The right remedy?

IN LATE December, on the advice of a local GP, I took an elderly relative to the emergency department of a major hospital in metropolitan Melbourne. His body was breaking down. He had a severely infected toe, which gave him enormous pain, was passing blood and was having trouble breathing. We waited five hours to see a doctor.

During those five hours, as he got weaker and increasingly disoriented, we were required to explain his health problems on four occasions: first, to a desk clerk and then to three members of the nursing staff, without treatment. Then finally, to the doctor, who did not have the benefit of our four previous briefings. Once inside the hospital, we had to start dealing with the bureaucratic and internal power structures that encourage duplication and waste.

This may seem churlish to the Victorian Premier, John Brumby, and his Health Minister, Daniel Andrews, as they try to extort $1 billion from the Rudd government before co-operating on health reform, but not once during that day - which resulted in major surgery and a month-long hospital stay - did it occur to me that Victoria had a great hospital system.

There is no question that Victoria's hospital system is more efficient and effective than those in New South Wales and Queensland. It also appears that the Victorian government's efforts to cut back on the frequency of patients spending nightmarishly long periods on emergency room trolleys are bearing fruit. But the throwaway assessment that has taken root this week that, because Victoria does better than the worst states, it is the model for the rest of the country is nonsense.

During the past few years, I have had more exposure to the public hospital system than I would have liked. I have dealt with a lot of amazingly talented and dedicated people. I have also seen hidebound, blinkered management practices, pointless miniature empire building, and ridiculous turf wars between and inside hospital departments. Now, it seems, some state leaders want to carry out the same games on a national scale, potentially to the community's great cost.

It is almost 70 years since the inexorable move towards centralisation of government in Australia began, with the Commonwealth taking over the taxation system. The result, all these years later, is a broken federation in which the states are reduced to acting as special interest groups, dedicated to protecting their powers, institutions and bureaucracies.

The Victorian government's initial response on the health plan demonstrated this. Its reflexive reaction was to see the opening of the reform process as an opportunity to demand more money. In doing so, it sought to shift the debate from being about the most effective way to spend each existing health dollar - in other words, about practices, structures and outcomes - to being about how to spend more. This is simply unsustainable. Unless a new funding arrangement is established, the states will collapse under the weight of having to deliver health services to an ageing population. That's the economic imperative.

Walk around any public hospital in suburban and regional Australia now and you will see a predominance of two types of patients. The first, a smaller group, is made up of younger, low-income patients, many of whom are in hospital because of lifestyle factors - diet, misadventure, drug or alcohol consumption. The second group, which is much bigger, is made up of elderly Australians, who are churned through the hospital system as their bodies gradually fail them. Unless something changes, this is the nation's future.

The challenge to the federal government and the states runs deep. Australians, quite rightly, demand better health outcomes. They will not get them unless all governments engage in a root-and-branch recasting of the health system, a series of changes that extend far beyond public hospitals. It could well turn out that the Rudd government is embarking on a quixotic, self-defeating venture with health reform.