Unhealthy federalism

This morning’s ACNielsen poll attracted most attention for adding another week to Labor’s remarkable lead in the polls, but it also reported some interesting issue polling.

Alas, support for federalism – at least so far as it concerns hospitals – is no stronger than the Coalition primary vote. 40% think that it would be better if hospitals were run by the states, compared to 42% who think the federal government should do it.

I doubt that this is an ideological thing; federalism (as opposed to parochial concerns with ‘state’s rights’) has never really been widely understood among the politically active, much less the masses. It is a pragmatic assessment of which level of government seems most competent, with 55% of those polled agreeing that the health system is ‘not very well run’, and nearly twice as many people (46%) blame the states for this as blame the federal government (24%).

Personally, I doubt the federal government would do a better job. The Canberra bureaucracy has relatively little experience of service delivery compared to their state counterparts, and with the added disadvantage of being very remote from the places they need to service. The one advantage of the otherwise poor policy on display in Mersey hospital takeover may be to provide evidence that the Commonwealth does no better at running hospitals than the states.

25 Responses to “Unhealthy federalism

  • 1
    Russell
    September 10th, 2007 21:18

    If the federal government took over hospitals it wouldn’t have to mean they were run from Canberra – the Health Department could have state or regional offices.
    Perhaps people are looking for an answer to the blame shifting (You don’t give us enough money/ You don’t manage your affairs efficiently) – which might stop if one government was clearly responsible. Not to mention the cost shifting – hospital beds (state) taken up with elderly people because there aren’t any nursing home beds (federal).
    Plus the other stupidities of state governments – why should the age of consent differ around the country, why can people here make surrogacy arrangements, but not there etc etc – it’s ridiculous.

  • 2
    Andrew Norton
    September 10th, 2007 21:34

    “Plus the other stupidities of state governments – why should the age of consent differ around the country, why can people here make surrogacy arrangements, but not there etc etc – it’s ridiculous.”

    But these seem like examples where there is no intrinsic benefit in uniformity, and federalism can usefully be used for social experiments. It’s likely that ‘progress’ in all these areas would have been delayed had a common national position been required first.

  • 3
    Russell
    September 10th, 2007 22:03

    “no intrinsic benefit in uniformity” – perhaps, but it could be like the argument for having everyone’s children in state schools: the whole system would improve led by those who demand change, maybe more slowly … but as it is you can be stuck in a state where something is illegal and not have the opportunity to get the benefit others enjoy.
    Besides doesn’t it cost to support all these different legal systems. I should have chosen business taxes as my example rather than surrogacy.
    A point I was trying to make is that federalism is broken when one level of government has all the money, and another provides the services. There needs to be some kind of re-adjustment.

  • 4
    Andrew Norton
    September 10th, 2007 22:36

    “but as it is you can be stuck in a state where something is illegal and not have the opportunity to get the benefit others enjoy.”

    But why look at it that way? You could just as easily say that at least in some places you can enjoy benefits that nobody would under a centralised system.

  • 5
    Russell
    September 10th, 2007 22:44

    But it wouldn’t be fair! (sorry)

    I hadn’t thought before you mentioned it, but it was the ACT that would have had gay marriage, and the NT that would have had euthanasia …. do you think their size had something to do with their ‘radicalness’? Easier for a well-organised group, or a charismatic individual to convince enough people in a small political entity rather than a larger one?
    Perhaps, living in a tiny state, you don’t feel the absurdity of the states, as I do living in WA. Just look at it on the map.

  • 6
    Francis Xavier Holden
    September 10th, 2007 23:55

    We don’t have to wonder how the Feds might do with running health. We have fairly recent evidence that they just can’t do it.

    The Repatriation Hospitals (rough equivelant of Vets Hospitals in USA – which arent much better) were in every state and run directly by the feds (Lib & Lab) until 1995 (I think – haven’t checked the dates). They were a bloody expensive and dangerous disaster. Featherbedding, numerous Professors of SFA, no systems, bad medicine, etc etc.

    There is a real problem with running life and death, razor balanced, demand/supply/costs type services from a national level in Australia or USA unless you heavily regionalise. But then you aren’t really running it. And anyway the states have largley regionalised already.

    No feds will take over health as there is a huge downside they are not at the moment exposed to and not much upside because, despite all the whinging, not many (if any) people in the world do it better than us in Oz.

