Monday, March 01, 1993

State Welfare Policy and the Juvenile Crime Debate

CHAPTER 8

INTRODUCTION

In recent years politics and public debate in Western Australia have been dominated by two topics:  the various forms of political impropriety commonly known as "WA Inc", and juvenile crime.  It is an interesting conjunction.  Both raise questions of personal and public morality;  both require us to think hard about the structure and design of our social institutions.  In the case of WA Inc the questions of personal and public morality have now been asked and answered -- with general public approval -- by the Royal Commission, though the institutional issues still require much further thought, of the kind pursued in this book.

There has been no "Royal Commission" or anything like it into the juvenile crime question.  A variety of parliamentary committees has considered aspects of the issue, but these have been superficial in both purpose and performance.  Of course, the subject is not one which a Royal Commission could hope to deal with, since the issue is not one of the performance or abrogation of public duties.  Nevertheless, public concern about the issue is in part a concern to see that we make clear the requirements of citizenship in our society and that we foster a culture and morality in which "marginalised" young people both belong to and contribute positively to our shared social world.  The first step by the Lawrence government in dealing with the problem, the 1992 Serious Repeat Offenders legislation, was a "law and order" response, one which had widespread political and public support (protests from some in the welfare world notwithstanding).  No-one feels comfortable about leaving the matter there, but once we move beyond that narrow focus the issues soon get lost in a fog of well-meaning woolly-mindedness.

The argument to be presented in this chapter will be based upon a longer analysis currently in progress.  In places it will be necessary to jump to conclusions which that analysis has not yet established.  The justification for this is that in practical policy matters it is impossible to do nothing;  to attempt to do nothing is to permit things to go on as they have been going on, which may well be worse than leaping to conclusions.  Where such leaps are taken they will be signalled as such

The topic under consideration has been introduced under the heading of "state welfare policy and the juvenile crime debate".  Both terms require discussion.  The scope and limitations of state welfare will be considered in due course.  "Juvenile crime" is a matter of public importance partly in itself, but mainly because the phenomenon is a symptom of larger social changes and problems.  This chapter is mainly about those larger matters.  "Juvenile crime" is the starting point only;  it is a justifiable starting point because crime data supply us with some important relatively hard evidence about the larger matters.


THE CRIME EVIDENCE

As the accompanying charts show (see Figures 8.1-8.4), the common belief that Western Australia is experiencing a crime upsurge is correct.  The evidence can be summarised as follows:

  • In the last decade crime of most kinds has been increasing rapidly, according to police reports.  Before 1984 the rate of rise was low.  Since 1984 police reports of most types of crime have at least doubled;  some have trebled;  sexual assault reports have increased eight-fold.  In 1991-92 alone, reports of sexual assault doubled.  (By way of comparison, the state's population increased by only about 25 per cent in the last decade.)
  • The real crime rate is of course not directly measurable.  Reported crime is a good index of the real crime rate, so probably real crime has increased at much the rate that these figures suggest.  Conviction rates are not a good index;  for property offences, convictions by police have fallen well behind the reported crime rates.  However, serious personal crimes are being convicted at a rate close to the reported crime rate, and vehicles reported as stolen are recovered at a rate close to the rate of reports;  both of these facts indicate that reported crime corresponds to real crime.
  • Victim surveys tend to suggest that real crime levels are higher than reported crime levels (perhaps twice as high), but, even so, we can take the changes in the rate of reported crime as refecting changes in the real crime rate. (93)
  • The crime rise has occurred among both adults and juveniles.  Juvenile crime is merely more visible and publicly shocking than adult crime.  Most crime is crime by teenagers and young adults, aged between 14 and 22.
  • The crime rise has occurred both rural and urban areas, so it is unlikely to be a function of "urbanisation".
  • Most crime -- about 80-90 per cent -- is male crime.  The female crime rate is rising at least as fast as the male rate, though from a much lower base.
  • Aboriginal youth is vastly "over-represented" in the crime rise, and also in court appearances and the prison population.
  • Some of this crime rise is by "serious repeat offenders", but even if we deduct their contribution there is still a serious crime rise occurring.
  • Sentencing practices ("leniency") may or may not have permitted the growth in the crime rate, but they are not a basic explanation of the rise.  It is unlikely that "tougher" sentencing will go far towards reducing the crime rate, though it may halt the crime increase.
  • Policing practices have changed relatively little in the 1980s, and so are unlikely to have contributed positively or negatively to the crime data.  Police numbers have fallen behind somewhat in proportion to reported crimes, despite a fifty per cent increase in numbers since 1983.

THE SOCIAL BACKGROUND

Policy formation requires some account of the causes which lie behind these changes.  If we misunderstand the causes, policy decisions may merely aggravate the problem.  Good Intentions are not enough;  there is by now substantial evidence that government actions, most especially welfare policies, influence social life in all sorts of unintended ways.  It will be contended here that well-meant but ill-considered government interventions at both national and State levels have played a large part in creating the crime rise.

Figure 8.1:
Crimes Reported to Police -- Serious Assault (Year ended 30 June)


Source:  ABS Cat. No. 4103.5, Compendium of Demographic and Social Statistics, Western Australia, 1991, pages 90 and 91;  WA Police Department, Annual Report, 1992, pages 26-28.


Figure 8.2:
Crimes Reported to Police -- Rape (Sexual Assault) (Year ended 30 June)


Source:  As for Figure 8.1.


Figure 8.3:
Crimes Reported to Police -- Motor Vehicle Theft (Year ended 30 June)

* Note:  Data for vehicles recovered not available for 1990, 1991 and 1992.

Source:  As for Figure 8.1.


Figure 8.4:
Crimes Reported to Police -- Break and Entering (Year ended 30 June)


Source:  As for Figure 8.1.


The (bi-partisan) Select Committee on Youth Affairs, in its 1992 Discussion Paper No. 3, Youth and the Law, includes a short discussion of "Causes of Offending", based on public submissions to the committee.  The paper lists eight possible causes:  family breakdown, unemployment, poverty, educational failure, child abuse, drug and alcohol abuse, underlying psychological or psychiatric conditions, and wardship. (94)  The list is a plausible one, as far as it goes, though other possibilities need to be considered.  To think sensibly about this sort of issue we need to be able to distinguish between correlates, conditions, causes and consequences.  And to do this we need to look at the trends through the late 1970s and early-to-mid 1980s, the crucial period in which the crime rise seems to be rooted.

We also need direct evidence on the lives and experience of offenders.  This we now have, in a 1992 study of 409 young people in Longmore Remand and Detention Centre by psychologist Phil Watts, which was focused mainly on drug-taking behaviour and on suicidal tendencies, but which also collected data on family background.  The study population was highly representative of young serious offenders:  median age 15-46;  90 per cent male, 10 per cent female;  50 per cent Aboriginal, 50 per cent not;  18 per cent at school, 10 per cent working, 72 per cent unemployed.  Although they are a young group, 34 per cent had been away from school for at least two years. (95)

In this present discussion, two assumptions will be made:  that the 1992 Longmore group is typical of all serious juvenile offenders of the past decade;  and that older offenders are similar to this group in most respects.  Many of today's older offenders are of course the young offenders of yesterday;  some are the older brothers and cousins of today's Longmore group.

Watts' study shows very high levels of unemployment (72 per cent), though such a young group would not normally be expected to be in the workforce.  We can assume that most older offenders are also unemployed.  Does this make unemployment an important cause of offending?  Analysis of the period shows that, contrary to common belief, youth unemployment trends bear little relation to crime rates.

As Figure 8.5 shows, in 1982-84 crime was low while unemployment was high.  Between 1983 and 1988 unemployment fell as crime rose.

To say this is not to downgrade the importance of employment.  Clearly, since so many offenders are unemployed and since being employed makes people feel valued and part of a social order, it is a significant background condition to the problem.  But to describe it as a background condition is to say that by itself it could not and did not produce the crime upsurge.  The unemployment of the offenders may itself be a product of other factors;  they may be -- as many have said they are -- unemployable.

The facts about poverty are open to debate.  On this subject we have to work from Australia-wide data, but on most such matters Western Australia is fairly typical.  ABS data on changes in (pre-tax) income distributions in the 1980s show two trends:  rapid gains by the highest income decile only;  and heaviest losses to middle-income groups.  The two lowest income deciles lost income share slightly, but their loss was only half that of the third and sixth deciles, and only a third that of the fourth and fifth deciles.  In other words, bottom income groups gained at the expense of the middle, and all lost against the highest. (96)  Taxation, of course, will tend to level off these apparent disparities, as also will non-cash benefits to pensioners and beneficiaries, making the lowest income deciles relatively better off.  In general, since the mid-1970s welfare payments have more than held their value against inflation, while wages have made little or no real gains.  All of this does not add up to a picture of increasing immiseration of the poor.

Figure 8.5:
Youth Unemployment Rate (Male) WA (Year ended 30 June)

Note:  here the reported rate for breaking and entering is being used as an indicator for the general crime trend.

Source:  ABS Cat. No. 4103.5, Compendium of Demographic and Social Statistics, Western Australia, 1991, pages 90 and 91;  WA Police Department, Annual Report, 1992, pages 26-28;  ABS unpublished data on male youth unemployment in WA.


Youth incomes did fall in the 1980s, but since most offenders were unemployed this fall is irrelevant to them.  The income fall will have raised the relative value of unemployment benefits, making welfare subsistence more tempting.  The replacement in 1988 of Unemployment Benefit for under-18s with a Job Search Allowance of lesser value may have lowered the incomes of some young people, but it comes too late to explain the mid-1980s chime rise.  In the mid-1980s young unemployed were eligible for substantial benefits;  this did not prevent a rapid upturn in the juvenile crime rate.

