Tuesday, 24 November 2015
Universal Declaration of Human Rights, Health Care
Last week I had the pleasure of launching a book, Freedom From Religion, at the Paperchain bookshop in Canberra. I believe it is a very important publication, and I recommend it to everyone. This book concerns article 18 of the Universal Declaration of Human Rights. It is in no way a dry book. It might sound that way when you mention an article, but it goes to the heart of many issues that we are grappling with—our values, our beliefs, our acceptance of others—and how this important treaty, the Universal Declaration of Human Rights, impacts on our lives and shapes our society.
Article 18 establishes the rights of all individuals to adopt personal moral values, whether religious or otherwise, and the right to practise, observe and teach the tenets of that belief. It was a very significant document, particularly when it was first adopted, immediately after the Second World War. It has now been adopted by 195 member states of the United Nations. In fact, the provisions of article 18 are repeated in many international treaties.
Ms Meg Wallace, who has written this book, addresses specifically the response of governments to article 18 and its interpretation and oversight by the United Nations and the European Council. She proposes that perhaps, with the best of intentions, those responsible have overwhelmingly failed to fulfil the promise of article 18. This is why this book is so significant. Article 18 has shaped so much in our treaties, in the way we work, in our very parliament, and here we have a significant writer calling for there to be a reassessment.
Imprecision in both the terms and implementation of article 18 has led to a distracting concentration on the meaning of religion, what constitutes a religion, which religions are acceptable to government and what limits government can reasonably place on religious practice. What becomes glaringly clear is that protection of non-religious beliefs is mostly ignored. In fact, article 18 has been used to justify what amounts to sectarian interests and all the damage that goes hand in hand with that. Using a right-from-religion perspective, Ms Wallace reveals inherent biases in our society.
While I do actually strongly agree with Ms Wallace's assessment of article 18, I wish to still acknowledge the significance of article 18 and the whole United Nations Universal Declaration of Human Rights. As I said, it came out of the aftermath of the Second World War. It was 1948, shortly after the war had ended, and you can imagine how significant it was at that time to help ease the trauma of that terrible period where fascism for a time looked as though it could have taken over the world. I do believe that this treaty and even article 18 would have helped ease the feelings about the abuse and all the vile acts that had occurred, and it would have been done with the best of intentions.
However, at times we need to reassess, even with a human rights treaty, and that is why this book is so important. Ms Wallace's work is relevant to how religions operate in Australia and indeed how governments operate. The colonialists that established Australia as a secular nation and the leading decision makers have been presenting a dominance of Christian religion. Early governments in the 19th century actually worked not to encourage sectarianism. This is what is very significant when you examine it in the context of Ms Wallace's analysis. Those early governments did not give official recognition to one church over others. State schools were required to be secular. There was no established church as there was in England.
Helen Irving has written extensively on this. In 2004 she wrote:
This policy was reflected nationally in the Commonwealth Constitution. The Constitution' framers faced two questions head-on: was Australia a nation with a particular religious character? Should the Constitution recognise this? They answered no to both. During debate, much concern was expressed about the potential for religious intolerance, even official support for religious persecution. Governments, framers said, should not inquire into the beliefs of individuals.
That approach, I believe, is in keeping with the spirit of article 18, but, tragically, the way article 18 has come to be interpreted and used has now changed considerably. Helen Irving, in her essay entitled 'Australia's foundations were definitely and deliberately not Christian', also quotes the words of the first Prime Minister, Edmund Barton. He said:
The whole mode of government, the whole province of the State, is secular … and there is no justification for inserting into your secular documents of State provisions or expressions which refer to matters best dealt with by the churches …
Those are our forebears, those who were the drafters of the important Constitution of this nation.
