional is how much a person’s skill and time taken are calculated. Educational component takes into account concomitant teaching occurring when the doctor is consulting and has been the basis of a submission I made to government some years ago. Then, instead of valuing each individual item of service, the government could consider providing the benefits on the basis of bands: one for episodic treatment for acute cases and second, courses of treatment for the chronically ill.

Patients’ benefits can be set either based on episodes, (predominantly acute – e.g. appendicectomy) or courses of treatment (predominantly chronic e.g. radiotherapy for cancer), or a mixture of both ( e.g general practitioner attendances). This would enable the schedule to be collapsed in a range of benefits, based on the above considerations. It is a pity that the AMA no longer has expertise in this area, because this was the basis of the AMA / Government Inquiries where neither the AMA nor the Department was asleep at the wheel.

Because of the indifferent quality of the Health Ministers since Michael Wooldridge, with surprisingly the possible exception of Tony Abbot, the Health Department has little desire to be involved in health financing – at least seriously – and increasingly finds itself at the mercy of the financial strictures of the “central agencies” – so very little changes unfortunately and thus neglecting the truism incorporated in Dick Scotton’s prescient words over 50 years ago.

A reminder of what I wrote in my blog

As I write this blog on Easter Sunday, maybe Albanese will start to rise to the task; and the proposal for an Integrity Commission is a very good place for him to start.

One thing he should remember is to pick on the topic where the Government is vulnerable and then hammer it. Add a pinch of climate change and the country being held to ransom by the very wealthy “oligarchs”, whose wealth has been tied up in fossil fuels, and the formula becomes stronger. However, whether Albanese can dispense this prescription will unfold over the next little while.

The problem with “over a next little while” is it is as long as a piece of string – as short as a piece string for that matter.

One great advantage Albanese has is, in one word, Dutton, completely unelectable outside Queensland. A second great advantage is the former Prime Minister, who should relinquish his electorate of Cook and this time have a long holiday evangelising outside Australia, under volcanoes reminding him of his fire and brimstone Pentecostalism. Hawaii – the Big Island would be a good start.

Mouse Whisper

A civilised community exists on a basis of trust.

When you destroy that trust, then in the end you believe in nobody. You are in a dark forest inhabited by the symbols of demons or warlocks or any of the representations of Beelzebub, because they are the enemy – and you alone are the symbol of purity. What has happened to America is a man with artificial golden mane, golden face, golden geegaws (unsurprising given from ancient times religious icons are smothered in gold) burst upon a country, already conspiracy ripened by the pastors of the Second Coming and satanic interpretations of the Book of Revelations. Coupled this with those playing in the shadow isolation of video violence and how can anybody trust anybody. In the end the one supreme person who did not trust, who never trusted the law, did not understand impartiality reigns supreme with all the bodies whom he/she/it did not trust littered all around.

On that cheerful note…

Happy Christmas from Mousehole.

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 – Marcus Aurelius

How depressing to see the Prime Minster spending “quality time” with Lachlan Murdoch, at a time when Murdoch is trying to bully the newsletter publisher, Crikey into submission. The description of Crikey as a minnow is to underestimate its clout and the intention of Eric Beecher to confront what he perceives as the malign influence of the Murdochs.

It is important to place Beecher in context, and while his own bio is scant, this quote from the Public Interest Journalism Initiative provides a summary of his early achievements. Beecher started in newspapers as a journalist on The Age in Melbourne and later worked at The Sunday Times and The Observer in London and The Washington Post in the US. In 1984, at age 33, he became the youngest-ever editor of the Sydney Morning Herald and in 1987 was appointed Editor-in-Chief of the Herald and Weekly Times newspaper group.

He has spent a large part of his later life as the pamphleteer, railing against the privileged plutocracy, which has grown under cover of globalisation and the so-called information revolution. He has explored alliances with other writers with a like attitude.