There is a very strong correlation between educational failure and youth crime.  Only 18 per cent of the Longmore survey group were attending school;  34 per cent had not attended for two years.  A Department for Community Services survey found that "87 per cent of the children of compulsory school age who had appeared in court five times or more had not been at school for a year".  It is said that most young offenders are unable to read or write. (97)

Some hold that this failure is being brought about by processes in the schools;  others that it has its origin outside school, mostly in the family.  It is said by those of the first view that "the education system through large class sizes, inappropriate teaching methods and lack of individual support leads to poor achievers falling behind", causing them to give way to despair and anger. (98)  Was support for such students withdrawn in the 1980s?  It would seem not.  Expenditure per secondary student per year did not fall:  class sizes did fall.  Retention rates rose dramatically (for males as well as females) between 1980 and 1991 -- just when offenders were dropping out of school. (99)  No-one thinks that school standards and expectations rose much in this period;  many think that they fell, so offenders are unlikely to have been "pressured" out of the school system by excessive academic demands.

The alternative view is that a new population of students arrived in the schools in the late-1970s, who for non-school reasons found themselves unable to cope with school life.  As one submission to Youth and the Law put it, "These children have not acquired the life-skills which are informally part of the school system and, therefore, they cannot participate in a classroom setting". (100)  A Deputy Principal of a primary school described a playground world of gangs, vandalism, verbal abuse and violence, adding that "The majority of these children's parents acknowledge their children's antisocial behaviour but have lost control in directing them due to inconsistent measures of discipline and parental supervision". (101)  These parents had had advice and assistance from the local social worker, the school guidance officer and the police community liaison officer, to no apparent avail.

The evidence sketched here does not strongly support the thesis that the schools themselves are failing their weaker pupils.  It tends to point to prior causes, causes which operate earlier and deeper than school practices (though obviously school discipline failures can make matters even worse).

Child abuse and neglect was also considered a contributing cause to the crime rise.  There are a number of difficulties in discussing this claim.  One is a paucity of evidence:  Western Australia has no publicly available long-term analysis upon which we can draw.  Another is the elasticity of the concepts.  All will agree that rape or persistent and pointless beatings are forms of abuse, but the surrounding penumbra of possibilities is a very grey area.  A parent trying to keep a child in line with physical punishment may well be doing the best he or she knows, and using methods accepted by peers and the child.  Welfare professionals who would prefer some other forms of control may simply be reflecting nothing more objective than their own judgement and milieu.

The absence of evidence makes it impossible to say whether serious abuse or neglect of children increased in the early 1980s.  Submissions to the Select Committee are not reported as noting child abuse as a significant causal factor in Western Australia, with the exception of one youth worker from Karratha who commented on a high incidence of sexual abuse as a cause.  The Longmore survey has nothing to say on the subject, but Phil Watts' personal view is that quite a few girls who end up as serious offenders haw suffered sexual abuse in the past.

Child abuse seems to be a very much smaller problem than juvenile misbehaviour.  Thorpe's study of reports of child maltreatment in four months of 1987 found that 672 reports were made, of which 228 were found to be substantiated and a further 108 thought to be "at risk". (102)  This would suggest an annual figure of about 700 substantiated maltreatment cases and 324 "at risk" cases, or somewhere around 1000 in total.  By contrast, in the year 1986-7, juveniles were convicted of 33,000 offences in the Children's Court. (103)  We do not know how many distinct individuals committed these offences.  If, on average, offenders committed five offences, there would have been 6,600 offenders.  Unless the incidence of crime is very much higher than this, juvenile offenders seem to outnumber child maltreatment cases quite substantially.  It seems to follow that relatively few juvenile offenders can have become so as a result of parental maltreatment.

The Western Australian government's "Advisory and Coordinating Committee on Child Abuse" holds that international studies show a strong link between child abuse and delinquency.  Reviewing this literature, James Q. Wilson and Richard J. Herrnstein conclude that "There is strong evidence that abusive homes produce more aggressive children, and there are good reasons for supposing that early aggressiveness in the family is associated with later aggressiveness outside the family", but an abusive home is "only an imperfect indicator of the existence of a complex array of factors that contribute to criminality. ... Some abusive parents will teach their children to express their frustrations by resorting to violent action, but the object of the child's later violence can vary greatly depending on other aspects of the family experience and on the situation in which he finds himself". (104)  To evaluate the child abuse thesis takes us into the wider question of parenting practices -- a question too broad to be dealt with here.

The Longmore survey has established beyond all doubt a very strong correlation between drug and alcohol abuse and crime.  Most of the survey group were found to have high levels of abuse:  daily cannabis use (25 per cent), weekly binge drinking (28 per cent), daily (10 per cent) or regular (33 per cent) amphetamine use, and regular LSD-type drug use (27 per cent).  Nearly half used at least one drug (other than tobacco) daily;  two thirds used one or more drugs at least once a week.  Nearly half of the 281 alcohol users reported usually drinking more than a bottle of spirits or twelve cans of beer in a single session. (105)

We have no proof that total drug and alcohol abuse amongst the young grew rapidly in the early eighties.  It does seem likely that the intensity of consumption by some groups grew, for there are no reports of such intense consumption before this one.  Some drugs are new arrivals on the scene, most especially amphetamines and glue-sniffing.  No-one doubts that drugs and alcohol are the proximate causes of much crime.  We need to look deeper, however, before we can count this consumption as a cause in its own right.

Behind this intense consumption is a strong desire "to escape reality and stress", as Watts puts it.  It is obvious that this self-destructive behaviour is closely related to family experiences.  Watts concludes that "Whilst it is uncertain whether the family situation is causing drug taking or vice versa, the results are clear --- drugs are not a problem isolated from the families of juveniles". (106)  Research into drug addiction seems to show that drug risk is almost entirely predicted by family factors. (107)  Equally certainly, juvenile offending is closely related to both the drug abuse and the family failures.  Furthermore, "The strong association between family dysfunction and drug use ... means that family interventions should be an integral part of the [drug abuse] treatment process.  Without the family therapy component, treatment is likely to have reduced efficacy". (108)

One deeper kind of cause might be psychological or psychiatric conditions.  Almost one quarter of the Longmore sample were rated as clinically depressed;  quite a few had suicidal tendencies.  To disentangle these mental problems from the drug-taking or from other social problems is obviously no easy matter.  One might also note that "only" one quarter were rated as clinically depressed -- the rate is surely much higher than that of the general teenage population, but it is not very strongly correlated with crime.

Wardship, as such, is unlikely to be counted as a cause of juvenile offending, though it does seem to correlate somewhat with offending, particularly serious repeat offending.  Children become wards as a result of family failure to care and protect them, and it is this prior failure which is likely to be the basic cause of subsequent criminal behaviour.  Often neither foster homes nor Departmental hostels can control such youths.  Youth and the Law reports a submission which speaks of young people in hostels who "offend as regular as clockwork, because they are all mixing with each other" -- not a good reflection on the Department's achievements. (109)

Between 1984 and 1989 the number of young people in substitute care fell by 40 per cent. (110)  The trend is running in the opposite direction to what we would expect if it were a cause of crime;  if anything, it seems to suggest that reduction in substitute care may have contributed to the crime rise.  However, we have no independent reason to assume that to be the case.


FAMILY BREAKDOWN

Having considered all but one of the possible "causes of offending" listed in Youth and the Law, we can turn back to the one cause which it lists first but deals with most peremptorily:  family breakdown.  Here the evidence of a causal relation to crime is strong -- though perhaps not quite complete or conclusive -- at both the macro and the micro levels.

We can begin with the "micro" evidence of the Longmore survey.  When the 409 youths were asked their current address on admission, it was found that only twenty per cent of these young people were living with both their parents, and only 56 per cent were living with any of their parents.  Three quarters were not living with their father;  half were not living with their mother.  Twenty per cent were living in a two-parent family;  presumably even less than twenty per cent were living with both their biological parents.  In answer to the question "Are your parents still together?" 68 per cent answered No, 32 per cent answered Yes.  This implies that of the 44 per cent living with neither parent, only 12 per cent had a two-parent family to which they might return. (111)

These remarkable facts about family structure are not exactly matched by the youths' perceptions of family relationships.  Asked whether their parents had a good relationship, half said No, half said Yes, which does not fit well with the fact that 68 per cent of parents were not living together.  However that question had a high level of invalid answers (78, or 20 per cent), possibly because the question made little sense to those whose parents had little or no relationship.

The question "How well do you get on with your mother?" resulted in 64 per cent answering "good", 22 per cent saying "OK", 10 per cent "bad" and 5 per cent "no relationship".  For fathers the response was worse:  46 per cent "good", 28 per cent "OK", 13 per cent "bad" and 13 per cent "no relationship". (112)  This suggests more positive contact between the youths and their parents than is indicated by the family structure questions.  On this point Phil Watts remarks that people generally tend to report themselves as having better family relationships than other measures would indicate to be the case.  It would be interesting to compare the responses here with responses from a random sample of the same age group.

We know that, in the general population of 15-year olds in Western Australia in 1986, 77.3 per cent were living with both natural parents, compared with less than 20 per cent in the Longmore sample.  14.5 per cent were living with one parent only and 8.3 per cent with one parent and a step parent. (113)  If these census figures are accurate then the number of 15-year olds in the general population living with neither of their parents is statistically insignificant, yet in the Longmore sample it amounts to no less than 44 per cent.

The "macro" level shows very high levels of family breakdown.  By far the most striking change in family life in Western Australia in recent times is the rise in the divorce rate, Before 1971 the divorce rate hovered around 4 divorces per year per 1000 married persons;  since 1976 it has levelled off at around 12.  Twelve per thousand may not sound much but it amounts to a divorce rate for newly-formed marriages of one in three, as against one in ten for marriages in the previous generation.  (See Figure 8.6.)

