Monday, August 26, 2013

Health spending needs reform

ELENA DOUGLAS

Health spending needs reform

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Health spending needs reform
Western Australia is netting significant savings by privatising public hospitals, with other states to follow. Photo: Sylvia Liber
The reform of any system requires three things: incentive, clarity of authority and responsibility. Australia’s health system lacks all three, yet significant change is necessary to curb government health spending that, in the past 10 years, has increased by an unsustainable 80 per cent.
Firstly, take incentive to reform. States run the lions-share of health. Under current GST arrangements, states don’t benefit fiscally from their reform efforts. The Business Council of Australia’s proposal for GST by population would close this incentive gap.
Incentive is necessary because hard decisions are required, like private provision of public care. A 2009 Productivity Commission study compared government-owned and non-government-owned hospitals and found that on average, across the country, NGOs delivered services at lower cost, with better infection control. Internationally, post-ideological Sweden embraces the purchaser-provider split – 20 per cent of public hospital-care is delivered privately and 30 per cent of public primary-care.
Western Australia is actively privatising public hospitals: St John of God runs the Midland Health Campus, netting significant savings: $1.3 billion to date. Queensland is following suit: private providers will build and run Sunshine Coast University Hospital – to be Australia’s largest publicly owned, non-government-run teaching hospital. NSW is commissioning a non-government-designed, built and managed solution for the new Northern Beaches Hospital.

AUTHORITY SHOULD BE DEVOLVED

The second question is authority. The consensus is authority should be devolved as much as possible, to the local hospital, service delivery level. However to make meaningful change, local managers need the authority to hire and fire clinical staff on flexible terms, circumventing state-wide employment conditions restricting hospital productivity. This is the states’ reform task.
In Kevin Rudd and Tony Abbott we have two contenders who are both natural centralists. Rudd is running a scare campaign on Abbott’s “cuts to health”. In 2010 it was then health minister Nicola Roxon running a scare campaign on Rudd in an infamous Sky News interview when she recalled how, “with four days’ notice”, Rudd wanted to “take over the entire health system” without any materials for Cabinet or legal advice. Now that’s scary.
As a former federal health minister, Abbott’s instincts are centralist but he’s changing his tune. In the sanitised, updated 2013 edition of Battlelines Abbott says: “John Howard was right to express scepticism about whether Commonwealth bureaucrats would be better at running hospitals than their state counterparts, but wrong to imply that a Commonwealth assumption of responsibility for public hospitals would just swap one lot of bureaucrats for another.”
Shadow health minister Peter Dutton on the other hand is a fan of devolution. Dutton will close the “12 new health bureaucracies” in Canberra and “bolster front-line services by redirecting resources from bureaucratic structures that don’t provide patient care”. The Coalition will have local boards managing hospital budgets and appointing chief executives.

RESPONSIBILITY BUCK STOPS WITH US ALL

On the final issue: responsibility, where does the buck stop? The answer’s obvious: with each of us. When it comes to health spending, transparency and individual funding are paramount to engage citizens in spending health dollars wisely, putting a value on health and the behaviours which support it. Change must come. Incentive for reform is essential; authority should be clear and personal responsibility for health must be taken by each of us.
Make no mistake, there are votes in health. It has polled highest as “very important” to federal voting intentions in every Newspoll for six years bar one.
Elena Douglas is an economic and social policy commentator based in Perth.
The Australian Financial Review