Lachlan Murdoch is targeting him in the defamation jurisdiction on Earth most sympathetic to the complainant – namely NSW. Nevertheless, Beecher has taken the decision after initially retracting the offending comment to challenge the Murdoch Empire of “alternative facts”. As Beecher has commented, any morality in journalism has been sacrificed in the pursuit of financial profit, and Murdoch, once the supporter of Whitlam and the Republic, has given over to a son without any connection to Australia, apart from a father who has long deserted his citizenship, again in the pursuit of profit.

Thus, it is tedious to see the Prime Minister giving the Murdochs the normal vassal symbolism of going cap in hand to them. When will they learn? Remember, Rudd was entrapped by a Murdoch operative in a New York strip club. Prime Minister, have you forgotten the disgusting behaviour of Murdoch in Great Britain, where yon Rupert almost apologised by closing down the “News of the World”? But then it was the other son James in the firing line, rather than Lachlan.

I’m not surprised that Marles joined in the pilgrimage to Compostela de St Rupert, given his common Geelong Grammar School heritage with Rupert. Marles, as with Murdoch, had an elderly father, and both his parents were high achievers. So, both “slumming” in a working class electorate and rubbing shoulder with the establishment is a recurrent behavioural pattern among some of the Victorian Labor party private school elite.

But really, Penny Wong! Or were you just practising dealing with some of the unsavoury types lurking around the world in some of the foreign affairs portfolios?

Presumably to demonstrate neutrality in the ongoing stoush, the Prime Minister should visit Crikey and break bread with Eric Beecher and his crew in a less plush setting but in keeping with his electorate’s wish.

Finally, yes, we have contributed to Crikey’s defence.

St Kilda

I have been reading about St Kilda.

Not the beach suburb of Melbourne, although I must admit that I was surprised of an association; I’ll come back to this later.

St Kilda was a few rocks stranded in the Northern Atlantic Ocean about 60 km from the Outer Hebrides and where, for centuries, a small group of hardy settlers subsisted. Until the nineteenth century, they lived a very isolated existence with the occasional ship calling carrying salt, iron and timber for which they traded cows, sheep, feathers and grain.

It was a hard life, living in such a state without money, where the whole population gathered as their local council, with strict observance of the Sabbath with Christianity interwoven with pagan practices, where the infant death rate was greater than 50 per cent because of neonatal tetanus, which is terrifyingly described.

The islanders raised sheep and cattle and grew some crops, barley and potatoes. They did not fish, but rather raided the bird nests which were clustered in the steep cliffs which ringed the islands.

The largest and inhabited island was Hirta and thus the inhabitants were more commonly called Hirtans rather than Kildans. The link with Melbourne is that some of the islanders apparently found their way to Melbourne. St Kilda beach in Melbourne may have sea birds on its sands, but that was the only similarity. The immigrants would have missed their roasted puffin, but surely cooking a puffin reminds one of the old recipes about cooking a galah with a stone.

Collecting eggs and birds from the cliff face was a Hirtan skill, which even to today’s rock climbers would have presented a challenge, as the ropes they used were very rudimentary, with much jollification while this hazardous operation was happening.

In the nineteenth century, St Kilda became a tourist spot, even though landing on the island presented problems, especially when the weather was bad. There was a post office where postcards could be stamped. Photographs of the islanders became popular. Paradoxically, the standard of living rose, as shown in contemporary photographs of the improvement in the housing, but the attrition of a population, now exposed to the mainland “delights” increasingly losing their previous self-sufficiency, accelerated.

The final paragraph of the description of the Hirtans in Shadowlands is evocative. By 1930, the population was reduced to 36.

“…in the dying days of August 1930, the final postcard was sent. Its message, from a tourist called Freda, said, just “Last Greetings from St Kilda.” Then the post office was shut forever. The final service was held in the church and bowed by sorrow, the islanders rounded up their dogs, those indomitable hunters and guardians, tied weights around their necks, placed them in sacks, and dropped them from the pier, looking sorrowfully on as the yelping bundles sank beneath the waves. They returned to their houses and waited for HMS Harebell.