Figure 8.6:
Crude Divorce Rates WA (annual divorces per 1000 population)

Note:  here the reported rate for breaking and entering is being used as an indicator for the general crime trend.

Source:  ABS, Divorces Australia (various publications)


Clearly this is a massive change, in its own way quite as striking as the rises in the crime rate about seven years later.  The obvious question is:  are they related?  Is the divorce boom a major cause of the crime wave?  There are two ways of showing connections between them.  One is to argue that no other changes occurred in the relevant period -- the early 1980s -- which could possibly account for the rise in crime.  We have shown that most of the possible causes listed in Youth and the Law cannot be causes. (114)  The other is to show directly that the juvenile offenders of the late 1980s came from families which had broken up in the divorce boom.  The Longmore survey seems strong evidence that this is the case.  In Figure 8.6 the relation between the divorce rise and the crime upsurge is indicated, showing a seven-year time lag between one rise and the other.  Such a lag is as one might expect, if divorce is a cause of crime, for on this view the disruptive effects on a young child's development will be likely to manifest themselves in the social arena at adolescence.

Interestingly, the figures on ex-nuptial births in Western Australia show no sudden rise in the 1970s, but rather a steady progression from 5.6 per cent of all births in 1961 to 22 per cent in 1989. (115)  There is here no dramatic change capable of accounting for the suddenness of the mid-1980s crime rise.  Most unmarried mothers identify a father on the birth form for their children, though of course it is questionable how stable these relations are in reality.  Teenage ex-nuptial births are even less suited to explaining the crime rise:  the numbers rose from 610 in 1966 to 1,033 in 1971, dropped to 971 in 1976, then rose again to 1,057 in 1981 and 1,120 in 1986. (116)  The changes here are not great and the numbers are insufficient to account for any great changes in overall juvenile behaviour.  In 1986 only about 3.5 per cent of all 17-year olds would have been born to unmarried teenage mothers, no great increase on the percentage in 1981.  By contrast, in 1986 22.7 per cent of all 15-year olds had experienced the divorce or separation of their parents.


WELFARE DEPENDENCY AND THE UNDERCLASS HYPOTHESIS

Another possible cause of the crime boom is welfare dependency, which has risen dramatically in the relevant period.  We have seen that income poverty is not a cause of crime, but it remains possible that the cause is to be found in "underclass poverty", poverty which goes with long-term welfare dependency, and which seems to lead to antisocial behaviour problems.  Can it be shown that underclass poverty is strongly associated with crime and that it rose in ways which might have caused the recent crime increases?

There is no doubt that long-term adult welfare dependency rose rapidly in the 1970s and 1980s.  Both long-term memployment and long-term sole parenthood increased vastly in this period.  Between 1971 and 1986 the number of long-term unemployment beneficiaries (over six months on benefits) rose from about 300 to about 25000 (at the height of an economic boom period). (117)  Today, with unemployment nearly twice the 1986 level, the number is certain to be very much higher.

Similarly with sole parents (again working from Australia-wide figures).  In June 1974 there were 105,000 sole parents receiving welfare payments in Australia;  in June 1986 the figure was 268,400.  In 1986, 34 per cent of Class A widows (most of whom were not widows but divorced or separated women) had been on the pension for 5-10 years;  16 per cent had been on the pension for over ten years.  Although sole parent pensions became widely available only in 1973, already by 1982 13 per cent of sole mother beneficiaries had been receiving the benefit for more than five years;  by 1986 that figure had risen to 17 per cent.  In 1986 the official median durations were 5.7 years for Class A widows and 2.8 years for female SPB recipients. (118)  Actually the real median durations are probably much higher than this, because these figures refer only to median durations for each period of receipt, not to median durations per total period of receipt for each recipient (this figure is not made public).  No doubt many recipients went on and off the pension a number of times.  Taking this into account could well boost the median durations quite considerably.

The underclass hypothesis holds that a life of welfare dependency distorts the social experience and attitudes of those who fall captive to it.  Far from welfare support integrating such families into the community, the overall effect is disintegrative, breaking up couples into non-working males and struggling sole mothers, with children who are loosely controlled and poorly socialised.  The children of such families tend to feel little sense of obligation to the society which "supported" them.  Rather, they often fail to learn the habits required to become economically productive;  they feel acute anger, boredom, envy and exclusion;  they can see no future for themselves in mainstream society.  Some have no respect for either public or private property.  To protect their fragile egos they unite into militant gangs such as "the KGB".  Like little children they desperately need the attention of mature adults but they cannot handle one of the basic messages of adult society, which is that they should "get a job" and become self-supporting.  Consequently their attention-seeking becomes a dangerous game in which they set out to break the rules of society (particularly through such activities as high-speed car chases in which the police can be engaged and targeted) while learning to plead innocent and victimised when brought to account for themselves by society's authorities.  Their lives become a mixture of depression and false bravado, in which drugs and alcohol mask from them their real predicament while also providing the temporary illusion that they are powerful and important.

The basic problem with these children seems to be that they have never enjoyed the pleasures and the hard lessons of structured family life, a form of life characterised by "a pragmatic blend of love and discipline" (to use John Embling's very apt phrase). (119)  Both in their families and in their relations with the wider community they have failed to learn that with rights go responsibilities (also an Embling motto).

This is a familiar and all too plausible story, though we lack some of the direct evidence needed to fully test the hypothesis.  In particular we have no direct evidence connecting juvenile crime with welfare dependency.  All we can say about this is that family breakdown, which is connected with juvenile crime, itself tends to lead to welfare dependency, through dependency on sole parent benefits.  A study, along the lines of Watts' work, of the welfare history of juvenile offenders and their families would go a long way towards settling this issue.

At its core the underclass hypothesis asserts a statistically strong connection between four phenomena:

  1. unbalanced state welfare incentives or poorly designed welfare eligibility criteria;
  2. high levels of sole parenthood, unstable de facto relationships, and long-term unemployment;
  3. poor quality parenting practices;
  4. high levels of anti-social behaviour such as crime, drug addiction, voluntary unemployment and school truancy.

That (2) and (4) are today real and important social phenomena can hardly be denied by anyone acquainted with the evidence.  The truth of (1) is controversial, but the accumulated evidence is substantial. (120)  (3) is a more difficult matter, since social research has no very good access to people's private lives, and what counts as good parental behaviour is somewhat -- though not endlessly -- debatable.

The underclass hypothesis is relatively strong on three out of four of its components.  As for internal correlations, we have seen a strong correlation between (4) and (2), and it is possible that (4) and (2) correlate strongly with welfare dependency, which is in turn likely to be a product of (1).  The evidence presented here suggests a causal sequence from (1) to (2) to (3) to (4).  The case is not conclusive, particularly in relation to (3).  But even without (3) we still have a moderately strong claim to consider.  It is strengthened by the evidence of a time lag from (1) to (2) to (4), with the temporal direction indicative of the causal process.  If this evidence is moderately strong then it will need to be taken into account in the way we design our welfare institutions, policies and practices.

In a fuller analysis it would be necessary to discuss the relation between the underclass hypothesis and Aboriginality.  There is little doubt that Aboriginal people are more welfare-dependent than the rest of the population.  In the 1986 census Aboriginal people were found to have an unemployment rate of 39 per cent, compared with 9.4 per cent for the total population. (121)  Aboriginal families with dependent children also showed relatively high levels of family breakdown.  According to Families in Focus, in 1986 there were 4130 two-parent and 2242 one-parent Aboriginal families with dependent children in Western Australia -- about 35 per cent sole parent families, compared with about 16 per cent for the rest of the population.  The ratio in Perth was 65:35;  in the agricultural areas it was 72:28;  in the pastoral regions it was 67:33;  so there is no great variation between regions of the State. (122)

These broad figures are consistent with what we would expect on the underclass hypothesis, if we are trying to explain Aboriginal "over-representation" in crime.  But other explanations may be possible or necessary.  The difficulties of Aboriginal historical dispossession and the possibility of racial discrimination need also to be taken into account.  We are hampered in doing this because census data on Aboriginal people are poor, making trends difficult to trace.  (There is plenty of first-hand evidence to suggest that many Aboriginal people are doing very well, in education and the workforce and in their families, at a time when the Aboriginal crime rate also appears to be rising.)  Testing the underclass hypothesis also requires us to compare like with like.  It is at least arguable that the Aboriginal crime rate is no higher than that of non-Aborigines with the same levels of employment, education, income, welfare dependency, and family breakdown.  The complexity of these issues and the paucity of good evidence makes definite judgements impossible at this stage.


FORMING SOME POLICY GUIDELINES

On the evidence presented here, the key to reducing youth crime and disaffection seems to be to help keep families together and to increase parents' work commitment.  To achieve the first of these we need to make government-funded sole parenthood financially less attractive and to require some work commitment.  This can be done with no injustice to sole parents, since sole parents can fairly be expected to participate in the workforce at least at the level typical now of married mothers.  The incentives in favour of separation are now very considerable:  fiscal incidence analysis by the ABS (counting all taxes and all social expenditure) shows that in 1988-89 governments in Australia gave sole parent families an average net support of $224 per week, or $11,648 per year;  two-parent families, on the other hand, were net losers of $62 per week, or $3,224 per year. (123)

To increase work commitment more generally, welfare benefits for the unemployed need to be tied to a work or vocational training requirement.  The assumption that welfare payments are a "right", involving no reciprocal commitment to the community, was never plausible and is no longer widely shared.  Commitment to the community can be demonstrated by workfare, which is widely used in Scandinavia and coming to be accepted in the US.  The rationale for workfare -- making welfare conditional upon acceptance of work offered or of vocational training -- has to be cultural, not economic, for it is not cheap to administer.  Its value is that it does seem to increase the self-esteem of long-term welfare dependants, it makes them far more marketable in the labour force, and it reduces counter-productive and self-destructive behaviour such as crime.