If you look at the words of more recent leaders, you would think we were a Christian nation. Former Treasurer, Peter Costello, at a National Day of Thanksgiving Commemoration, said the Ten Commandments 'are the foundation of our law and our society'. Mr Costello said that not only our law, but our moral standards and values derive from the 'Judeo-Christian tradition', or, more specifically, from Australia's 'historic Christian faith'. Former Prime Minister John Howard similarly claimed we are 'predominantly a society instructed by the Judeo-Christian ethic'. And according to former Governor-General Major General Michael Jeffery, Australia has a 'Christian heritage', and 'faith in God has been an important establishing and unifying principle for our nation'.
I think that contrast of going from the Constitution and what our forebears actually wrote when drawing up the Constitution, to ensure we were a secular state, to fast-forwarding about 100 years later, where a very specific religious stamp is put on our society, is very strong evidence of how important Ms Wallace's book is.
As I explained, article 18 of the Universal Declaration of Human Rights establishes the right for all individuals to freedom of thought, conscience and religion. But these personal, so-called 'civil rights' are not absolute. They are distinguished from political rights. Article 18 requires separation of religious interests from state power, or maybe I should say it should require that separation. Article 18 effectively promotes, by reference to its religion-related language, that it has become used as a manifesto about religion, despite the fact that it applies to everyone, and that should have been what always remained the essence of article 18—to atheists, to agnostics, to the unconcerned as well as to religious people. However, article 18 has been used by some churches as a pretext for demanding political, economic and social benefits, and we see that in our own society and in many societies.
In Australia, religion permeates so many of our institutions. Our own chamber starts with certain religious prayers every day, and that was the dominant religion. We see the dominance of religious instruction in our schools and financial benefits to religious institutions, through funding and tax exemptions. I would argue the interests of religious institutions and individuals are reflected in government policy and legislation too often. Religious institutions throughout the world have thus become politically influential and, I think very unfortunately, very wealthy, because of how they have entwined themselves with the state, sometimes to the tune of billions of dollars.
Ms Wallace writes that we need to rethink article 18 and what it means, if we are to realise its promise. It had promise and I believe it still has promise. The intention of article 18 is not to privilege anyone's religion or beliefs, but to ensure that governments protect religious freedoms from impartial policies and legislation, allowing individual religious and others groups to flourish according to accepted democratic governance. Freedom from religion or belief, it is argued, is the real promise of article 18—that is, freedom from suppression or imposition of religious or non-religious doctrines by the state or anyone else. As Ms Wallace said herself, 'Article 18 fosters the privileging of religious beliefs, hindering the equal right of others to exercise the same right.' It does not have to be like that, and I still believe that we can ensure the real intention of article 18 is realised.
On another matter, in New South Wales and around the world, health systems are fragmented and bureaucratic. This creates dissatisfaction amongst patients and healthcare professionals alike. Good clinicians go to work every day at good hospitals, yet the overarching system impedes their ability to provide coordinated care. Health policy experts agree that greater coordination of services is necessary to develop a more effective and sustainable health system in New South Wales. The New South Wales State Health Plan has some remarkable features. They are very admirable, including the aim to develop new models of integrated care. I would like to outline two innovative, evidence-based approaches to integrated care that could be used to guide this vital work and improve health services across our state.
The Greens have stressed the need for improved primary care services, including dental care, to keep people healthy and reduce their need for expensive hospital care. A greater focus on primary care is absolutely essential to reducing health system expenditure, and this is especially important due to the increasing number of people with chronic health conditions requiring ongoing, long-term treatment. What we need to do is imagine a health system where people are well and hospitals are empty, and develop strategies to help us move towards that vision. This is where the idea of integrated care becomes so critical. Effective models of integrated care can assist people's journeys towards better health, and reduce the number of people requiring episodic emergency treatment for acute illnesses. The question is one of how we can redesign the NSW health system to enable integrated care. While there are some Australian examples of how this could be achieved, our efforts could also be guided by models of effective integrated care from the United States.
