Academic journal article Journal of Australian Political Economy

Whose Health Service Is It Anyway? Community Values in Healthcare

Academic journal article Journal of Australian Political Economy

Whose Health Service Is It Anyway? Community Values in Healthcare

Article excerpt

Who influences the shape of our health services? Many Australian citizens seem to want more health services than are currently available. There may well be many other 'stakeholders'--politicians, doctors, nurses, patients, patient advocacy groups, or the media--who agree with this wish, but this doesn't stop governments holding a tight rein on health spending. Furthermore, healthcare spending decisions made within budgetary constraints are not generally made in close consultation with the community. Here we examine the arguments for drawing the community into the decision-making process. How can we elicit community values (drawing a distinction between the community and consumers) and at what level and over what issues might the opinions of the community be used to guide decisions?

Citizens' Juries

Citizens' juries are one way of introducing greater democracy into health service decision making. In 2000 and again in 2001, under the auspices of the Medical Council of Western Australia, citizens' juries were trialled in Western Australia (Medical Council of Western Australia 2000, 2001). To date these are the only two instances when such juries looked at health issues in Australia.

The principles underpinning the citizens' juries were:

* random selection--of citizens of WA without any specific 'axe to grind', drawn randomly from the WA electoral roll

* being community focused--jurors were asked to deliberate and make decisions for the whole community, not just themselves as individuals

* balance--the witnesses giving evidence to the jury have to provide a balanced view

* deliberation--time to discuss, ask questions and make decisions.

The first jury met in March 2000 in tandem with a health industry conference on health and economics and its recommendations were that there be:

* greater priority setting in health

* equity, based on equal access for equal need

* positive discrimination for disadvantaged people

* more spending on prevention and public health ahead of treatment of disease

* more spending for rural and remote health ahead of urban health

* more of a focus on community based health services (Medical Council of Western Australia 2000).

The second jury met in February 2001 and focused on equity, one of the priorities identified by the 2000 jury. The citizens on the 2001 jury began by deliberating on a concept of equity in health services. This was agreed to be equal access for equal need, where equality of access means that two or more groups face barriers of the same height and where the judgement of the heights is made by each group for their own group; and where nominally equal benefits may be weighted according to social preferences, such that the benefits to more disadvantaged groups may have a higher weight attached to them than those to the better-off groups.

The jury then applied this principle to three areas of inequity in WA health services:

* Aboriginal versus non-Aboriginal healthcare

* rural and remote healthcare versus urban healthcare

* aged versus other healthcare.

The jury was then given a nominal sum of money and, on the basis of their deliberations and listening to and questioning of the experts, were asked to allocate this money across the three identified areas. This they were able to do, giving greatest priority to reducing inequities in Aboriginal health.

The jury procedure is a way of discovering community values in a context that supports informed decision making (unlike, for example, opinion polls). In eliciting these values, there is an important distinction to be drawn between the community and consumers of healthcare services. The former involves citizens; the latter largely patients. Clearly, individuals can be, and often are, both. Citizens include patients, potential patients, taxpayers and insurance premium payers. …

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