Some of these general policy strategies may be adopted in some small degree in the future.  A Coalition Federal government might increase work requirements for sole parents with children over the age of 12.  A work-for-benefit scheme is also being proposed, on a two-days-per-week basis for those who have been unemployed for nine months.  State politicians might lobby for such schemes in Canberra, but State-level policies need to be devised which might succeed without support at the Federal level.  To do so, however, will require considerably more clarity of purpose than is presently evident in Department for Community Development publications.  In turn, State welfare authorities should accept that income support is a Federal responsibility, that current income support levels are at least adequate (sometimes making recipients better off than they would be if married or in the workforce), and that the State government's role is to cope as best it can with the behavioral problems which follow from the sort of Federally-funded welfare state that we have.

Much of what has been implicitly argued thus far is quite in accord with the Department's official goals.  These include "maximising opportunities for those with serious welfare problems to resume a constructive role in the community", "minimising the impact of those conditions that generate community needs for welfare services", and "strengthening the capacity of those individuals, families, groups and communities experiencing difficulties or problems to resolve them at an early stage". (124)  At this level of generality there is little disagreement;  the Department's critics, however, doubt that in practice it has done much towards realising these goals.


Institutional design

DCD is a large organisation, with a staff of 1,600 and a budget in 1990-91 of $110m.  Its expenditure for that year breaks up into the following categories (showing in brackets the proportion which is spent through non-government agencies, which totals $28m):

Corporate services$12m
Family and individual services$33m($i8m NGA)
Substitute care services$21m($5.5m NGA)
Child protection$$m
Financial & material assistance$11m($0.7m NGA)
Youth$4m($1.3m NGA)
Juvenile justice$19m($1.4m NGA}
Community affairs$5m($1m NGA)

On the face of it these seem like worthy social expenditures, but their merits depend entirely on the quality of performance.  DCD's performance is commonly the subject of a number of serious criticisms:

  • it is a top-heavy, desk-bound bureaucracy, in which career advancement matters more than job performance;
  • it is highly intrusive in the lives of those it is seeking to "help", sometimes disrupting and disturbing people who have done no wrong and who feel they have no redress against the Department;
  • it is governed by a welfarist mentality, which seeks ultimately to make its clients more, not less, dependent on the state;
  • it is a slavish follower of fashions in the welfare market-place;
  • it lacks any standards of efficiency and cost-effectiveness;
  • it has far too much autonomy and is subject to no external scrutiny.

In short, it is accused of being a bureaucratic empire, of especial distastefulness because it has such power over private family life.

In reply it might be urged that

  • some of the Department's functions are statutory requirements, reflecting not its internal processes but considered community values;
  • the crime upsurge, and the underlying social problems, are on a scale far beyond what the Department -- or the police -- can cope with;
  • the social problems it deals with are particularly intractable ones, and no-one can claim to have "answers".

It is not possible here to argue any definite position on these matters;  to do so must be a matter of detail, some of which is not readily accessible outside the Department.  An incoming Minister, however, must make decisions, and any decisions must in effect take a stand on the rationale and performance of the Department.  In the absence of a detailed critique of the Department the best course seems to be a review process which tackles the most difficult objections, particularly those which relate to family breakdown and welfare dependency.  Those in the Department who think they can demonstrate success in helping families and promoting workforce involvement will stand to gain from such a review;  and those who do not accept the analysis put forward here would have plenty of opportunity to present a better case.

The recent re-naming d the Department for Community Services as the "Department for Community Development" may herald a shift of emphasis, from service-provision to community-building.  The rationale for such a shift might be that crime and other social ills originate in poorly planned communities.  This view should be required to specify what is meant by the protean notion of "community" and to indicate what evidence we have for believing that improving "community" will reduce these problems.  It may be that poor communities are the effects of other causes which lead to crime.

In this debate it is important to bear in mind the evidence we have about people's sense of identity.  In a recent study which asked respondents to list those characteristics which determine how they see their identity, the following categories were listed as "very important":

Category%
Family group member62
"Australian"52
Gender33
Occupation30
Ethnic background23
"State"23
"Town/District"16
Religion15
Supporter of sports club12
Race10
Age10
Member of professional association9
Supporter of political party7
Social class7
Member of a trade union4

[Michael Emmison and Mark Western, "Social Class and Social Identity: A Comment on Marshall et al", Sociology, 1990, Vol. 24, No. 2, pages 241-53, page 247.]


Governments wishing to improve social integration might be advised to study lists of this sort.  The commonsense notion of community is perhaps closest to "Town/District".  Smaller community units such as ethnic clubs, churches and sporting organisations are important and could be encouraged.  But by far the most important unit is the family (with work also high on the list).  Such figures help to show why loss of family connectedness leads to social disruption, and why substitutes for it are so difficult to provide.  In general, government policies which hinder or disrupt the family are likely to be very disruptive to individuals' sense of their own identity.  Conversely, governments which wish to foster "community development" will need to be sensitive to ways of supporting families.

The Lawrence government's social policy was presented as a "Social Justice Strategy".  Its main instruments were the Community and Family Commission, seen as a way of discovering policy directions by consulting broadly in the community (the results of which were published as Speaking Out, Taking Part) (125) and the "Social Advantage" statement which followed the Commission's report.  Some of these initiatives were responses to a clear sense of social and family decline, and in that way appropriate.  This is not the place to discuss them in detail, but simply to highlight the mismatch between the "social justice" banner and the kind of practical policy steps presently needed.

"Social justice" is a misnomer for the main social task of any contemporary government.  That task is one of helping, or perhaps requiring, "disadvantaged" "underclass" people to become functioning citizens.  To see this as a matter of justice is to see these people as making claims against the rest of the community, claims which deserve to be considered and accepted.  But the underclass is not an organised group looking to the community for recognition.  Its main problem is its disorganisation, and this is a matter which is unlikely to be resolved by a policy of impersonal "community development" carried out by State government agencies.  The disorganisation is much deeper and more personal. (126)

"Community development", if it is to help these people, will need to teach ordinary elementary competencies:  how to stay in school, how to learn, how to sustain a family, how to find and keep work, how to keep off drugs and alcohol, how to resist the temptations of crime, how to deal with the remnants of racist and other abuse -- competencies which are normally taught within family life.  The assumption must be that underclass people, both parents and children, want to conform to mainstream values -- they are not a counter-culture -- but at present do not know how to.  But these values can be conveyed only by those who are strongly committed to them, and in the welfare field such commitment can not be taken for granted.

It is far from obvious that DCD is well equipped to carry out this very practical task.  The objections to it taking on this role are both institutional and matters of professional culture.  A general review, externally conducted, is the best means to respond to those objections.  But we also need to find ways of improving internal assessment.


Performance assessment

One of the highest priorities at present is to develop credible "performance indicators".  (These will be needed whether or not some of DCD's functions are transferred to private welfare agencies, for in the end DCD will decide allocations to those agencies.)  Welfare bodies have an interest in empire-building.  Welfare clients can be tempted to rely on unnecessary government handouts.  Welfare assessment can easily become a "conspiracy" between both parties to increase giveaways and cover up inefficiencies.  For this reason tougher than usual scrutiny is required.

There is a more basic point here.  The fundamental objective of welfare policy must be to foster independence and stable families which create independent adults.  We have seen that welfare dependency appears to be socially destructive.  To combat this destructiveness the only way forward -- if we rule out the possibility of abolishing or minimising welfare entitlements -- is welfare practices which counteract dependency.  It follows that successful welfare practice will tend to be cost-saving and empire-reducing.  At present all the incentives facing service providers work in the other direction.  Performance indicators must be designed so that they reward those who develop independence.

Here it is essential that the indicators not be written by the Department or by its client welfare agencies.  The design of performance indicators for business is now a specialist skill, and the government should not hesitate to make use of such skills in the welfare field.  (Another necessary reform, which ties in with this, is to not reward expenditure as such.  Spending less than budget allocations should be a prima-facie sign of success and efficiency, not of incompetence.)  Furthermore, performance assessments should be published, fully summarised, in each year's Annual Report.

The Department has a history of carefully managed "reviews", in which outside criticism is muffled and diverted.  Since the welfare culture is so pervasive, in the end success in ensuring proper standards will rest heavily upon the initiative of the Minister.  However, there is also a clear need for a review body of some sort.  Whether this should be a permanent role or a temporary taskforce is open to debate.  Since longstanding bodies are prone to be captured by the relevant interest groups, on balance it seems better that any review body should be short-lived.  Its main task should be to define the social role and strategy of DCD and to require DCD to show that it is performing positively in that role.  It is essential that the review should be carried out in the open, with plenty of opportunity for public comment, though other more objective evidence is also required.

Something like this was conducted by the Legislative Review of 1991, but that review was effectively in the hands of the Department (six of the review committee of eight were Departmental officers, and the other two were generally sympathetic) and its terms of reference did not cover the Department's current performance.  Much the same is true of the 1984 review, The Wellbeing of the People, which in the final analysis contained barely a critical word about the Department, except to urge more of the same.


