INSIDE THE JAMISON INQUIRY A CASE STUDY IN AUSTRALIAN HEALTH POLICY

Craig Bennett (Policy and Projects Division), and Barbara Deed (Southern Sector Office), South Australian Health Commission, 5000

DECISION-MAKING

Caveat This paper presents the personal views of two

members of the research staff of the Commission of Inquiry in to the Efficiency and Ad- ministration of Hospitals. It does not necessarily reflect the views of any other staff membersof the Jamison Inquiry.

After more than twelve months’ intensive work, and a cost of one and a quarter million dollars, the results of the Jamison Inquiry were very disappointing. T h e published work of the Inquiry has been severely criticised,’ whilst, in the major areas i n which Commonwealth Government decisions have been announced - funding of publ ic hospitals and health insurance, the recommendations of the Jamison Report were largely ignored. Some of the reasons for this are undoubtedly specific to the context and processes of the Jamison Inquiry. But we also believe that they reflect important and un- resolved aspects of the health care policy debate in Australia today.

Context T h e Jamison Inquiry was announced after a

decade of upheaval in Australian health care policy. Throughout the seventies, there had been several health insurance schemes and a host of reports from Committees and Inquiries into various aspects of the provision and funding of health care services.2 In addition, a number of specific health policy issues had become important in the late seventies. For example, the agreements between the Commonwealth and the States of New South Wales, Victoria, Queensland and Western Australia ’ together with the Northern Territory, for the sharing of the agreed net operating costs of recognised hospitals, were due to expire on 30 June 1980.5 There was also great concern over the level of health spending in Australia and its increasing proportion of Gross Domestic Product (GDP).‘

Accounting procedures and financial man- agement techniques in hospitals had been severely criticised by the South Australian Public Accounts Committee., In New South Wales, substantial new hospital facilities were about to be opened! Finally, 1980 was a national election

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year, with health looming as a n increasingly controversial policy area.

These background factors influenced the Jamison Inquiry in three main ways. First, the deadlines set for both the Interim and Final Reports were extremely tight. T h e Interim Report was originally intended to be completed in time for it to be used as a basis for the Commonwealth’s re-negotiation of those cost- sharing agreements due to expire o n 30 June, 1980. When this proved impossible due to delays in reaching agreement o n theTerms of Reference and the composition of the Commission, these agreements were extended by a year to 30 June, 1981 and the date for presentation of the Interim Report was extended until 30 June 1980. When the original rationale for such a Report disappeared, there was no expectation of what it would deal with. Although several possibilities for the interim report were discussed as early as February 1980, n o firm decision was made about its format and content until early June. This resulted in much frustration and wasted effort. T h e Final Report, originally envisaged for mid- 1980, was required to be presented by the end of 1980, although the possibility of a n extension of time being required was flagged from a n early date.

Secondly, the Inquiry’s Terms of Reference were very broad. Although the Commission’s title referred to the effzciency and administration of hospitals, the Inquiry’s Terms of Reference covered most aspects of the funding, ad- ministration and provision of health care services, broadly defined. T h e breadth of these Terms of Reference reflected the extent of Government cortcern about health care a t both the Commonwealth and State level.’ Even the list of matters for particular attention by the Inquiry was imposing.

Thirdly, i n appointing as Commissioners people with no direct experience of health administration or health policy, the Com- monwealth Government was clearly indicating its desire for a fresh approach to issues that had bedevilled and Muddled Governments, whether Liberal or Labor, for more than a decade. By itself, the decision to appoint ‘outsiders’ todirect

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this national inquiry was of no great concern. A sufficient number of the research staff appointed to the Inquiry had health backgrounds to ensure that technical advice could be given and material prepared in accordance with the Commissioners’ direction. However, the appointment of these ‘outsiders’ as Commissioners also imposed upon them tremendous obligations - to tackle the task with enthusiasm, to learn willingly from what had happened in the past and to use fully the available resources to get the job done.

It was a daunting, yet exciting, prospect. There was widespread optimism that the first national inquiry in this area would tackle the problems and point the way to a comprehensive, efficient and effective health care system for Australia. This was certainly the feeling amongst the research staff when they gathered in Sydney in January 1980 and the Inquiry began its task in earnest.

Process The way in which the Jamison Inquiry went

about its task can best be described in terms of its major undertakings. In approximate chrono- logical order, these comprised the visits, analysis of the submissions, preparation for and conduct of the public hearings and compilation of the Interim and Final Reports.8 These are discussed in turn.