And up on the stacks of Boreray, from their nests in the cliffs, the birds rejoiced.”

It is an example of the problem of civilisation intruding on a community which has achieved a fragile ecological balance and then, over time, from being endangered they are rendered extinct. Our forefathers characterised the Australian Aboriginal people as remnants of the Stone Age whereas they had developed a very complex hunter/gatherer society, but unlike the Hirtans they had a far bigger canvas upon which to work. Nevertheless, what have we learnt from the Hirtans, especially as with the Australian Aboriginals, there was no written language – not even an ogham?

Same Old Rubbish?

I have been a supporter of the Essendon Football Club for most of my life. It was because of the Doust family, who lived on the corner; and then after WWII they went back to Britain, leaving me with a black and red scarf. We lived nowhere near Essendon, and so it was quite a trip across the city to watch them play. The Victorian Football League (VFL) then was essentially composed of inner suburbs extending west and north. The only team in the eastern suburbs was Hawthorn, and when I was small, its team was a “basket case”.

Essendon did not conform to the original teams when in 1897 the VFL was formed. Essendon was not an inner working class suburb. Yet Australian Rules was essentially a working person’s game, despite having a posh beginning as a game between an Anglican and a Presbyterian private school.

Many of the clubs were both Irish and Roman Catholic, none more so than Collingwood in the era when John Wren virtually owned the club. Essendon was not Roman Catholic – far from it. But the nuances of this history were lost on one small boy, even the fact that Essendon once played their games in East Melbourne where the railway yards now stand and they were nicknamed “the Same Old”.

By the time I became a supporter, the team was located at Windy Hill, high on the hill in Essendon where the gales blew. In winter it was a place for the frozen spectator, even rugged up and with the obligatory Thermos in hand; and because the suburb Essendon had become the location of Melbourne’s airport, the football club adopted the nickname of the “Bombers” in 1940.

It was a different time with the VFL progenitor, Victorian Football Association (VFA), having many of its teams in the eastern, south-eastern and southern Clubs still active. Oakleigh, nicknamed the Devils even though they wore gold and purple colours, just down the road was my club, but I was never as addicted to Oakleigh in the same way as I was to Essendon.

This long introduction is to say that most of my life has been consumed in my support of Essendon, even at one time being a paid-up Essendonian. However, that changed when the game became an exercise in keepings-off and Essendon relinquished its Windy Hill home.

Sport at the top level is now a moneyed game driven by TV rights. There is also a stadium fetish, to ensure that the pampered few are spared the rigours of winter with access to glass boxes awash with alcohol. The players from teenage years are moved around as well-paid commodities without, in most cases, any deep-seated loyalties. After all, being doled out in a draft means that these players are separated from their hearth and home. And that gnaws away at the special nature of the Game loyalties.

Curiously, the game is reverting to the original game where there seemed to be limitless players, running on and off in a blur, to maintain the momentum of the game, keepings off, scragging; little men in yellow running around making arbitrary decisions so they can keep up with a game, which is driven by the manic desire of those who run the game to make it faster and faster. The only difference between the original game in 1958, which perhaps should be introduced, is running among the gum trees in Yarra Park and the length of the playing arena when rules as today were arbitrary or non-existent – and of course the little yellow officials.

However, there is a veneer of corporate civilisation. As somebody wrote about the Essendon worship of bright and shiny baubles “Walking up the concrete steps, Essendon’s headquarters feels like a corporation. The generic nature of the massive building continues inside where it becomes immediately clear the home of this historically great football club – which has not been anywhere near great since it moved to Tullamarine – has no heart.

That is my problem – once a fanatical supporter who imparted the same spirit to my sons and then they to most of the grandchildren. But then only one of these six was alive – just – when Essendon won its last premiership in 2000. My heart has gone – I no longer care.

