Hospitals and the endless pressure
Ambulances circle Sydney, like pelicans searching for a stretch of sand. Emergency departments turn away all but the life-threatened. Doctors threaten to walk out. Yet the world outside hospitals is different. GPs are busy, but available. X-rays and blood tests demand few queues. There are more pharmacies than you can shake a stick at. Why does it have to be like this? The answer is money. Not the lack of it, but the way it is controlled.
Health expenditure is substantial for all governments. Australia's health spending has grown by about 4 per cent a year over the past decade, which is faster than the economy generally, and much faster than inflation. So tight control over spending is important.
The biggest item in health is the public hospital network, which takes up 38 per cent of recurrent expenditure by governments and individuals. This is the easiest spending to control. Governments can simply limit access to public hospitals. They can close beds. They can close wards. They can even close hospitals.
The next most expensive areas are doctors' services and pharmaceuticals. These two areas grow rapidly, sometimes at 10 per cent a year. Demand in the former and costs in the latter drive the rapid growth. Spending here is difficult to control - people make their own decisions about whether or not to visit a doctor and, to a large extent, whether or not to take a drug. Governments can influence these decisions, but not make them.
So the health system's big budget items are paid for in different ways. There is a cap on the budget for public hospitals, which are government enterprises. There is no cap on the budget for subsidies to doctors and pharmacists, who work in the private sector. When governments need to reduce spending, they choose the easiest way. The hospitals suffer.
There is no solution to the pressure on public hospitals at present - the drama at Port Macquarie Base Hospital is but the latest sign - because there is no will for meaningful change. The last thorough review was carried out by Jenny Macklin, now deputy leader of the Opposition, in the dying days of the Hawke government. That review tried to straighten out, among other things, the confusion of funding mechanisms and the distortions they produced. It failed. Until such change takes place, public hospitals will remain under pressure. The majority of patients will receive decent and timely care, but an unlucky minority will not. Some will wait at home, or in hospital corridors, while state and federal politicians fingerpoint. Others will get into hospital, but suffer the mishaps that must happen when a system continually tries to do more, and faster, without the commensurate increase in resources. And on some days, it will all be too much. The doctors will say "no more", and the pelicans will circle, hoping in vain for a clear stretch on which to land.
The unevenness of learning
Equality of opportunity underpins Australia's embrace of compulsory universal education. If children are to have the best chances their talents allow, they should have as uniformly good preparation for schooling as the nation can afford. A child left behind at the start may struggle for years, not just because of the initial knowledge gap, but because the leeway at such a vulnerable age can batter self-esteem and discourage the pursuit of learning.
Australian preschooling is a disjointed clump of systems where access to quality and affordability is more a lottery than a right. An independent study, commissioned by the Australian Education Union, has found preschool education fragmented, of variable quality and access, lacking national vision, commitment and consistency and characterised by different approaches, funding formulas, terminology, child ratios, curriculum, costs and opening hours. The result is that 40,000 children a year are denied fit preparation for the transition to school. The poorest and those living in remote areas are the most likely to miss out.
Since the Commonwealth withdrew from preschool block grants 19 years ago, the only national policy - apart from some direct funding for indigenous children - has been to not have one. The luck of the draw is emphasised in NSW where two state government departments run separate systems. The Education Department funds about 80 preschools, with another 20 to come. It charges no fees. The Department of Community Services funds 800 and charges parents an average of $60 a week. Victoria is the only other state to levy preschool fees. Unsurprisingly, preschool participation in NSW is a meagre 62 per cent compared with Queensland's universal coverage.
The Australian Education Union study concludes that the most beneficial systems involve the one government department taking responsibility for preschool, child care and school. This heartens parents, who see the three tiers working together, and gives the single agency control over curriculum continuity.
How much more efficient this would be if the Federal Government took the steering role in a national system. The Federal Government already funds long-day child care for infants. It possesses the only structures capable of facilitating and co-ordinating a clean-up of the existing preschool mess. Only this month, Canberra made a reasonable fist of revamping family payments so that children in struggling circumstances might get a better shot at life's opportunities. The Federal Government needs to go the next step, to help overcome the inequities of one of life's early steps.