Privatisation

As the budgetary figures above show, only about one quarter of DCD's budget is spent by non-government welfare agencies.  Excluding from the remainder administration costs and about $12m of Commonwealth money specifically mandated for supported accommodation, there is approximately $60m spent by DCD which might be spent by private welfare.  There is no obvious reason why government bodies should have a monopoly on this spending.  As part of a review of its operations, DCD should be required to show good reason why this money, and the powers that go with it, should be part of the public service bureaucracy.  Most of private welfare funding ($18m) now falls under the DCD description of "family and individual services";  some of it ($5.5m) under "substitute care services".  Private welfare might well be encouraged to take on more of a role in the remaining areas.

It is exceptionally difficult for public officials to deal constructively with severely troubled children and teenagers.  Young people from families with no consistent rules are not at all likely to respect the rule-bearers of society, unless personal connections are established which build a bond of trust.  What is required is constant, almost daily contact, on a scale possible normally only in the family.  To create family-like settings, affections and disciplines involves almost a full-time commitment, which conventional public servants and even social workers have no reason to give.

Some exceptional individuals and small groups will give this sort of commitment.  They should be sought out and encouraged.  Such work is best done on a contract basis.  Those interested to do it should be allowed to tender for tasks.  Public service social workers should be used only when such people can not be found.  Most will applaud the initiative and dedication of people such as John Embling in Melbourne or, in Perth, Teen Challenge (which the Department does support).  Many, however, are highly sceptical about the motivations and the achievements of social work professionals.

The main difficulty with a privatisation strategy in the welfare field is that the dominant culture in the larger private organisations is very little different from that of the State bureaucracy.  The larger bodies have absorbed the standard social work conviction that "the poor" are "victims" of vague impersonal social forces.  Under the aegis of this idea they have turned from close but critical involvement in the lives of those they would assist, to a mixture of handouts and sympathy.

The much-needed but difficult work of reconciliation in families and returning people to the workforce can be accomplished, with the right motivations.  Those who can do this work should be supported -- though some who want to do it are so opposed to the welfare mentality that they will take no government money for the purpose.  The role of DCD must be nothing more than to clear the way for such people and then to stand aside, though with some overall scrutiny to ensure that the power granted is not abused.  It is important that social work projects be openly and fairly tendered for, and that performance by contractors be measured as rigorously as possible.


COPING WITH CRIME

It is not the place here to debate the merits of the 1992 Serious Repeat Offenders legislation.  It is probably too early to judge its effects (car theft declined last year, but sexual assault doubled and serious assault is still rising).  Much will depend on what is done to accompany the tougher penalties.  Criminologists agree that certainty of punishment matters more than severity, and certainty requires both a stronger police presence and less discretion in the courts.

Beyond that our best guide is the work of John Braithwaite in his recent Crime, Shame and Reintegration. (127)  Braithwaite's thesis is that crime-reduction requires a steady effort at all levels of society to shame offenders, in ways which make quite clear the moral unacceptability of crime while still leaving the offender room for reconciliation with the rest of society.  Obviously this is often difficult to achieve, and in some cases it might be close to impossible

Some of Braithwaite's evidence is strongly relevant to the argument presented here.  In his view "reintegrative shaming" is part of the normal process of socialisation within the family.  Arguably, it is the loss of this experience in highly fragmented families which leaves so many young people ill-equipped to adapt to adult society.  He notes evidence showing that young people are most strongly deterred from crime by the thought of what their families and friends would think. (128)  And he defends the importance of having families and friends appear in court with offenders, just because this is an effective form of shaming.  South Australia is now moving to introduce parental liability for damages for criminal acts by their children;  this too deserves close consideration, and should not be opposed on the grounds that welfare-dependent parents cannot pay, for welfare payments are quite adequate to cover some damages costs.

The art of reintegrative shaming is one which both police and social workers need to master.  At present it is arguable that police have a better grasp of it than do the social workers.  A review of DCD might consider seriously whether much that is now spent on State welfare would not be better spent extending community policing.  There is good anecdotal evidence that where crime rates have fallen in the North-West towns the cause has been not social work but police commitment to those communities.  DCD staff should be required to produce evidence that their record in crime reduction is a credible one.

Some offenders seem beyond reintegration by informal methods.  As Watts' study shows, hundreds of young people lead lives of drug-taking, violence, aimlessness and desperation.  In some of these cases something like psychiatric treatment is required, but at present very little psychological insight is being offered to them.  Such insight will need to find ways of unravelling the effects of family failure and the welfare mentality.  Family reconciliation will be part of this, but to achieve that will involve follow-up after release from detention, which at present is minimal.

In his 1984 Foreword to The Wellbeing of the People, the then Minister for Youth and Community Services, Keith Wilson, commended it "to everyone who is mindful of the need to establish a fairer, more comprehensive, efficient and publicly acceptable programme of welfare throughout Western Australia".  That now seems like a very distant ideal.  As we have seen, 1984 is a turning point in the recent history of welfare failure in Western Australia.  Since then the social climate has altered dramatically, in some degree just because welfarist ideals have become so pervasive.  A new welfare review will need to work with a more critical notion of fairness and more rigorous criteria of effectiveness.  Our problems today are the problems of welfare dependency, family breakdown and rising crime rates about which The Wellbeing of the People had almost nothing to say.  Keith Wilson thought that that report would "cover society's needs until the end of the decade and lay the basis for the next century".  Instead, as we can now see, it was out of touch almost from the moment of writing.



ENDNOTES

93.  On crime measurement see James Q. Wilson and Richard J. Herrnstein, Crime and Human Nature, New York, Simon and Schuster, 1985, pages 30-35.

94.  Select Committee on Youth Affairs, Discussion Paper No. 3, Youth and the Law, 1992, pages 10-13.

95.  Phil Watts, Youth in Custody Project: A Profile of Juvenile Offenders' Drug Use Patterns, Longmore Remand and Assessment Centre, DCS, May 1992, page 6.

96.  ABS, Social Indicators 5, Table 6.1.l, page 244.

97Youth and the Law, op. cit., page 11.

98Ibid., page 12.

99.  ABS, Social Indicators 5, Figure 4.1.3, page 120.

100Youth and the Law, page 11.

101Ibid., page 12.

102.  David Thorpe, Patterns of Child Protection Intervention and Service Delivery. Report of a Pilot Project, University of Western Australia Crime Research Centre, April 1991, Table 2, page 9.

103.  ABS Cat. No. 4103.5, Compendium of Demographic and Social Statistics, Western Australia, Table 8.4, page 92.

104.  Wilson and Herrnstein, op. cit., page 261.

105.  Watts, op. cit., pages 8-12.

106Ibid., page 17.

107.  See Richard Blum and associates, Horatio Alger's Children, San Francisco, Jossey-Bass, 1972.

108.  Watts, op. cit., page 19.

109Youth and the Law, op. cit., page 11.

110.  Department for Community Services, Annual Report 1990, page 14.

111.  Phil Watts, personal communication.

112.  Phil Watts, personal communication.

113.  The Office of the Family, Government of Western Australia, Families in Focus in Western Australia; ABS Cat. Nos 4105.5, 1988, Tables 8.d and 8.e, pages 33, 34.

114.  Child abuse may be a cause but it may also be a by-product of family breakdown, since most child abuse involves sole parent and "blended" families. Thorpe found that of 672 reported abuse cases only 30 per cent involved children living with both of their biological parents; 49 per cent involved sole parent families, and 18 per cent blended families (Thorpe, op. cit., Table 4, page 12). However, we do not know what percentage of abusers are members of the child's family, so nothing much can be said about the processes at work here.

115Families in Focus in Western Australia, Chart 7.3, page 26; Compendium, Chart 2.2, page 27.

116.  Calculated from Families in Focus in Western Australia, Table 7.h, page 25.

117.  Estimated from the Australian figures given in Bettina Cass, Income Support for the Unemployed in Australia: Towards a More Active System, Social Security Review, Canberra, AGPS, 1988, pages 67-8, 177, assuming that the Western Australian figure is one-tenth that for Australia.

118.  Judy Raymond, Bringing Up Children Alone: Policies for Sole Parents, Social Security Review, Canberra, AGPS, 1987, pages 51, 62.

119.  John Ernbling, Fragmented Lives: A Darker Side of Australia Life, Ringwood, Penguin, 1986, page 100. The importance of family in forming character is in some ways obvious, in other ways often wholly ignored. It is nicely brought out in M, Scott Peck, The Road Less Travelled, London, Rider, 1985, and Paul Pearsall, The Power of the Family, New York, Bantam, 1991. Moira Eastman's work is a valuable survey of the research into these questions and its many ramifications: see her Family. The Vital Factor, Melbourne, CollinsDove, 1989. Peck, Pearsall and Eastman all show that belief in the importance of family is in no way a matter of exclusively "middle-class" values.

120.  See, for instance, Alan Tapper, The Family in the Welfare State, Sydney, Allen and Unwin, 1990, pages 63ff. Detailed analysis of sole parent pensions and average two-parent family incomes, taking into account taxation, welfare fringe benefits and family size, seems to show that the pensioner family is little, if at all, worse off than the average two-parent family. With Homeswest housing the pensioner will be distinctly better off. An analysis of this sort is forthcoming.

121.  ABS, Cat. No. 4107.5, Aboriginals in Western Australia, 1989, Table 5.1, page 26.

122Families in Focus, Table 2.b, page 7.

123.  ABS, Cat. No. 6537.0, The Effects of Government Benefits and Taxes on Household Income, 1992, Table 5, page 19.

124Annual Report 1990, page 1.

125.  Office of the Family, Government of Western Australia, 1992.

126.  On this theme see the lucid and fair discussion of the American poverty debate in Lawrence M. Mead, The New Politics of Poverty: The Nonworking Poor in America, New York, Basic Books, 1992.

127.  John Braithwaite, Crime, Shame and Reintegration, Cambridge, Cambridge University Press, 1989.

128Ibid., page 70.

