We can’t work under these cynical conditions

5 minute read

Underfunding healthcare, particularly general practice, will hurt us all in the long term, including the doctors trying to give best care.

Moral hazard is an economic term for when, in a contract, one person bears the risk of the transaction and the other party, with less risk, can therefore engage in more risky behaviour.

This describes well the contract between Medicare and the medical profession. The government bears no risk of falling standards driven by underfunding. Clearly, the“greedy doctors” – a political spin term of giant proportions – are at fault. It’s an ironic term when you contrast the pitiful superannuation of any GP with that of a parliamentarian. 

Consider the lamentations of “the healthcare worker did not take enough time with the patient” and contrast that with emergency departments and waiting rooms heaving with the acute and chronically unwell. “Go faster” applies to factory robots, not healthcare services. The suggestion that “doctors are always complaining” is an excuse to ignore the suffering patients.

The medical workforce numbers everywhere are falling as early, mid, and late career healthcare professionals quit, both quietly and noisily. Sadly, this quitting is happening at peak productivity after years of investment by the individual. The grief we collectively feel on our colleagues’ behalf and on behalf of quality patient care is monumental.

Economics has struggled to be seen as a science, and indeed, given its lack of understanding of the human healthcare system, that accusation currently seems warranted. Incentivising poor quality by not funding the health care system properly is costing us all dearly. We are in healthcare, palliating the flawed policies of a collective lack of vision for our country’s health transformation.

We have had poor digital infrastructure – the My Health Record a case in point – foisted upon us and an unsuspecting public; a pernicious political split between state and federal health systems leveraged against the good of the people for the good of the career politician; political donations out-influencing good science; and poor funding of public health. Professionalism is at risk, a faint and sad echo of the nobility and independence of the professions necessary to the checks and balances of a functioning civil society. The privilege of professional life creates an obligation to advocate for the voiceless.

The public has lost faith in institutions just as the commercial profiteers sweep in to malign and silence any objection with slick advertising and health propaganda.

As Professor Paul Komesaroff has written:

“The debate [about the My Health Record] has drawn attention to a deep-seated, abiding suspicion in the Australian community of government and the public agencies more generally. The reasons for this are not hard to find: they include widely held feelings that the public sphere has been degraded by crude personal and commercial interests, that politicians are concerned primarily with their own power and advancement, that business is devoted to the ruthless generation of profits regardless of social implications, and that public agencies — including those established to support vulnerable members of the society — operate punitively, within a blame culture. In such a setting, it is no wonder that members of the public may think twice about entrusting intimate personal details to a government-run database.”

I fear populism is in charge, and pirates run the cinematic advertorial panorama while pillaging a world-class health system. It isn’t pretty.

GPs know the moral hazards best of all healthcare workers. Patients don’t like role substitution and physician continuity of care is cost-effective. The fetish for simple measurement, however, is misapplied to the continuity of care paradigm as economists demand a return on investment within a single consultation when a patient’s care stretches over a lifetime.

We don’t have to keep proving the worth of general practice; if so, we are being made to jump for biscuits. The health system needs to embrace the role of generalism, and some academic system thinking seems sorely lacking in those managing by spreadsheet. The constant call for “cost efficiency” is only a quarter of the quadruple aim for high-functioning healthcare systems.

A recent opinion paper in JAMA discussed the nexus between the compromised professional workplace and compromised professionalism, and called for the moral hazard of healthcare to rest not only on the individual physician but also on society at large. With an increasing load of burnout and its effects on cost efficiency, healthcare quality, standards, capacity and outcomes, a systems view cannot be ignored if those in power are to reattach the label of their discipline as a science or as evidence-based policy (see here and here).

The moral hazards are increased as the fetish for measurement blends perniciously with the fetish for compliance at a distance. We have seen the automation bias in “robodebt” and where the mystic reverence for AI trumped the commonsense of human reasoning. You can’t digitise ethics, care, or human reasoning, and the ethics of care are missing in the national conversation.

This cannot go on and all solutions so far seem fragmentary at best and commercially driven at worst. All solutions fail the complexity theory underpinning a high-performing health system by ignoring the role of generalism, preventive health, and continuity of care of general practice.

Fund the area of health which the WHO calls the best bang for buck. The moral hazards otherwise will bite hard on those responsible when the order descends into chaos, as it surely will. The disrespect shown for the fundamentals of health systems, for quality patient care, for healthcare workers and especially for GPs seems, to put it mildly, unwise.

Adjunct Professor Karen Price is a GP, immediate past president of the RACGP and a PhD candidate at Monash University. The title of her thesis is The role of peer connection in general practice.

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