Alaska's Southcentral Foundation recently won the highest award for healthcare quality in the United States for its model of integrated care: the Nuka System. The Nuka System has been described by Dr Donald Berwick, the former administrator of the Centers for Medicare and Medicaid Services, in the United States, as an internationally leading example of effective health care redesign. The Nuka System of Care provides integrated medical, dental, behavioural and other types of support services to around 60,000 people. It aims to support wellness in the community rather than solely addressing sickness. The approach involves multidisciplinary teams providing ongoing support to individuals in primary care centres and also in the community. The aim is to help people self-manage their health and journey as necessary through different parts of the health system. This is combined with a broader approach to improving community wellbeing, which aims to tackle domestic violence and other problems through education and community engagement.
The overarching principle is that care should be delivered by a healthcare team, not by individual professionals working in comparative isolation. Relationships between people and the multidisciplinary teams that care for them are at the forefront of their work. There is recognition that people control their own healthcare decisions, so ongoing engagement is necessary to encourage positive decisions that promote improved health and decreased need for hospital care.
The Nuka system has produced stunning results, including 25 per cent fewer admissions to hospital emergency departments, producing significant cost savings. It has also led to a decrease in family violence, showing that a holistic, integrated model of care can produce social benefits beyond the traditional indicators of health system effectiveness.
A second innovative model of integrated care was developed by the Camden Coalition of Healthcare Providers in the United States, led by Dr Jeffrey Brenner. The program aims to reduce the amount of unnecessary hospital care for people whose complex physical, behavioural and social needs are not well met through the fragmented US healthcare system. These people, known as 'super utilisers', often move from emergency department to emergency department, from inpatient admission to readmission, receiving chaotic, costly and ineffective treatment.
While there are clear differences between the US and Australian health systems, super utilisers are equally problematic in New South Wales and, I imagine in other parts of the country. For example, during 2011-12, two per cent of the New South Wales population attended an emergency department three or more times, accounting for 35 per cent of all emergency department attendances. These figures highlight the potential implications of Dr Brenner's approach in the New South Wales context.
Super utilisers often lack financial resources and an understanding of how to use the healthcare system effectively. Many have no source of regular, coordinated medical and social support services—which are the very thing they need for stable health. To address these issues, super utiliser programs provide intensive care management to these high-need, high-cost patients outside hospital settings. The heart of the approach is a patient management program to improve the transition of super utilisers from the hospital to outpatient care and ensure they continue to get the medical and other services they need so that they do not end up back in hospital.
A multidisciplinary care management team visits the patient in the hospital, conferring with doctors and nurses and helping plan the discharge. Team members visit the patient at home immediately after discharge and provide ongoing support, including connecting them to a GP, accompanying them to appointments and helping line up needed social services. The goal is to leave patients with the ability to manage their own health—surely what should be central to our approach to our health system.
The results were interesting. The first 36 patients averaged a total of 62 hospital and emergency room visits per month before the intervention compared to 37 visits per month afterward. Their hospital bill total fell from a monthly average of $1.2 million to just over half a million dollars. If results of this magnitude could be obtained in New South Wales, the reductions in health system expenditure would be significant.
The Nuka System of Care and the super utiliser program both demonstrate the feasibility and potential benefits of innovative models of integrated care. Both involve the same groups of healthcare professionals that we also have in New South Wales but coordinate their activities more effectively to help them deliver better care. As such, these two models would likely be well received by doctors, nurses and allied health professionals in New South Wales, who are currently frustrated by the fragmentation of our health system.
The Nuka System of Care and the super utiliser program are applicable to New South Wales and could be trialled and refined to support the state government's objectives, as detailed in the New South Wales health plan. Trials should occur at the local health district and Primary Health Network level. The two approaches outlined today have the potential to provide best practice models of integrated care that could be scaled up to a state or national level over time.
The Greens are in agreement with the government that change is needed to address the impending challenges facing the New South Wales health system. This change will require us to redefine our traditional conceptions and place effective models of integrated care at the centre of our future health system. The approaches I have outlined today I believe provide practical, evidence-based templates to help guide these important efforts.
Senate adjourned at 22:12