Thursday, August 8, 2013

What today’s politicians can learn from the Federalists

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What today’s politicians can learn from the Federalists
The Royal Exhibition Building in Melbourne depicting the Federation of Australia. Photo: James Lauritz
ELENA DOUGLAS
An election campaign should be an opportunity to compare and choose between different visions for a country. What is an election for, if not to reflect on the nation we want to be? But in reality, given Australia’s brutal political climate, we know better than to expect either side to paint on a broad canvas.
Lifting our gaze and asking questions about the deeper meaning of the national experience may seem naive, even quaint. There is no time like now: Australians crave noble sentiments and a sense of national purpose. Yet neither side of politics is able to define a meaningful narrative. Perhaps this is because we have an inadequate sense of our past.
The future is as much about memory as imagination. Politicians draw from the past to paint the future. An inaccurate or narrow rendering of history limits our mental range.
Australia’s political style does not tend toward idealism. Pragmatism looms large. The country’s story has been told as a litany of sensible choices and pragmatic compromises. Australians are proud of this earnest, rational, calculated political tradition. None of your high-ideals palaver in realpolitik Australian style, thank you.
But what if this conception doesn’t capture the fullness of Australia’s story and thereby limits the view to the horizon?
In critical policy areas the debate has narrowed so there’s little difference between the major contenders. They slug it out at a level of unholy detail. Border protection has descended into who has more tents; tactical differences in taxing or pricing carbon becomes high drama; the economic argument, if not the documented performance, is represented in different shades of fiscally conservative grey. These are fights over detail, not national direction or destiny.
The fact Australia’s founding narrative, Federation, is told in a tactical, practical, even utilitarian light may be to blame. In the popular imagination Federation is a transactional arrangement designed to reduce cross-colony tariffs, promote inter-colonial trade and make the country secure against the threat of foreign invasion by redefining its place in a mutually defensive empire.
This story is told in black and white, bleached of idealistic colour. But in fact, Australia was brought into the world by high idealists. They saw the nation’s promise writ large: a continent as a country; the story of a nation born of the desire for union alone, without bloodshed or tears, here to show the world how it was done. The Federalists saw Australia as a moving new chapter in the human story.

A SENTIMENTAL NOTION

As historian John Hirst celebrated in his splendid book timed for the centenary of Federation,Sentimental Nation: The Making of the Australian Commonwealth (Oxford University Press), the Federalists saw their project as one in a movement of nations forming a pathway to a better future for humankind. Theirs was a sacred endeavour; inspired, sentimental and philanthropic. The Federalists, in particular Alfred Deakin and Andrew Inglis Clark, were moved by notions of society’s progress, especially as it was embodied in 19th-century European nationalism. They saw an escape from tyranny and foreign domination in Giuseppe Garibaldi and Giuseppe Mazzini’s unification of Italy and in the nationalist movements in Poland and Hungary.
The Italian story in particular galvanised them. Clark wrote poetic tributes to the heroes of European nationalism, sensing himself something of a prophet:
Thus ever have the saviours of the world
Behind the things that seemed to other men
Eternal facts, seen truthful dreams
That others would not see
Until the facts in fragments at their feet
Fell down, and in the face of all men stood
Revealed the visions which the prophets saw
And followed unto death
Australia’s was a noble birth. Restored to their rightful place in our national story, who knows what imaginative possibilities these dreams might open up?
History is painted in the hues fashionable to the times in which it is drawn. Unlike the lyrical works of John Hirst, mid-20th century historians of Australia, and their protégés, went in search of rational and scientific accounts. Seek such answers and you will find them. But Federation cannot be understood solely by economic and security concerns.
With the more sentimental colours restored, the picture of Federation is inspiring. Absent the high ideals and their broad resonance, Federation would never have got the numbers. Similarly, expanding Australian immigration in numbers and nationalities has always been a story of inspiration, leadership and education. Of course, the commitment of the Federation movement to racial purity and a white Australia, as well as the intentional exclusion of Aboriginal people, is now seen as completely unacceptable. But Federation’s blend of global ideals and local education, inspiration and perspiration, deserves emulation.
While moved by idealist philosophy and the dream of higher things, as is true for all statesmen and women, statecraft involves balancing global aspiration with local realities. In the case of asylum seekers, more could be done to expand the conversation, reminding us Australia is one piece in a global jigsaw. While creating insuperable disincentives to people smugglers, we should expand the case for a bigger, richer and more creative Australia – on which our immigration program depends.
However strong the border protection, the rhetoric need not descend to demonise people who want to start a new life in our country. A proper response to satisfying the less generous instincts of the large mass of Australians, and constituencies in Sydney and Melbourne’s outer suburbs is to challenge their sentiments. Sometimes politicians must be prophets. The crowd is not always wise and virtue lives in the stories we tell. Give people the chance to rise to the occasion. Give them poetry.

