Diagnosis clear. Prescription Unwritten

Wishful thinking and self-interest dominate discussion on this topic amongst Australian doctors, in their organisations and by the media’s political commentators. The large elephants in the room are ignored, while attention is focussed on minutiae of interest only to affected minorities in the population and in the profession. These elephants need to be acknowledged if there is to be any realistic appraisal of what is likely in the future.

The largest African elephant is trumpeting loudly that no nation can afford to provide first-class health care to all of its citizens. He is not heard because we do not want to hear him. What he is saying goes against all our ingrained egalitarian democratic principles.

The enormous flapping ears of the second African elephant are trying to tell us that there is a world-wide shortage of doctors and nurses. Medicine is no longer a profession which appeals to many bright young people in this IT age. The feminisation of the medical workforce has reduced the overall number of medical hours worked annually, as women doctors take time out to have babies and raise children. The many opportunities now open to young women in the professions and in academia have reduced the pool of those who might wish to become nurses. The intellectualisation of nursing — not to mention the politically correct pseudo-intellectualism — has turned away many who wish to care for people in distress.

Standing next to these two large African elephants is a smaller Indian elephant. His trumpeting is more localised than that of his African cousins; it can be heard only in Australia. He is trying to tell us that, in so large a land, with a significant population scattered across 8 million square kilometres, it is impossible to provide medical services of an evenly high quality to everyone.

Finally, there are two pygmy elephants, whose strength is not matched by the stridency of their trumpeting. They make much noise, but are constrained by their inability to do very much in the short time they are pulling in one direction, before they have to turn around and pull another way. Unlike their Republican cousin in the United States, who is opposed by a Democrat donkey, the pygmy elephants represent both political parties. They are evenly matched in their trumpeting and weak resolve.

However our health care financing problems are to be solved, it is pointless to ignore the three larger elephants and concentrate on the pygmies. They are powerless against the might of the Africans and the Indian.

But all need not be doom and gloom. It should be possible to ameliorate the larger problems, even if they cannot, like a quadratic equation, be solved with no loose ends dangling.

How do we tackle what the largest elephant is telling us? He is saying that we should focus our attention on those who need help most; that spreading the available cash to cover the needs of every Australian, no matter how much the many affluent Australians are able to help themselves, is to misdirect our efforts. But his trumpeting falls on the deaf ears of those who maintain that the payment of selective benefits or the provision of services to poorer people is stigmatising. It does not seem to occur to the proponents of that argument that treating equally people who are already disadvantaged causes further inequality.

The second African elephant has a simpler message: train more doctors to overcome the impact of feminisation. But to do that, we need to expand the services provided by hospitals, not reduce them. Medicine is a practical science. Without patients in the hospitals, how do medical students and junior doctors learn? We need to make nursing attractive, once again, to young people who wish to demonstrate the soft side of their personalities and who are not interested in intellectual pursuits at universities.

The Asian elephant is trying to tell us that non-urban Australians need health care. This does not always need to be provided by doctors. Russia has long trained feldschers to provide primary care to its people scattered over an area twice that of Australia. China has trained ‘barefoot doctors’ to provide primary care to its non-urban people, scattered over an area somewhat larger than Australia. This elephant is simply describing our ‘tyranny of distance’. Why can’t we see and hear him? 

Our two political pygmy elephants are trumpeting so shrilly that they cannot hear their larger cousins. Both being short-sighted, they cannot see them either. Concerned only with where they will be in three years’ time,  they prefer not to be aware of the presence of their cousins. They hope, hysterically, that if they ignore them, they will simply go away.

Floundering, blind and deaf, around these five elephants, are our doctors and nurses. Each is concerned with finding and consolidating their own niche, finding somewhere safe where they will not be trampled upon, and resisting any moves by anyone who tries to direct their attention to the presence of the large elephants.

Our medical organisations will not be persuaded that one size does not fit all. Some medical services and some locations are better served  by salaried doctors, some by the British capitation system, and some by fee-for-service. Universal ‘first dollar’ insurance (a rebate every time you use a medical service) makes as little sense in health care financing as it does in motor car insurance (money back on every dent and scratch). Payment by a third party invariably carries with it the ‘moral jeopardy’ of insurance – “who cares what it costs, I’m not paying!” But it suits the doctors and bribes the voters.

And, finally, of course, there are the sufferers (from the Latin = ‘patients’ — at any election a small percentage of the voters), waiting for their appointments, diagnoses, investigations, operations, radiotherapy, chemotherapy, rehabilitation and long-term aged care. They, alone, can hear the African and Asian elephants, but they are powerless to do more than feed first the one pygmy elephant, and then the other one. And, for fear of offending anyone — the doctors, the nurses, the affluent, the urban dwellers — the pygmy elephants do nothing.

Dr Peter Arnold is the author of A Unique Migration: South African Doctors Fleeing to Australia