DR DAVID LEGGE is a lecturer in public health at La Trobe University. JENNIFER THOMPSON, interviewing him on the effects of cuts to the health budget, began by asking about the $314 million cut to state hospital grants over the next four years, promoted as a response to "cost shifting".
The real beginning of states shifting costs was the closure of outpatient services in NSW after 1986. By closing outpatients, you force patients to go directly to doctors' and specialists' private rooms and therefore get billed on Medicare. Since then, for example in hospitals in Victoria, there's been a concerted attempt to reduce the prescription of drugs through the hospital pharmacies, requiring patients to have their drugs made up through the Pharmaceutical Benefits Scheme, which is funded through the Commonwealth.
The new arrangements, however, are quite problematic. In this kind of game the people who are caught as the political football are poor people facing increasing queues as the two sides jostle to reduce their own burden.
The specific changes the Commonwealth is proposing are really another form of cost shifting back to the states. There are no absolute standards for saying this was shifting and this was appropriate distribution of costs.
The states' response to the Commonwealth finger pointing about cost shifting over the last few years has been — and this was under the Labor government — that the funding available for hospitals, particularly under the Medicare agreement, was so mean that the states were left with no options except to try to cut somewhere. Commonwealth funding for the state hospital systems didn't give states enough money to maintain the promise of universal access under Medicare.
Question: What will be the general effect on public health of the budget proposals, including to transfer responsibility for preventive health programs to the states?
I think this minister sees himself as having a commitment to public health, including, importantly, immunisation. Australian children's health will be improved by getting those immunisation levels up to a more realistic standard than they've been. He's also committed himself to a more strategic approach to diabetes. I'm cautious about whether the broadbanding of the women's health programs, for example, into a public health package is going to be good or bad. Clearly there has been a strong bipartisan picture with respect to the HIV/AIDS program.
On the other hand, the closure of the public dental program is a draconian, appalling attack on public health, on the health of poor people.
The cuts to the ATSIC budget, which may fall particularly on community programs such as women's centres and social and cultural and language programs, have very serious implications for public health. There are two different paradigms of public health. One is disease prevention and the other is health development.
The health of the community is a complex issue — related to the delivery of services, sure, but also to quality of life and whether people are needed and feel that they are participating in a society that cares about what they can contribute. The increasing social polarisation, the general economic trends and the really draconian withdrawal of funding to unemployment support programs and the attacks on Aboriginal funding all look very poor for improved health.
The government is strongly committed to deficit control and inflation control, and has accepted unemployment levels as simply a consequence. That approach to losers and winners is visible in grosser terms in the way the Victorian state Coalition government operates, with its favouritism to the winners and callousness to the so-called losers.
The total effect of this government on public health can be predicted with reasonable certainty, in so far as the health of disadvantaged people is shaped by a lack of resources to buy things like dental care and a sense of exclusion.
The notion of youth suicide prevention as a specific program is based on the disease prevention model, specifically on what is called secondary prevention, namely the identification of young people who are at risk of suicide.
That's a very individualised response to a much wider problem of alienation and exclusion from where the main game's being played. There is nothing in the national suicide prevention program which is going to change that, compared to the dramatic withdrawal of support programs for unemployed people. Alternatively a long term kind of economic planning would value the creation of a more coherent society with full employment and so forth. n