AUSTRALIA AS A YOUNG QUEEN

One of the best known Federation poets, William Gay, wrote to Alfred Deakin in 1895: “Though Australians will federate in their own interests yet, from the point of view of world history, the chief importance of Federation will be in its being a necessary step in the progress of civilised man.”
The story of Federation is perhaps best told in the poetry it inspired. Forgotten now, thousands of Federation poems were written. A jewel in this firmament is The Young Queen by Rudyard Kipling, that great raconteur of empire, to honour the new Commonwealth of Australia. It was first published in Britain’s TheTimes then the New York Tribune. The moment it reached Perth, Australia’s first port of call from London, it was telegraphed and printed in newspapers across the country. It was wildly popular.
Australia is represented as a powerful, young warrior queen presented to the old queen (Britannia), reluctant to crown her as Australia is already a queen in her own right:
How can I crown thee further? I know whose standard flies
Where the clean surge takes the Leeuwin or the coral barriers rise
Blood of our foes on thy bridle, and speech of our friends in thy mouth
How can I crown thee further, O Queen of the sovereign South?
But the young queen, a gallant warrior who fought in the Boer War, insists that her sovereignty and fealty are one, and, on her own terms, demands to be crowned:
And the Old Queen raised and kissed her, and the jealous circlet prest,
Roped with the peals of the Northland and red with the gold of the West,
Lit with her land’s own opals, levin-hearted, alive,
And the Five-starred Cross above them, for sign of the Nation’s Five
So it was done in the Presence-in the Hall of the Thousand Years,
In the face of the Five Free nations that have no peer but their peers;
And the Young Queen of the Southland kneeled down at the Old Queen’s knee.
And asked for a Mother’s blessing on the excellent years to be
Having recently watched Australia’s first female prime minister vanquished, it seems we’ve forgotten our nation was conceived and born in the female form. Sometimes she was a queen, often a goddess, embodying universal ideals and civic virtues: justice, reason, truth and art.
It may be testament to the manner of Julia Gillard’s appointment, but it seems sad for a country that finally achieved the milestone of a female prime minister to have failed to savour the moment and instead descend into a misogyny debate. A dream nurtured over generations was realised, then passed over, with little comment or celebration and a total absence of grace.
Australia now paints itself in masculine imagery. The nationalism born of Banjo Paterson’s verse has prevailed. It was written to celebrate the outback and the values of its men: cattle drovers, miners, farmers, Aboriginal stockmen and trackers; brave, foolhardy explorers, squatters and bush-rangers; wild colonial boys, miners and diggers, proving their bravery in foreign wars. We have forgotten the femininity of the early Commonwealth.

MORE POETIC THAN WE REALISE

The new nation achieved something else drawing on the highest ideals: it was not born in war. It is a splendid distinction, again little savoured. Australia’s true midwives (women and men alike) were civic nationalists concerned with the state and the principles and values it could reflect and advance. Moreover, as Hirst points out, Australia’s origins were more democratic than our American or Canadian counterparts: the representatives to our convention were elected by the people.
The Federation project was romantic in its conception, poetic in its expression and embodied classical ideals of the good, the true and the beautiful. Without denying the rational case for Federation, an understanding of the idealism that inspired it could enrich our contemporary politics. We need to open up spaces for more nuanced conversation where good and noble, yet pragmatic and achievable, solutions can breathe. Time to stop filling the air with tweeted sound-bites and slogans, and the false gods of personality politics. The country’s history, in full colour, tells us we were more idealistic, cosmopolitan and poetic than we know.
To have a new vision of the future, it has always first been necessary to have a new vision of the past: countries are made as much of memory as imagination. But each generation adds its history to the canvas, sometimes by painting over the original with the colours of the present.
Only restoration brings it back to life: the Anzac legend was retrieved when historians and film-makers reclaimed it. The triumph of the bush poets in the public imagination was a contingent, not an inevitable thing. The task falls to a new generation of storytellers – historians, poets, artists and film-makers – to illuminate the true colours of the national story, starting with its birth.
In an election campaign Australians yearn for leaders who help them see their best selves, who can explain the country’s meaning and purpose, its farthest horizons. In a utilitarian age, in a nation defined by its pragmatism, this is a big call. No matter. Now is the time for Kevin Rudd and Tony Abbott to paint the future on a canvas as grand as the continent itself. Now is the time for them to ennoble Australia’s story, and tell us their vision for how we can fulfil this country’s great promise.
Elena Pasquini Douglas is convenor of the Centre for Social Impact at the University of WA Business School. She is a writer and film-maker and is currently completing a PhD on the history of economics and virtue.
The Australian Financial Review