Maybe a flicker of nostalgia when I read about Michael Hurley’s complete loyalty to the club. (pictured)

The AFL has a heritage round, but what is meant by heritage? True heritage would be playing twenty a side – eighteen on the field with two emergencies, which came on as replacements and were not interchangeable. Yet that rule only operated from 1946 until 1978 when the interchange rule was introduced. The longest time the rules of the game have not been changed was nine years between 1877 and 1886. Now, there is more year-to-year fiddling with the rules than in a Bullamakanka bush band.

Then see how the spectators would enjoy it. The grounds are more uniform than in the past. When playing at Hawthorn, you were on a compressed ground wedged against the railway lines – and with the right conditions the full back kicking out, if accurate enough, could kick a goal at the other. I repeat “if the conditions were right”. Oh, for the suburban grounds that had character.

Now, what an exercise in sterility, but the AFL is now politically correct. Gillon McLachlan, scion of the South Australian Establishment, you have left your legacy – you have pasteurised the game behind pay walls. Well done.

What the Butler saw

The Strengthening Medicare Taskforce is bringing together Australia’s health policy leaders. The diverse membership has been drawn from across the health professions, and includes consumer, rural and regional and Aboriginal and Torres Strait Islander representatives.

The Taskforce will work to deliver concrete results through its recommendations, including:

Improved patient access to general practice, including after-hours.
Improved patient access to GP-led multidisciplinary team care, including nursing and allied health.
Greater patient affordability.
Better management of ongoing health conditions including chronic conditions.
Decreased pressure on hospitals.

Here we go again. The Same Old!

Mark Butler, a lawyer and union official prior to being elected to Parliament, under Rudd had an exposure to matters relating to Health, in various parliamentary secretary and ministerial positions between 2009 and 2013. He had been Shadow Minister for Health since January 2021

Unlike another South Australian, Neil Blewett, who maintained continuity in the portfolio whether in Opposition or Government to became one of the best Ministers of Health, when the Labor Party went into Opposition, Butler was handed the shadow environmental portfolio by the then Opposition Leader, Bill Shorten. The Health shadow portfolio was passed to Catherine King. After the 2019 election, the shadow Health Ministry was held by Chris Bowen, until it was passed back to Mark Butler. The Health portfolio seems to have been in the “pass the parcel” category among the Labor gentry.

One of the prerequisites for the Health portfolio incumbent is that unless one learns the language of Health, it condemns you to being at the whim of translators. Blewett as a linguist was fluent in Health, and he also had a bunch of public servants who had served in health matters for a considerable period, and while they were not necessarily health professionals, they were more or less fluent in Health. Guys like Alan Bansemer and Bernie MacKay.

A 17 member committee is doomed to failure as anything but a megaphone, given that allows every member an average of 3.5 minutes an hour to speak. Also the bigger the Committee the more unwieldly, although technology allows for everybody not to be in same room for a meeting; however, that introduces the trickiness of the membership being in isolated cells, without any meaningful interaction. But maybe that is a deliberate ploy. I have faced public service running interference and have dealt with it mostly – without winning any popularity polls.

Scanning the list of Butler’s Committee, the only one with any decent corporate memory is Stephen Duckett; like all of us who have been in the health sector for as long or, in my case, longer than him we have our own set of biases. Duckett sure has his, and his bias against private practice is well-known. He is sure to raise salaried practice and capitation as alternatives; but Medicare has served Australia well, even under conservative governments where it is always allowed to decay. Added to this the central agencies hate uncapped programs as Medicare has been.

My problem with the medical representation is that each is there because they have been elected as distinguished members of one of the many tribes of medical graduates, not as experts in health economics and policy. To them, reforming the health system is not a full time pursuit, but a task force gives them all the opportunity to whinge, and in a couple of years these office holders are gone.

The only medical graduate on the committee, a former President of the AMA with some experience of the vicissitudes of Medicare, is Hambleton. He does not fill me with any confidence because once when I asked why the AMA had ceased being deeply involved in establishing doctor’s incomes, he seemed confused about the value of the bilateral Medicare Enquiries between the AMA and the Federal Government last held in 1984.