Health

CHAPTER 7

INTRODUCTION:  THE PROBLEMS IN CONTEXT

For nearly twenty years now, health has been the most difficult public policy problem facing Australian governments, both State and Federal.  Demand is apparently boundless;  vested interests proliferate;  problems of inefficiency and unaccountability afflict supply;  irrational considerations of ideology make rational policy discussion almost unattainable.

The problem, moreover, will get worse.  While it is comforting to know that many treatments, surgical or otherwise, get shorter and safer, the necessary technology tends to get more expensive.  And health care, like income security, involves generational considerations:  expenditure on each citizen grows dramatically as the citizen gets older, a considerable problem as our population ages.

Looking at overseas experiences gives little cause for encouragement.  No comparable country has a long-established total health system which comes anywhere near perfection, or which offers a readymade model for transplanting to Australia.  And looking at other countries offers us, in fact, a hypothesis that would make any self-respecting treasury official despair:  expenditure on health tends to increase as nations and their citizens get wealthier -- health spending becomes a "positional good", like spending on leisure or any other "quality of life" good.

None of this should discourage us from defining and pursuing the basic policy task, which is, in essence, to deliver in the most efficient manner possible the combination of quality and quantity of service decided on by some properly accountable means within the funds decided on by the political process.

Even by that broad essential definition, Australian health policy is not to be judged a notable success.

Expenditure, bath as a proportion of the Commonwealth Budget and as a percentage of national product has steadily increased over the last twenty years:  from 10.5 per cent of the Budget in 1972 to 13.4 per cent in 1992, and from 5.9 per cent of GDP in 1972 to 7.7 per cent in 1992.  Evidence of apparent unmet demand is everywhere in the form of patient queues.  There is at the same time considerable spare capacity in many public and private hospitals.  Accountability is poor:  good and current information on both costs and quality is not easily accessible to the general public or to professional enquirers.  From what is available, however, it is clear that efficiency and quality vary greatly across the country.

The Federal government's policy responses to continuing difficulties include price control, and controlling the number of providers.  The private hospital sector is implicitly discouraged from major new initiatives, although it may be permitted a peripheral, even "last resort", role.  The potential role of private health insurance in relieving pressures has so far been explicitly rejected.  Public debate about the problems has been acrimonious;  over the last year the Federal government has countered State requests for more money for the public hospital system with arguments that efficiency improvements within State hospitals would release hundreds of millions of dollars.

This last matter brings us to the starting point of our own study of health services in Western Australia.  The State government -- any State government -- operates within the constraints -- ideological and financial -- imposed by the Federal government.  The price of accepting Commonwealth funding for the State hospital system is free treatment for Medicare patients in public hospitals.  Since the 1992 Federal Budget, the strings attached to the Medicare funding have become tighter, and now, for instance, include a requirement that the States pass legislation which entrenches the principles of Medicare.  At the time of writing, the outcome of the protracted post-Budget negotiations was still far from clear;  it seemed likely that a shift in the overall political balance among the State governments might force a result more rational than was the case in August.

These constraints severely limit the ability of the State government to find better ways of running a more efficient and accountable hospital system.  Fully-fledged privatisation, for instance, would seem to be ruled out.  A very courageous government might try going it alone on public hospitals, and indeed one health economist has suggested a method of doing just that. (87)  It is something that should be considered by a new State government;  in this chapter we will concentrate on approaches more clearly within the limits of political possibility.

A complicating factor is that, with a change in government possible at the next Federal election, there may be a fundamental change in overriding health policy;  at least to the extent that a new Federal Minister for Health might be willing to contemplate new arrangements within individual States.  We believe that our suggested approaches will fit in with any likely policy changes in Canberra, and that the principal model suggested will deliver a better hospital system under any likely Federal regime.  A first recommendation, however, should be made here:  the new State government should seek, together with its counterparts in other States, a more rational funding arrangement with the Commonwealth.

The focus of this chapter is very much on hospitals.  The maintenance of the public hospital system is, of course, only one of the Department's functions.  It also provides the normal policy, monitoring and administrative functions;  community health facilities;  nursing homes;  psychiatric facilities;  alcohol and drug services;  school dental services;  and a good deal of public health propaganda.  Some of these will be the subject of comment at a later stage.  But since hospitals account for over 85 per cent of the State's health budget, it is sensible to focus on them.

Health, indeed, is the second biggest item in the State Budget.  At $1271 million, it represented 16.5 per cent per cent of outlays in the most recent State Budget.  This in itself makes it an obvious candidate for scrutiny.  Experience and theory suggests other more compelling reasons.  Most of the State's hospital care is provided at no immediate cost to the consumer by organisations with near-monopoly status controlled, directly or indirectly, by bureaucrats and providers.  We would reasonably expect the system to display certain characteristics common to such arrangements, including:

  • indiscriminate overprovision;
  • severe problems with resource allocation;
  • lack of control over costs;
  • poor product information for consumers;
  • defective quality control;
  • lack of accountability;
  • openness to pressures from politics and vested interest;
  • bureaucratic expansionism:  and
  • credentialism.

All of thee appear to be present, although they may not have been officially diagnosed as such.

Many can be identified as implicit in the numerous publications of the National Health Strategy Unit over the last two years.  The Federal Minister has certainly established to his satisfaction the existence of unspecified "inefficiencies" in the State systems.  The last State government itself commissioned, in January 1991, the Metropolitan Health Service Review, whose terms of reference explicitly asked for better efficiency and effectiveness, including considerations of accountability, resource allocation, and management.  Anecdotal evidence, of course, abounds.

The difficulty for the outsider -- a very considerable difficulty -- lies in trying to locate the inefficiencies, given the very poor quality of the available data.  (Since the publication of the Royal Commission's two reports, accountability has been brought to the fore in political debate.  This might be a good place to suggest that one useful subsidiary definition of accountability is the publication of enough data to enable the construction of satisfactory policy alternatives.)

An initial, broad, judgement can be made on the basis of the comparative material published annually by the Commonwealth Grants Commission.  The following table compares the State's actual expenditure, per capita and in constant dollars, on general medical services with the all-State average, adjusted for Western Australia's peculiar social and geographic circumstances.

Table 7.1:
Commonwealth Grants Commission:  W.A. (1984-85 prices)

1982198319841985198619871988198919901991
Standardised3143173194244334S1472471471478
Actual379374389472477487488503505519
% over-spend21%18%22%11%10%8%3%7%7%8%

Note:  Yeare refer to fiscal years (e.g., "1982" refers to 1981/82)

Source:  CGC data


The table shows that, using the reasonable index established by the Grants Commission, Western Australia has for some time now been spending somewhat more on its public health system than it need.  The next table is perhaps even more useful:  it shows the same comparison, actual against standardised, for Queensland.

Table 7.2:
Commonwealth Grants Commission:  QLD (1984-85 prices)

1982198319841985198619871988198919901991
Standardised306308310406414432459458458465
Actual282284290320325325334333328330
% under-spend8%8%7%27%27%33%37%37%39%41%

Note:  Yeare refer to fiscal years (e.g., "1982" refers to 1981/82)

Source:  CGC data


The data for the two States can be brought together and expressed graphically:

Figure 7.1:
Percentage Overspending per Capita
CGC:  WA and Queensland


Source:  Commonwealth Grants Commission data

A few other figures relating to the public hospital sector in Western Australia and Queensland will reinforce the comparison.  In 1989-90, the cost per occupied bed day in Queensland was $429, the cost per separation $2449;  the same costs in Western Australia were $515 and $3026 respectively.

There is no reason to believe that Queensland's public health services are in any way worse either than those of most States or those of Western Australia.  (One fairly coarse measure of adequacy can be found in State-by-State levels of private health insurance:  Queensland has the lowest level of private insurance in Australia.) (88)  If Queensland can maintain this unexceptionable level of service by spending less than its standardised figure and less -- far less -- than Western Australia, then it is virtually impossible to escape the conclusion that Western Australia overspends and spends in a way which, prima facie, appears to be very inefficient.  The first table also shows that per capita spending an public health (not hospitals as such) has been rising steadily.

(A note of caution does need to be sounded here.  While interstate comparisons are useful in many respects, not least in uncovering areas of gross discrepancy, they are not to be taken as policy prescriptions per se.  The limitation here is not simply one of comparing very different institutional structures, with their own history and rationale;  but rather that whatever usefulness cost comparisons may have is severely limited by the absence of quality comparisons.)

In the case of most States, a detailed analysis of the sources of inefficiency would not be easily possible;  lack of data would prevent it.  That would be the case, too, in Western Australia, if it were not for the existence of the Metropolitan Health Services Review (hereafter, MHSR). (89)  The recommendations of the Review are for the most part ineffectual (reflecting political constraints);  the statistical appendix, however, contains a good deal of raw data which can be made to show where some of the acute problems lie.

Three explanations are usually brought forward to explain cost pressures on our public health systems:

  • excessive demand;
  • increases in capital costs;  and
  • increases in equipment and drug costs.

It is worth looking at each of these in turn.

In the absence of a freely-operating market, demand is somewhat difficult to measure;  indeed with an apparent price of zero, demand is perhaps meaningless.  More or less reasonable substitute measures have to be found elsewhere.  We can look at the throughput of hospitals, as found in the number of patients discharged -- "separations".  We can look at the intensity of treatment, at the pressure a patient places on hospital resources -- bed days.  On the basis of the MHSR data we can say that between 1986-87 and 1990-91, separations in teaching hospitals rose by 17.3 per cent, or 3.5 per cent per year, and bed days in teaching and non-teaching hospitals rose by only 1.5 per cent.  Neither figure reveals any strong indication of excessive demand.  It might be further noted that over the same period admissions increased by 14.7 per cent, or 2.9 per cent per year, another indicator of weak demand.

