Back in 1987, then Australian Prime Minister Bob Hawke said that by 1990 no Australian child would live in poverty. It was simply unachievable as a promise. The number of children living in poverty then was around 500,000. Today, depending on the definitions used, the number is perhaps 750,000.
I was mulling over this because of what I see as a growing public policy trend, making unachievable promises. Worse, many of those promises have adverse side effects.
Now many would argue that this has always been the case. But as someone who has been involved with politics and public policy for many years, I would argue that the position has become far worse. I say this for several reasons.
The first is that Government has become far more pervasive and complex. Of itself, this is not necessarily a problem. However, the process reflects the way that we as citizens have come to demand things even though our demands cannot or should not be met.
Problem one is that the difference between an aspiration and a promise, a deliverable to use modern jargon, has become blurred.
It is one thing to say that our aim is to reduce child poverty with the objective of eliminating it entirely. But when dates and words like "will" are attached it, it moves from an aspiration to a deliverable, and then it becomes silly.
Politics is all about values. When we vote, we want to vote for someone whom we think will go in the right direction. When, in the supermarket approach to politics, we demand and vote on narrow specifics, we distort the process.
This links to problem two, our current obsession with control and measurement. This distorts things across the board to the point that public policy itself has ceased to deliver.
It has always been the case that people respond to specific promises and in their own interests. Politicians have always taken advantage of this.
In NSW, Sir Henry Parkes was a master of the factional system, giving a mess of pottage here, one there, to garner votes. Recent NSW Governments have been masters of this art. Yet Sir Henry Parkes also gave NSW its first public education system, its first child welfare system. I find it hard to see any current equivalent.
This is not of itself an attack on recent NSW Labor Governments. I still blame them, but now think that the problem is systemic and not just in NSW.
A few examples to illustrate.
NSW has seen great expansion in national parks. But there is not enough money to develop and run them. Further, the cash required means that there is less money for other environmental causes.
In NSW we have mandatory reporting for children at risk, but not enough money to follow up the reports generated. The net effect is that children at most risk suffer.
Still in NSW, we have literally thousands of performance indicators that cascade down from high level indicators across all agencies. There is no way that all these can be delivered on.
Public including media scrutiny focuses on headline cases. There is no way that anybody can properly monitor the mass. In the meantime, there is little debate on overall priorities in a cash constrained world. We all get lost in the detail.
NSW is not a unique case.
I don't think that this post was really clear enough.
The core problem lies in the interaction between increasingly complex public systems, the political system and the Australian public.
Consider the health sector.
Under our constitution, health may be a state matter in theory, but the Feds increasingly dominate.
Let's start with the training of doctors.
Registration of doctors is a state matter, although the Australian Medical Council has been playing an increasing role as we push towards national standards.
The initial number of doctors trained depends upon Federal funded medical places in universities controlled by another arm of the Federal Government. That other arm has pushed for full fee paying students. This does not affect the formal number of places open to Australian students, but it does affect overall approach. That other arm also mandates a whole series of planning and reporting requirements for universities.
Those doctors largely receive their clinical training in state hospitals. There are an increasing number of private hospitals indirectly funded by the Federal Government through its subsidisation of health insurance, but their role has been less in medical training.
In NSW state hospitals are controlled by Area Health Authorities as part of their overall role health role. Each Area Health Authority has to prepare an annual business plan and is subject to a hierarchy of reporting arrangements and key performance indicators dictated by the State Government.
Traditionally, after initial medical training doctors went into practice as GPs or onto further specialist training.
As part of the continuing professionalisation of Australian life, General Practice was declared a profession, requiring doctors to undergo further training before becoming eligible to receive medicare rebates, another Federally funded program.
Other specialist training is carried out by specialist medical colleges. These set curricula and exams, accredit training posts, oversight the specialists providing on-the job training.
In funding terms, training posts are largely provided by and funded by State Governments (and the New Zealand Government) in public hospitals. In addition to training roles, these posts are also central to service delivery.
Students pay fees that cover the College's direct costs. The supervising specialists provide their time for free.
All this means that, with the exception of general practice where the Federal Government ended up paying for the system, there is no direct Federal support, while State support is limited to funding of training posts.
The training of specialists has become increasingly complex.
The specialist colleges themselves have pushed for longer training programs. These are now generally five years. This means that doctors are now 32 or 33, sometimes older, before they start to practice.
The Australian Competition and Consumer Commission, another arm of the Federal Government, has sought to break the college's monopoly on specialist training, laying down principles that colleges must observe.
Consistent with the national concern about standards and accreditation, the Australian Medical Council has laid down accreditation processes that colleges must follow. Costs here are born by colleges and that means students.
Upon graduation as specialists, doctors enter a complex world.
They have to manage relations with patients within a web of legal controls and complaint procedures.
These run to thousands of pages and include, inter alia, the mandatory child abuse reporting procedures that I referred to earlier in the post. They have to find insurance in an increasingly litigious increasingly dictated by esternally imposed requirements.
Is it any wonder that more and more doctors are opting for salary positions where they do not have to worry about at least part of this legal and administrative overhead?
This is but a taste of the complexities in the health arena. But, and to link back to my opening remarks about system complexity, a problem in one part of the system can compound and compound.
A few examples.
Example one: Back in the second half of the nineties, then Federal Health Minister Michael Wooldridge felt that Australia had too many GPs and that this was leading to over-servicing and excessive claims on Medicare. The number of doctors in training was reduced. Today we struggle with a shortage of GPs.
This is worsened by the other controls.
Take my sister-in-law as an example. She went into medical training at an older age, then decided that she was simply not prepared to do all the extra training required to become a specialist including a GP. Initially she was happy to work as a locum in NSW emergency departments on a temporary basis. Now she largely works as a doctor on overseas cruise ships.
Example two: Because of budget constraints, the NSW Government cut back on physician training posts in emergency departments, especially in country areas. This led to a collapse in certain types of physician training, with New Zealand training ten times as many as NSW. Now there are further gaps in service delivery.
Country gaps: We all know that there are shortages of doctors in the country. Some of these shortages are simply a shortage of overall doctors. Others are an outcome of the training programs themselves.
Most training is metro dominated. By the time a doctor is ready to set up practice at 32 or 33, they have partners, often children, and are well entrenched in particular areas. So relocation becomes a problem.
Governments do try to respond to these types of issues. But their responses are often slow and ad hoc.
As citizens, we make things worse.
We do not, cannot, see the nature of systemic problems. We respond on particular issues, problems, as they arise. Governments then respond to us, further twisting responses.
Chile abuse is a problem, introduce mandatory reporting. We must be more efficient. A child dies from a particular disease. Create new reporting arrangements. A patient has a premature birth in the toilet at Royal North Shore hospital while waiting to be seen in emergency. Hold an inquiry, build a new hospital.
A child dies of a disease. Introduce new guidelines for GPs. A small number of doctors abuse the Medicare system. Introduce new compliance arrangements. There is a shortage of doctors in an area. Bring in more overseas doctors, create nurse practitioner's able to prescribe certain drugs without a doctor.
And so it goes on.
Most times we do not stand back to ask about systemic problems. We do not ask what can actually be achieved. We and our Governments deal with issues as they arise, independent of anything else.
Health is not a unique case. We can see the same type of problem across the whole public policy domain.
There is no magic bullet. The only thing that I can do is point to issues and questions, recognising that if increasing systemic complexity does not stop, our whole system risks coming down.