Looking down the list it seems that the aim is to include every player in the provision of primary care and a wish list of aims without any means of achieving it. Thus presumably, the Department will prepare a series of working papers – a variation on the Jenny Macklin National Health Strategy Initiative where she was asked to review Australia’s existing system, which produced a series of discussion papers of varying quality. That task force was disbanded in 1993, without any discernible effect on the health system. My involvement goes back to listening to Gough Whitlam expounding on health reform in 1969 at the time of the Nimmo inquiry, when the genius of John Deeble and, to a lesser extent, Dick Scotton provided the intellectual capital for both Medibank and Medicare.

The crux of the primary care problem is that despite all the talk about professions working together, it just does not happen spontaneously. I am a patient in a very good general practice, with very competent medical and nursing staff. They have their tasks and they don’t spend their time in formal training in how to get along. As a patient, I want to be able to converse with my general practitioner and yet realise I have a limited time to do so. Yet despite its caring profile, this long term traditional suburban general practice has been absorbed into the corporate world, and if it were not profitable, you could bet your bottom dollar that this world would not be there. This presents a bit of a paradox. Substantial investment on the one hand; crying poor on the other.

The other variable is general practices now closing off appointments for new patients, which effectively caps throughput. Given that Medicare is uncapped – and the rule of thumb is to maximum daily limits for doctor – namely seeing 80 patients a day for 20 days a year or 30 telehealth consultations for the same period a year, otherwise any more will attract a reference to the Professional Services Review Committee. That is the only comment on optimal throughput – two extreme positions. The Committee should address optimal throughput.

Given that the public has been used to bulk billing in general practice, I can now ask a question: “What is general practice?” and then ask, “what is the most cost-effective way to deliver general practice?”

My premise is that general practice is heterogeneous. Yet it conforms to certain rules. For instance, at least three doctors are required if the practice provides a 24-hour service. Yet how many practices exist as standalone services providing such a service? In rural areas in the small towns such a service is problematic, but general practitioners there do have a local hospital to back them up. I have no idea what the “urgent centre” proposed by NSW and Victoria is; and where does the staff come from – Mongolia?

In any question of general practice, one must ask the question of what level of coverage by general practice yields the most effective return. The fact that the so-called 24 hours clinic or general practice attached to urban hospitals has not become standard suggests this is a work pattern unacceptable to the majority of the general practice workforce, notwithstanding that its income is underwritten by government.

From a question of what is general practice, and the most cost effective organisation of same, then it becomes a cost accounting exercise. The best cost accounting depends on ensuring that all the assumptions underpinning the process are clear. There are times when approximations will be made; and it is the test of any good cost accountant to know when to approximate. After all, if one waits for a complete census of any population when 90 per cent will provide a useful approximation and if the information can be obtained in a reasonable time, then delays are avoided that otherwise can render the data of limited use.

The problem is that the advice provided by cost accounting is ignored by government, because it is often inconvenient. We once showed that the most effective radiation oncology practice was one based on three linear accelerators at any one site. What happened was the States bent to political pressure and scattered one machine facilities across its jurisdiction; as well as being uneconomic, these facilities had difficulty maintaining staff.

In the end, once the true costs are known, then it can be discussed what should be the professional cost of the practice, the expected income of the general practitioner, which is subsidised through fee for Medicare benefit and what can be gained by additional charges that the patient has to find. This figure is complicated by the corporatisation of general practice. After all, general practitioners can charge what they believe is fair and reasonable. What does their corporate boss want to charge?

The Federal government provides a patient benefit not a doctor’s fee. The patient benefit is constitutionally valid; but setting fees is not. The Australian voters in the 1973 referendum rejected Federal control on prices and income.

And there you are. Answers are gained, and the 17 member committee can deal in facts adorned by assumption rather than opinion warped by bias and, I hesitate to say, “enlightened self interest”.

Where fantasy meets reality

In the Boston Globe, Stephanie Ebert runs a regular opinion piece chronicling what is happening due to the Supreme Court ruling, overturning Roe v Wade. This is her latest update I’ve edited hopefully without affecting the original content.