By the time most of the research staff had joined the Commission, two of the Com- missioners had already visited a number of country and city hospitals.9 Throughout January, February and March 1980, research staff accompanied the Commissioners on further visits, mainly to the major city hospitals in New South Wales. The two Commissioners attached considerable importance to these visits. They saw them as an opportunity topublicise theexistence of the Inquiry, to gain cooperation from people in the area and to learn about hospitals, the health care system and the issues of importance to the providers of care. Frequent references were made to the visits in the’public hearings, in Commission correspondence and in the Interim and Final Reports.

The submissions to the Inquiry, although of variable quality and relevance, were important inputs.10 First, they provided both the Com- missioners and the research staff with essential background reading. Secondly, they were used by the Commissioners to designate which organisations, institutions, health service representatives or individuals were to be called to the public hearings. Finally, they provided both hard data and direct quotes that were to be

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included in the material published by the Commission. They were therefore analysed in detail. At the behest of the Director of Research, the research staff prepared a pro-forma assessment sheet on each and every submission and later analysed them again according to a computer-based ‘keyword system’ structured around the Terms of Reference.”

One of the Commission’s most substantial undertakings was the preparation for and conduct of its public hearings. The Com- missioners had high expectations of the evidence and data that would become available from these public hearings and enormous effort went into them. From several weeks prior to the Commission’s first public hearing in mid-April to their completion in early July, much of the staff’s time was absorbed by this task.

Research staff prepared a brief for each hearing. A typical brief included background information on the organisation, institution or individual appearing, a summary of any relevant submission and a detailed set of questions to act as a suggested text for the Commissioners.lZ At the public hearings, however, the Com- missioners tended to ask questions to gather information rather than to develop hypotheses or follow u p issues or themes. The transcripts of these public hearings were later analysed in detail by the research staff. The ‘keyword system’ developed for the submissions was also used for this purpose.

After the public hearings had commenced, a team of only four was assigned to prepare the Interim Report. Not only did this represent less than one quarter of the Commission’s total research capacity, but the remainder of the research staff was specifically excluded from helping to prepare this Report. In comparison to the public hearings therefore, the Com- missioners gave the Interim Report a very low priority.

Several substantial draftsof the Interim Report summarising historical developments, current issues and the evidence gathered so far were produced, ‘only to be rejected by the Com- missioners as unsatisfactory. In early June, while the Commissioners were in Darwin for public hearings, matters came to a head and a directive was sent to the Director of Research in Sydney that the draft material was to be reorganised in order to focus upon Term of Reference 1 - that is, factors behind the costs and escalation ofcosts of hospitals and associated or related institutions and services. A reconstituted Interim Report Team was instructed to produce a framework within twenty-four hours and a complete first

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draft within a week. T h e Interim Report was eventually produced

on time. It relied heavily on information and views contained in submissions and data supplied by the Commonwealth Department of Health.13 Because i t came to n o firm conclusions about the causes of the cost increases it documented, the Interim Report made little public impact and left interested parties mystified as to the direction the Commission was taking. It prompted one observer to comment that:

‘the important issue is not thecontentof this preliminary, largely pro-forma Report, but the likely emphasis in the final version. It is difficult to believe that all of the Com- mission’s terms of reference can be accorded equal treatment, given the short time available to it. It is in the choice of matters for attention that the significance of its ultimate findings and recommendations will lie.’I4

T h e quest for a format for the Final Report can be divided into two distinct phases. T h e first phase lasted until the commencement of the public hearings in mid-April, while the second phase began when the public hearings had been completed in early July and lasted until the format was finalised by the Commissioners in early October.

T h e first phase involved a series of research staff meetings as well as meetings between the Commissioners and the research staff. An internal two-day workshop was held i n February, after which a number of frameworks for the Final Report were drafted.15 T h e Commissioners, however, made n o com- mitments to any of these draft proposals and this type of work lapsed as the public hearings drew closer.

