Related Articles


  1. 1

    Ben Harris-Roxas

    Interesting piece Patrick. I agree with most of what you’re saying but it concerns me to hear you perpetuating the line, popular in this era of social determinants, that health has nothing to do with healthcare. While we can’t ignore the importance of equality and broader social, environmental and political conditions as population-level determinants of health, the health sector still has a critical role to play.

    Your piece reminds me of McKee’s (2002) observation that McKeown’s influence on public health was to popularise the view that improvements in mortality were mostly due to improvements in living conditions (McKeown 1979). Mackenbach and his colleagues refuted this by demonstrating the decline in deaths from conditions that were altered through health care represented a major part of overall improvement in life expectancy in the Netherlands between 1950 and 1984 (Mackenbach et al 1988).

    The recent WHO Commission on the Social Determinants of Health confirmed the importance of health sectors in addressing health directly and acting on the social determinants of health (WHO 2007). I think there’s still an important role for health services in contributing to a reduction in health inequalities and ensuring population health gains and saying that the health sector is just a bucket with a hole in it is inviting Treasury to gut non-emergency health services, such as the population and preventive interventions that will actually make a difference.

    I did like your point that demands on healthcare are essentially infinite. I do think a broader public debate is required about what sort of treatments and technologies we, as a society, are willing to fund and what taxes we’re willing to pay to achieve that.


    Mackenbach J, Looman C, Kunst A, Habbema D, van der Maas (1988) Post-1950 mortality trends and medical care: gains in life expectancy due to declines in mortality from conditions amenable to medical interven-tion in The Netherlands. Social Science and Medicine 27:889-894.

    McKee M (2002) What can Health Services Contribute to the Reduction of Inequalities in Health?, Scandanavian Journal of Public Health, 30(Supplement 59) p 54-58.

    McKeown T (1979) The role of medicine: dream, mirage or nemesis? Oxford: Blackwell.

    WHO (2007) Challenging inequity through health systems – final report of the Health Systems Knowledge Network, World Health Organization: Geneva.

  2. 2


    Patrick offers up some interesting but important observations about the health care system and the pressures on it to reform. The health care system, and the difference perceptions about it, seem analogous to the “Emperor’s new cloak”. Each government wants to make its mark and be shown to be doing something that improves a service that touches us all, increasingly so as we approach death. Death is apparently a failure of the system despite our increasing longevity which is widely touted as a leading indicator of how well we do. If we don’t ask questions about who and where the system is failing then for more it is good than bad.

    But there are several questions that are often overlooked, such as who benefits from the current organisation and delivery of health care, and who should be heard in proposing and progressing changes. Hospitals have changed their focus over the years from an isolation role for infectious and communicable disease, to a greater capacity to deal with trauma and lifestyle related diseases such as neoplasms and cardiovascular disorders, and are seeking a prominent role in treating chronic conditions. Because the infrastructure exists, because it is familiar, there are pressures to use it but questions remain about how effectively and how efficiently.

    There are four different unreconciled mindsets in health care, each with different expectations and preferences. The first mindset is Community, comprising those who seek unfettered access at least personal cost and who were represented through Boards of Directors. The second mindset is Control, comprising those who seek to manage resources in some way and include politicians and bureaucrats. The third mindset is Cure, comprising those with a medical orientation based upon a biomedical model of health and individualised clinical practice. The final mindset is Care, comprising those with nursing and allied health orientations that have a team or multidisciplinary view of health care. Everyone wants a quality health care system but agreement on the personal and collective cost and differing remuneration for outputs and outcomes is where the debate begins to heat up. If we cannot agree on more then we will continue to praise the Emperor’s new cloak without recognising our naivety.

  3. 3


    The debate about limitations is important. Society needs to make an informed decision on the trade off between care and cost.

    In theory to maximize care, everyone would need their own personal doctor and constant check-ups, tests, etc… This is clearly too expensive. Unless you are Michael Jackson and it didn’t work out so well for him.

    This debate exists in electricity. What is an acceptable security of supply? Some people try to argue that there should never be any blackouts. The trouble is that a one in a hundred year heat wave requires significantly more capacity than a one in ten. And for almost every year you end up with a very large expensive asset not getting used.

    Final parallel is with defense. We have a big enough army/navy/airforce to deter Indonesia. Possibly big enough to stop them. But we don’t even bother thinking about trying to stop China.

  4. 4


    Having worked in hospitals, then in the healthcare industry, what surprises me most about this whole debate is the completely different attitude of both government and healthcare staff to ‘problems’.

    In most industries, ‘problems’ are solved relatively quickly because a company or person comes up with a better product to solve the ‘problem’.

    The real ‘problem’ with healthcare is that it is inflexible. It’s over regulated, dominated by guilds that threaten to walk out if their inefficient practices are ursurped. All in all – it’s like 1930’s communism in the 2000’s (apologies to the communist believers out there but I don’t think it really worked to well).

    Many will say ‘oh but America has a free-market model of healthcare and they are worse off than us’. But the reality is they have just as much regulation as we do – just in a different form.

    Real health reform will not come through top-down attempts at proper management – that is usually a sign in the real world that a company is in major trouble and is no longer competitive. It will only truly change when we rethink our entire approach to health beginning with opening up the workforce to reflect the structural and financial realities and unmet needs of consumers.

  5. 5


    Thank you Patrick (other those who’ve made comments) for taking the time to share your thoughts and some interesting facts.

    What struck me most was that whilst error rates and the high level of unnecessary care were identified as part of the problem but did not rate a mention in the solutions. To my thinking these are the two areas where we have data against which to track progress.

    As distinct from bureaucratic micromanagement which ‘results in alienation of the workforce without improving performance’ we have to create forums for the health care workforce to communicate and better understand each other.

    According to your statistics our ‘overworked’ health care sector that is spending a third of their time (and a third of the financial resources society allocates to health) doing what is unnecessary (and potentially harmful!)

    The solution is not trying to squeeze more of less – which is the mantra of every health reform in living memory – but to slow down and create the space for the intellectual capacity we have tied up in knots to improve the system.

  6. 6


    This comment is posted on behalf of Steven Lewis (co-author of this recent pertinent article in the MJA:

    He says: “Two fundamental points are debatable:
    1. There is always more that can be done than money to do it. Literally, of course, this is true, but if we apply any sort of “reasonable” test to marginal benefit, it is at least plausible that we have passed the point of over-medicalizing what ails us and/or intervening at such a rate that we are actually doing more harm than good. That conversation needs to take place.

    2. The only way to make the health system cheaper is to reduce services. Not so: the other way is to reduce prices. New Zealand’s generic drug costs are 23% of Canada’s.

    But the rest is very good and raises the right questions. The system is designed to drive up costs of course, precisely because we have collectively either concluded, or conceded, that very fragmented, autonomous decision-making is in the best interests of both the individual and society. That is conceivably correct, but as Patrick Bolton points out, you’d better eliminate conflict-of-interest temptations if that’s your stance and you hope to achieve a modicum of financial prudence.”

    Steven Lewis is a health consultant in Canada and holds appointments at the Menzies Centre for Health Policy at the University of Sydney, and at the University of Calgary, and Simon Fraser University.


Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

© 2015 – 2020 Croakey | Website: Rock Lily Design


Follow Croakey