The consequences of withholding reproductive choice were expressed in stark and varied terms, by a Republican state legislator in South Carolina, by voters in New York, by political pundits balling up their midterm predictions, and by HBO viewers shocked by the premiere of the “Game of Thrones” prequel “House of the Dragon.”

But before we get to Westeros, let’s stop in the Palmetto State (South Carolina), where a Republican state lawmaker’s abortion regret clearly struck a chord.

Rep. Neal Collins told an emotional story about the real-life fallout of the “Foetal Heartbeat Bill” he had supported, which prevented a 19-year-old whose water broke at 15 weeks from terminating a pregnancy that was not viable. She was sent home from the hospital with a greater than 50 percent chance of losing her uterus, he said, and a 10 percent chance of developing sepsis and dying.

“That weighs on me. I voted for that bill,” Collins said in a video clip that circulated on social media. “These are affecting people.”

The clip was picked up by CNN Politics, where commentator and former Trump aide Alyssa Farah Griffin said that in some states, the GOP was going too far with abortion restrictions.

“This very extreme position will backfire on Republicans — not having exceptions for rape, incest and life of the mother — and I absolutely think we need to course-correct,” she said.

That’s the view of many political observers who are rewriting their predicted narratives for the midterm elections since voters began having their say at actual ballot boxes. A special election victory by Congressional candidate Pat Ryan — a New York Democrat who campaigned on abortion rights after the Supreme Court struck down Roe v. Wade — is a sign that Democrats are now more competitive in the midterms than anticipated.

Anger over the abortion ruling is translating into new voter registration and could fuel a pushback at the ballot box, several new analyses suggested.

Tom Bonier, CEO of the political data firm TargetSmart, dug deep into Ohio voter registration and reported that women out-registered men by an 11 percentage-point margin since the Supreme Court’s Dobbs decision on June 24 — a huge change from the 2018 midterms.

Bonier documented the surge of women who registered to vote in Kansas after the leak of the Supreme Court’s draft ruling in early May before Kansans voted overwhelmingly to preserve abortion rights in the state’s first-in-the-nation referendum on the issue.

Not to be outdone, the New York Times’ The Upshot examined new voter registration in 10 states and found the number of women registering to vote rose by about 35 percent after the decision was leaked, while men had an uptick of 9 percent.

Meanwhile, abortion bans have taken effect in 12 states. But in one of those, Idaho, the Justice Department prevailed in a legal challenge that partially blocked criminal prosecution of doctors who perform abortions. A federal judge agreed with the Justice Department that Idaho’s abortion ban conflicts with the federal Emergency Medical Treatment and Labor Act, which requires hospitals that receive federal funding to provide treatment in medical emergencies.

In Texas, the decision was the exact opposite. A federal judge agreed with Attorney General Ken Paxton that the state can’t be compelled by the federal government to save a pregnant woman’s life with an abortion.

In other news

Once vulnerable, N.H. Senator Maggie Hassan is suddenly benefiting from abortion ruling, other Democratic breaks – The Boston Globe.

Google, criticized for steering those search for abortion to anti-abortion crisis pregnancy centres, takes steps toward clarity – Bloomberg

The aforementioned HBO series “House of the Dragon,” which requires both trigger and spoiler alerts for a brutal childbirth scene that was upsetting to many women.

Still, one of the showrunners told the L.A. Times that the women consulted during production offered positive feedback. “Some felt it wasn’t violent enough,” he said.

Was it gratuitous – as was often said about its patriarchal forebear “Game of Thrones?” Was it transparent in its intentions, like a latter-season “Handmaid’s Tale”? I was surprised to discover it was written and filmed well before the Supreme Court ruling.

Mouse whisper

Appalling taste. According to The Economist, there are those Brits who are promoting Larry the Cat as the next British Prime Minister. Extraordinary how the Brits have embraced this serial murine killer. But then Larry has had to deal with Boris Knotgudonov, who has tried to portray himself as a cool cat, but turned out to be an appalling mouser.