    Mersey Hospital is a worse debacle than it first appears. If the Feds do what they say they will they will not only be running one hospital certainly more expensively and also possible badly, but sabotaging the already better, safer and more efficient hospital 50 ks up the road.

    Based on the evidence, not the rhetoric, Abbott and his Dept are rushing madly to do nothing at Mersey except entering into vague “talks”. My bet is that Mersey will all go quietly away after the election even if JWH and Abbott are back in. They may “take it over” but they will either have to kill the ICU at the other hospital or implement pretty much what the TWO planning excercises recomended for Mersey.

  • 7
    Damien Eldridge
    September 11th, 2007 00:07

    One of the things that mnost concerns me about proposals for a uniform national school corriculum set by the Commonwealth is the possibility of a race to the bottom. While voting with your feet is costly, at least having different state school curricula allows this possibility. It also provides a set of benchmarks that can be used by each State to assess its own performance. Tiebout competition may well be a good thing!!!

  • 8
    Sukrit
    September 11th, 2007 04:50

    “The Canberra bureaucracy has relatively little experience of service delivery compared to their state counterparts,”

    No government has any experience in any field whatsoever…governments never learn – only people learn.

  • 9
    Andrew Norton
    September 11th, 2007 07:03

    Russell – I’m glad you mentioned those two good examples of how controversial, but in my view good, policies could have been trialled were it not for centralised power.

  • 10
    conrad
    September 11th, 2007 08:02

    I wish they’d actually ask people what they think is wrong with the public hospital system, versus just whether they think it is bad. I wonder how many people have had enough experiences with it to comment meaningfully, or for that matter, have had experiences with other systems to compare with. Australians have some of the highest life expectancies on Earth, which is amazing given the disgusting diets people have. This is no doubt in part due to a functional health care system.

  • 11
    Andrew Norton
    September 11th, 2007 08:34

    Conrad – You are right that the Australian public hospital system does fairly well from a health outcomes perspective. I think the ‘dissatisfaction’ comes from long delays for admission to public hospitals.

  • 12
    conrad
    September 11th, 2007 10:02

    I’m not even sure how bad the waiting lists are. Digging around I found this:

    http://www.audit.act.gov.au/auditreports/reports2004/Rpt8_2004.pdf

    which doesn’t look too bad to me, although obviously its going to differ from state to state. It would be interesting to know what the overall means really are.

  • 13
    Andrew Norton
    September 11th, 2007 10:08

    It’s not just waiting lists, but also treatment of non life threatening conditions in emergency sections. That can take many hours.

  • 14
    Russell
    September 11th, 2007 12:32

    FXH -I remember taking my grandfather to the repat hospital when he had a stroke – it was exactly what a hospital should be: not just excellent medical care but really friendly, respectful care from all the unhurried staff. It’s now an excellent private hospital, but without the special atmosphere.

    All the private hospitals I’ve visited are excellent, but I’d rather die than end up in Royal Perth – though it would be interesting to see what patients thought. The much maligned NHS in the UK might really be doing better than the media make out – they have a website called patientopinion.org.uk where patients can say what they think of their hospital treatment, and nearly all the comments seem mostly positive.

  • 15
    David Rubie
    September 11th, 2007 13:23

    Andrew Norton wrote:

    It’s not just waiting lists, but also treatment of non life threatening conditions in emergency sections. That can take many hours.

    I’m not sure that’s a function of govt ownership vs. privatised hospitals (or state vs. federal management).

    Some things just aren’t emergencies. Sure it’s hard to wait with your kids for a few hours at the local hospital, but even private hospitals have resource allocation problems that aren’t magically fixed by waving money around or having private health insurance. We’ve received poor service at private and public hospitals alike (although, the single actual emergency that we had was treated very, very promptly at a public hospital).

    It comes down to perceptions: when you are waiting to see a doctor, but the nurse comes out to check every now and again (as they do), you can be pretty much assured you’re getting decent service. People die in hospitals – they deserve attention that your flu or broken arm might not necessarily warrant.

  • 16
    Andrew Norton
    September 11th, 2007 14:34

    David – I wasn’t making a public/private distinction here, though private hospitals can ration by price so presumably they are on average in less demand. They are also less likely to run emergency departments, and instead focus on scheduled procedures.