The argument for capital costs as a contributing factor is even weaker.  Data horn State Budgets show that real capital costs per bed day have fallen by 64 per cent between 1986-87 and 1990-91.

The two other components of costs mentioned -- equipment and drugs -- did increase.  In teaching hospitals, equipment costs per bed day rose by 44.4 per cent over the period studied, and accounted for 17.8 per cent of the total rise in real costs per bed day.  Equipment costs in non-teaching hospitals rose by 64.8 per cent by the same bed day measure, accounting for 8.3 per cent of the total rise in real costs.  (The difference between the respective contributions to total cost increases reflects the fact that teaching hospitals are more costly to equip and operate).  The real costs of drug supplies in teaching hospitals rose by 29.3 per cent by the same measure over the period, accounting for 11.4 per cent of the total cost increase.  These factors therefore contributed noticeably to cost increases, but are far from being major factors.

The principal factor is one which is not much mentioned in the public debate:  labour costs, particularly of nurses, doctors and administrators.  The omission is surprising, since health is essentially a service industry, heavily dependent on labour costs.

Table 7.3:
Real cost per bed day ($):  WA Teaching Hospitals

1986/871987/881988/891989/901990/91%
increase
% of total
increase
  Nursing
  Medical
  Admin
Total
110
62
37
322
113
63
39
324
112
62
38
319
116
72
39
338
120
76
41
349
8.8%
22.9%
9.9%
8.6%
21.5%
31.6%
8.2%
61.6%
  Equip
  Drugs
Total operating
18
17
79
18
18
80
17
20
83
21
21
85
26
23
89
44.4%
29.2%
12.7%
17.7%
11.3%
22.2%
Grand Total44444744447048910.1%100%

Source:  Metropolitan Health Services Review (MHSR)


Once again we can make a revealing (if limited) comparison between Western Australia and Queensland:

Table 7.4:
Average Salaries 1989-90 Total Public:  QLD v WA

QLDWA% Difference
Nursing$28,466$34,05219.6%
Medical$71,192$75,1675.5%
Admin$22,566$25,50313.1%
Hotel$21,792$22,4382.9%
Med Supp$28,342$35,29224.5%
Total$29,423$33,06712.4%

Source:  Australian Institute of Health (AIH), Hospital Utilisation and Costs study, 1989-90, preliminary data


The MHSR data show that between 1986-87 and 1990-91, the nursing salary component In teaching hospitals, in terms of real cost per bed day, rose by 8.8 per cent, and accounted for 21.6 per cent of the total cost increase in teaching hospitals.  It should be noted that over the same period nursing numbers fell;  so the rise is entirely due to salary increases.  It should be noted that this was largely imposed by circumstances outside the State government's control:  in particular the Commonwealth's support for a new national nurse wage structure.  In the same terms, doctors' real wages in teaching hospitals rose by 23 per cent, accounting for 31.6 per cent of the total cost increase.  In terms again of real wage per bed day in teaching hospitals, administrative salaries rose by 10 per cent;  numbers increased by 13.5 per cent.  We might also note that labour costs accounted for 62 per cent of the total rise in real cost per bed day in teaching hospitals, and for 72 per cent in non-teaching hospitals.

Wage costs are only a part of any full picture:  in the end, of course, productivity is the most important part.  As far as the data allow us to judge, there have been some minor improvements in productivity -- particularly of nurses -- but such benefits as have occurred have been captured by the hospital personnel rather than the taxpayer.  In trying to understand productivity issues it may be useful to look at the changes in staffing over recent years:

Table 7.5:
Staffing Levels per Occupied Bed:  Teaching Hospitals

1986/871987/881988/891989/901990/91% Increase
Nursing1.941.881.821.831.86-4.0%
Admin0.740.780.790.810.8211.3%
Hotel0.970.940.930.950.91-5.4%
Med Supp0.690.700.700.710.735.4%
Maintnce0.240.230.220.220.22-9.7%
Medical0.430.440.4S0.520.5528.5%
Total5.04.984.925.035.091.8%

Source:  MHSR


And the comparison with Queensland would seem to show that Western Australia has lower productivity in the areas of administration, domestic and medical officers:

Table 7.6:
Staffing levels per Occupied bed 1989-90, QLD v WA (Total Public)

QLDW.A.
Nursing1.971.70
Admin0.350.60
Hotel0.561.05
Med Supp0.760.47
Medical0.220.28
Other0.140.2O
Total4.004.30

Source:  AIH preliminary data (HUCS)


Looking at staffing, behind these statistics, reveals a number of problems which have been allowed to develop without any serious regard for the financial implications.  One significant problem is the switch from hospital-based to tertiary education-based training for nurses.  This has been the immediate cause of a particular cost factor, in that relatively poorly paid trainee nurses are no longer available for a wide range of routine hospital duties.  The benefits of the switch are not clear;  there are reasons for believing that the professional skills of new nurses are not as good under the new system as under the old, and the disappearance of the trainee class has left nurses without anyone to whom those routine duties can be delegated.

Another significant problem for Western Australia is the number of teaching hospitals.  It is not simply that we have five teaching hospitals, which seems rather a lot to service one faculty of medicine.  Expenditure on teaching hospitals in Western Australia is a higher proportion of total hospital expenditure than in any other State.  At about 60 per cent of the total, it is very considerably higher than in Queensland, for instance, at about 45 per cent;  and with about 40 per cent of total public beds in teaching hospitals, it is very considerably higher than Queensland's 25 per cent.

A further obvious area for examination is the staffing mix of hospitals.  In 1989-90, across both teaching and non-teaching hospitals, nurses accounted for 40 per cent of staff, doctors for 7 per cent, administrators for 15 per cent, domestic staff for 24 per cent, medical support for 11 per cent and other staff for 3 per cent.  Once again, it is interesting to compare this situation with Queensland's:  nurses accounted for 49 per cent, doctors for 5.5 per cent, administrators for 8.9 per cent, domestic staff for 14.1 per cent, medical support for 18.9 per cent and other staff for 3.6 per cent:

Table 7.7:
Staffing Mix 1989-90 (Total Public)

QLDW.A.
Nursing49%40%
Medical5%7%
Admin15%
Hotel14%24%
Med Supp19%11%
Other4%3%

Source:  AIH preliminary data (HUCS)


There would seem to be a good initial case for believing, first, that our hospitals are administratively top-heavy, and, second, that too large a proportion of hospital staffs are engaged in non-health care areas that might be handled better in other ways.

The comparison with the statistical profile of Queensland reveals another useful observation:  Western Australia has, proportionately, more large hospitals and fewer middle-sized hospitals.  This is in itself a source of cost and management problems.  As the National Health Strategy has pointed out, "... large hospitals exhibit decreasing returns to scale.  All other things being equal, 300-500 bed hospitals are considered the most cost efficient with diseconomies of scale occurring over 500 beds ... Studies of large hospitals in the U.S. and Australia ... have proposed the establishment of self-contained units of 100-150 beds as a means of counteracting diseconomies of scale." (90)

In two important areas, this short overview is deficient.

It has not been possible to say anything very useful about the quality of care.  This is simply because we have found no recent independent data which would enable us to make any sensible comparisons.  We will, therefore, take quality as given, and independent of State expenditure patterns.  In a very broad sense, this is justifiable:  international comparisons between developed countries show a very weak connexion between overall health expenditures and obvious indicators such as life expectancy.  And rationally we would expect that:  while the returns on the provision of the fundamentals of public health, such as clean water, good sewerage, and immunisation are high, returns diminish rapidly at the other end of the health spectrum, in the provision of very expensive, technologically intensive individual treatment.

Nor has it been possible to make any systematic criticism of work practices in our public hospitals, and for much the same reasons.  While there is now a wealth of evidence on work practices on, for instance, our waterfront, all the recent published studies of public hospitals shy away from explicit discussion of the relationship between the industrial relations context and efficiency.  In the course of this study, however, ample anecdotal evidence has emerged to make it perfectly clear that counterproductive work practices (including demarcation) are sufficiently rigid to induce severe constraints on efficiency.  Evidence now emerging in Victoria since the change of government offers further corroboration.


SOME FIRST STEPS TO REFORM

Given the constraints mentioned earlier, comprehensive reform of Western Australia's public hospital system is not possible without a fundamental policy change at the Federal level.  Such a change need not be radical:  anything which allowed the States freedom of experiment in maximising efficiency, without compromising the Federal government's proper need for accountability, would help.  Even with that freedom, the very nature of health care provision is such that perfect solutions are unattainable;  so here we are looking at third- or fourth-best solutions.  That need not worry us greatly:  the size of the sector is such that even marginal improvements in efficiency will be more than welcome.

(The Queensland comparison is instructive here.  Using the Commonwealth Grants Commission data, it is possible to show that if Western Australia's public health spending -- defined as "general medical expenditure" -- were managed in precisely the same way as Queensland's, we would save, in real terms, roughly $215 million per year.  This is not, as we have said before, a simple prescription for reform.)

The brief preceding sketch, however, provokes some immediate commonsense recommendations for reform.  We offer six simple proposals to begin.