  • 17
    David Rubie
    September 11th, 2007 16:30

    It’s very instructive to sit near the desk when waiting in the emergency department of any private hospital – especially when they are turning away ambulance cases. It’s hard to see exactly how a fully privatised hospital system would cope any better when the real issue is a lack of doctors. The private hospital we used to use in Sydney did run a (very good) emergency desk, but it was just as under resourced as the ones at public hospitals: I assume because it’s expensive to run that kind of facility and the returns are poor. There was no evidence of price rationing at either hospital – it’s first come, first served unless gazumped by a real emergency (car accident or whatever). They only asked for private insurance cards after treatment. First come/first served is, I would think, fair in most peoples estimation.

  • 18
    Damien Eldridge
    September 11th, 2007 17:38

    Sukrit, you are right that people, rather than organisations, learn. But that point applies equally to firms in the private sector. Public service departments are made up of people in the same way as private sector firms. Is there any evidence that the turnover of people in a public service department is more rapid than that in private sector firms?

  • 19
    Andrew Norton
    September 11th, 2007 17:50

    “Is there any evidence that the turnover of people in a public service department is more rapid than that in private sector firms?”

    In my experience, the problem is rapid movement around the public sector or around departments in a way that probably doesn’t show in labour mobility statistics. I regularly encounter or hear of a lack of corporate memory and program knowledge in the public service.

  • 20
    conrad
    September 12th, 2007 07:41

    Andrew,

    I don’t think rapid movement is a problem with just the public sector — its everyone’s problem. Wait until inflation comes back and see how quickly people are willing to move for slightly more money.
    Actually, in the university system, I think it is the opposite problem — people don’t move enough. This means there are never oppurtunities for people to get into the system (which detracts from people ever thinking about entering the system), and people don’t get a good idea of how things can be run in different ways. THis is partially caused by archaic (poor) managment which punishes people for movement in terms of promotions etc.

  • 21
    Andrew Norton
    September 12th, 2007 08:24

    Conrad – You are probably right. It is just that my job involves more interaction with the public sector than the private, so my experience affects my impressions. On the other hand, there seems to be a culture in the public sector of ‘generic’ policy skills being applicable to any area. It’s probably true over a sufficiently long period of time, but in the shorter term no matter how bright you are there are things you won’t know if you haven’t the experience.

  • 22
    conrad
    September 12th, 2007 09:10

    I think you are probably just used to bad managment Andrew (or at least used to seeing it). These are really generic problems of many businesses — many projects require long start-up times for employees. There are lots of simple (and commonly used) solutions to this — like offering bonuses for staying a certain number of years, increasing salary after a start-up time etc. . For example, if you get 20% of your salary paid into a fund that you only get if you stay 3 years, almost everyone is going to stay 3 years if they have already worked 2. Hence you get your 3 year project finished.
    Also, I don’t really see any alternative to the government taking people not perfectly in areas of interest. The real problem is that I assume many of the higher level jobs require very specific and intricate knowledge. You are therefore asking people that take those jobs to become specialists in often very low demand fields (but fields where you need people). If transeferrable skills wern’t valued, then the risk of doing this for the individual is huge, hence no-one would do it, so you end up with things that don’t get solved that need to be. I presume this a general problem low-demand/low-supply markets (this includes many areas of university teaching incidentally), where you always need someone, but that person does not neccesarily exist.

  • 23
    Sacha
    September 12th, 2007 09:51

    “…where you always need someone, but that person does not neccesarily exist.”

    This reminds me of a research job at a university being advertised for a third time that I am actually qualified to do. The question is, do I want to do it? (it’s the incentives again…)

  • 24
    Francis Xavier Holden
    September 12th, 2007 16:11

    russell – I too know of some people who got good care in Repats. But the solid evidence is they were bloody awful.

  • 25
    Russell
    September 12th, 2007 16:35

    FXH – Increasingly expensive to run as the old diggers died off, yes. But in the case of Hollywood Repat Hospital in Perth – a nice single storey building with pleasant gardens and open windows. You’d go in to visit and might find a nurse sitting next to a patient and reading aloud from the newspaper, both of them enjoying a laugh, or an orderly pushing someone around the grounds or helping someone out to a cane chair out on the lawn, in the sun – it all seemed so much more human and civilised than the horrors of todays rushed, enclosed, mechanised hospital factories – where would you rather die? What’s the point of getting richer if we can’t have a few luxuries?