  • It is important that government let the managers manage, within specified and publicly accountable guidelines.  This means appointing managers who understand the financial constraints of hospitals, rather than doctors (and, increasingly, nurses) who gravitate into management.  It means more businesslike boards.  It means increasing the distance between management and bureaucracy.  It means, also, better information on inputs and outputs:  an annual report along business lines is a great discipline.
  • In terms of costs and efficiency, the most important single area of management is industrial relations.  Perhaps the highest of all reform priorities is the immediate introduction of enterprise-based bargaining into public hospitals.  This will not, in a sense, be easy:  patients are not conveniently ill between 9 and 5, and hospitals are not factories.  Better industrial agreements will involve greater flexibility than is common in enterprise-based bargaining, and that flexibility will come at a cost, some of which will be the cost of cashing out complex and inefficient penalties and special conditions.  Any reasonable settlement will be worth the cost.  It is important that the "enterprise" be the smallest possible unit:  at the very least, the hospital itself;  in very large hospitals such smaller and separable management units as can be naturally created.  Different negotiated packages between hospitals will encourage competition for resources, and that competition will create further efficiencies.  It is, of course, essential that negotiations proceed without interference from third parties, most especially the government.
  • Hospitals and their management should attempt to manage only health care.  All other functions -- including, for example, data management, catering, maintenance, gardening, cleaning and transport -- should be contracted out by competitive tender.
  • The Department should investigate the possibility of buying beds from the private hospital sector where appropriate and where possible within the Medicare guidelines.  The experience of New South Wales in this area will repay examination (not least in designing contracts, which should perhaps specify DRG-determined services rather than "beds"). (91)
  • The number of teaching hospitals should be reduced.  If the specialty obstetrics and paediatrics hospitals are to be retained as such, then it may be difficult to reduce the overall number to less than four;  three would be preferable.  The all-State average of teaching to non-teaching beds should be a useful guide in effecting the reduction, and should be achievable within a term of government.  It will be important in this that the government have a very clear idea of the precise mixture of costs involved in running teaching hospitals:  existing data are inadequate, but it seems more than likely that there is some cross-subsidy between the teaching and medical functions which is at the moment far from determinable.
  • The arguments about diseconomies of scale should be thoroughly absorbed into future planning.  Current policy should examine whether some of the existing giants can be broken up;  whether, for instance, Shenton Park can be split off from Royal Perth.  An important part of the arguments about scale relates to continuing developments in day-care surgical procedures for ambulatory patients.  It is likely that major new hospital investment can be deferred for some time by concentrating on smaller day-care centres.  Planning should also aim to bring Western Australia's bed/population ratio closer to the national average.  As of 1989-90, this State's bed/population ratio was 5.18 beds per 1000 population, and the Australian average 4.9 beds per 1000. (92)  Current policy plans for 4.3 beds per 1000 by the year 2001.  As other States are adopting similar plans for reducing their own ratios, the 2001 goal will still leave Western Australia above the then national average.  A stricter goal and a shorter timetable are necessary.  Western Australia has the luxury (not available to, say, Victoria) that a more sensible ratio can be achieved without massive bed closures.

EFFECTIVE REFORM:  A STRUCTURAL APPROACH

These recommendations are all well within the bounds of political possibility;  their counterparts can be found in various public sector activities across Australia.  If implemented they would bring Western Australia's public hospital costs to more acceptable levels, and lay a more rational foundation for the inevitable future growth in the system.  The last few words are important:  whatever reforms are put in place have to cope not only with present problems but with the facts that Western Australia is a growing State, that the demand for health care will rise, and that another bout of major capital investment will be due some time in the next decade.

They do not, however, directly address the central policy problem identified earlier:  the fact that the inefficiencies are inherent in the structure of the system.  They arise, almost inevitably, from the fact that the purchaser of the service and the provider of the service are effectively identical.

In the world of commerce, such services would be bought by negotiation between supplier and buyer, at a mutually acceptable price which encompassed quality and quantity.  The public health system admits of no point at which such an arm's-length transaction can take place:  there is a continuum from the Minister through the bureaucracy to the hospitals.  Bureaucratic negotiation takes the place of market transaction.  This introduces all sorts of non-market difficulties, especially political and interest-group pressure.  It is doubtful that anyone in the process knows the real price of any relevant service, and, indeed, the system operates to suppress such considerations.  At best, negotiations on an annual basis will be conducted on the simple basis of last year's allocation plus a bit extra for inflation or expansion.  At worst, the process may be intensely political.

The problem then can be stated in this form:  how do we maintain a hospital system funded by the taxpayer, which satisfies the Medicare constraint, in which provider and purchaser operate at arm's length?

We offer two models, which the new government can refine.  The essence of both is that they provide a break in the continuum between Minister and hospital:  the government is clearly identified and established as purchaser, the hospital as provider.

The first step in both models is to establish the hospitals as independent, publicly-owned entities.  This is simply done by legislative means.  The legislation should specify that

  • each hospital has a clear charter to carry out its operations in an efficient, commercial manner;
  • each hospital has a fully commercial board, whose members are predominantly non-medical and can be replaced if they do not perform;
  • while answering to the board, the management of each hospital would be fully autonomous, especially in relation to assets, staffing, work practices, contracting-out, investment decisions, and commercial relations with other suppliers;
  • board and management alike in each hospital be independent of political influence, further specifying that ministerial intervention of whatever kind be by public correspondence, so that ministerial intervention, and disagreements between hospital managers and the Minister, be tabled in Parliament and reported in annual reports;
  • non-commercial undertakings requested by the government (which may include difficult medical resource allocation areas such as emergency and outpatient services, or more broad "community obligation" areas) be funded by transparent subsidy from the Budget;  and that
  • hospitals operate in a truly neutral competitive environment, most particularly with regard to payment of all relevant taxes and charges, to servicing of deemed debt, and to payment of dividends.

This new corporate structure for providers is common to both models;  the differences lie in the method of purchasing.

One way of handling purchasing -- call it Model A -- is to direct admissions away from hospitals.  The government would set up an allocation bureau as an offshoot of the Department.  Such a bureau would maintain a constantly-revised list of prices for beds and procedures, probably based on DRGs.  The admitting physician would ask for an allocation through the bureau, and the bureau would provide the physician with the range of going prices.  In the case of fully public patients (that is, those without private insurance for whom Medicare picks up the whole bill), the physician would have no choice but to send the patient to the cheapest provider.  Other patients would have the choice of selecting the price and quality desired, and paying the difference,

This case-by-case allocation method could be refined to a level of some sophistication.  It has the advantage of making prices very much more transparent to physician and patient than at present.  Consumer information is essential for effective competition.  (It is doubtful, however, that it can be achieved in any significant way under the Medicare arrangements.  Ideally, consumers of health should share at least part of the cost of service if the information is to be sought and used appropriately.)  Continuous pressures on efficiency are also an advantage.  The obvious disadvantages are the constraints it would place on rational forward planning, and the possibility of bureaucratic inefficiencies, though both could be largely overcome through appropriate design.

The alternative purchasing method -- call it Model B -- is closer to already-established systems of tendering for provision of services to government.  Quite simply, the Department, or some more independent bureau, would seek offers from the hospitals for the provision of so many beds over the coming year.  The tender would specify not only the number of beds, but the kinds of services attached to the beds, again by DRG or some similar classification.  Importantly, the contract or tender specifications would include quality standards, both medical and non-medical, and, to the extent possible, duration.  And where the treatment of Medicare patients is not the prime concern, it should be possible to include private hospitals in the tender process.

Again, the basic principle, here stated very simply, can be refined in execution.  In the process of refinement, the government should look closely at the new New Zealand system, basically identical in principle, now effectively in operation, and already yielding very good results.  There seem to be no obvious disadvantages attaching to this model, which has a considerable virtue in that it can operate well under either the present Commonwealth policy regime or under any more rational regime that changes of government may bring.

There remain questions of relatively minor importance that cannot easily be answered here for various good reasons.  Model B, our preferred model, is, for instance, clearly suitable to operation in the metropolitan area.  Does it apply elsewhere?  The answer to that is not easy to give.  Certainly even the smallest country hospital would benefit from the principle of autonomous management;  and we think it likely that the tender system would uncover potential efficiencies (for example, through specialisation within regions) not achievable under the present system.

Again, the question would need to be posed separately for other major functions, such as psychiatric care;  but, again, we believe that there are no reasons in principle why the model should not apply.  Even outside the complete hospitals system there is no reason why the separation of purchaser and provider should not be widely extended.  It is easy, for instance, to see how it could be applied to other major programmes such as the Continuing Care Programme.  In the case of drug and alcohol programmes, the applicability is again clear, and offers a good method of financing care through non-profit (volunteer, community and religious) organisations.

We have not in this chapter covered all the many functions currently carried out by the Department of Health.  The focus has been very clearly on reforming the major public hospitals, which account for the lion's share of expenditure and have obvious first priority in reform.  The government should, however, consider all aspects of the Department's programmes.  Particular attention should be given to health promotion and education programmes.  There is, in the first place, a need to ensure that the effectiveness of the programmes is measured by some impartial observer.  Second, those programmes which involve offence to commonly-accepted standards of morals should be debated, in and out of the Parliament.



ENDNOTES

87.  See J. Logan, "Public Hospital Funding: An Exercise in Political Monopolisation", Health & Welfare Policy Programs, Working Papers Series No. 2, Centre for Independent Studies, Sydney, December 1988.

88.  Queensland does have a different history of public health provision from Western Australia.  But here, as elsewhere, the discrepancy between the two levels of expenditure suggests that quality is less important a determinant than efficiency.  See the comments on CGC data in Chapter 5.

89.  Metropolitan Health Services Review, Final Report to the Government of Western Australia by Deloitte Ross Tohmatsu, Perth, December 1991,

90.  National Health Strategy, Issues Paper No 2, Hospital Services in Australia, Access and Financing, Canberra, September 1991, page 43.  It should perhaps be noted here that the particular figures cited are not beyond dispute, and that the argument may need to be adapted to local circumstances.

91.  DRG:  Diagnostic Related Groups

92Ibid., pages 40-41.