After the completion of the public hearings, a structure was formalised which assumed that one of the matters for particular attention, namely existing and possible Commonwealth/State arrangements for meeting (the) operating costs of hospitals and associated or related services, would be central to the Inquiry’s final recom- mendations.‘6

T w o teams were formed - one concerned with the efficiency of the machinery for allocating resources and strategies for rost ronstraint (the macro issues) and the other with internal hospital efficiency and strategies for cost constraint (the micro issues). These two teams. compiising equal

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numbers of research staff, worked and reported separately.17 Various attempts were made to coordinate the work of these two teams and also to devise tasks which would involve outside groups or individuals. For example, attempts were made to set u p working parties on clinical management, ‘hotel-type’ activities, financial and administrative practices and information systems. An attempt was also made to draw the work of the two teams together by exploring the differences between financial control and service control.’8

By this stage, the Commissioners were preparing to go overseas or had already left. Upon their return, they reviewed the draft material prepared on the ‘macro’ and ‘micro’ themes and, after a meeting in early October, insisted that work on the Final Report be divided into four sections based on the Terms of Reference. Research staff were then allocated to write certain specific topic papers with the Commissioners themselves, in some cases, writing sections. Eventually, these topic papers comprised Volume 2: Supplement. At a later stage, summaries of each of these topic papers were prepared by the research staff and they were then incorporated into Volume I: Report by the Director of Research in conjunction with a seconded j o ~ r n a l i s t . ~ ~ Volume 3: Selected Studies contained three reports commissioned from external consultants and some further results from the Commission’s sample survey of recognised hospitals throughout Australia.20

During December, the Commissioners, assisted by the Secretary and the Director of Research, reviewed the material at their disposal and prepared their recommendations. Draft material was edited by the seconded journalist. Unless specifically asked to add to certain sections, the remaining staff of the Inquiry did not see the final version of the material until it became publicly available in early January 1981. In fact, all staff other than the Executive of the Inquiry were denied access to the draft material from early December onwards?’

The Disappointments After a great deal of effort, most of the research

staff of the Jamison Inquiry were disappointed at its outcome and somewhat bruised by the experience. The Jamison Report itself was widely critirised. Nevertheless, we believe that there are important lessons to be learnt from the Inquiry.

From the outset, there was very little sense of direction about the work of the Jamison Inquiry. Scant attention was paid to the work of various Commonwealth and State Government inquiries into aspects of the Australian hospital and health care system during the 1970’s. Little effort was

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made to understand the context and processes of these earlier inquiries and reports and why their recommendations either had or had not been implemented. In one major area, relating to the appropriate delineation of responsibilities between different levels of Government for the care of the aged in Australia, the work of earlier inquiries was virtually ignored.22 This attitude also extended to concurrent inquiries such as the Commonwealth Grants Commission’s Review of States’ Tax Sharing Entitlements, a review commenced in 1978. There was some preliminary contact between the research staff of the two Inquiries on the development of alternative funding mechanisms. However, such contact was seen as potentially dangerous and was specifically prohibited by the Commissioners.23 In addition, academic work in relevant arras was largely overlooked. Detailed analyses of the effects of different health insurance arrangements on hospital utilisation rates, for example, were not followed through.”

Without an overall perspective, the Com- mission could neither digest nor process purpose- fully the enormous amount of information that it accumulated. We believe that this failure had a large bearing on the outcome of the Inquiry. Yet this need not have been the case, since several conceptually sound strategies were put to the Commissioners from as early as February 1980. No commitment to any of them was ever made.

Instead of beinga formulator of hypotheses and an initiator of original studies, research and ideas, the Commission therefore became essentially reactive. The research staff undertook virtually no original research. There was no research methodology. We were involved in mainly administrative tasks, such as evaluating sub- missions, preparing public hearing briefs and rrading transcripts of the public hearings. Even attempts at compiling a coherent set of statistics for use within the Commission and in its published material lapsed. Similarly, attempts at defining roles and objectives in health services, interpreting terms such as ‘efficiency’ and ‘effectiveness’ and mastering techniques such as the deflation of expenditure petered out.

An example of the Commission’s lack of direction and foresight was its decision to undertake a national hospital survey. A stratified random survey of 65 recognised hospitals throughout Australia was conducted during April and May 1980. It was designed to collect basic information on hospital performance, staffing, receipts and payments for both 1968-69 and 1978- 79. It was a small and limited survey, undertaken to gauge the availability and comparability of hospital expenditure and performance data

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throughout Australia and the subsequent feasibility of a comprehensive national survey. Preliminary results from this survey were included in the Interim Report and although further analysis was contained in a short report in Volume 3: Selected Studies, little follow-up work was undertaken after May. We do not know why.

We therefore believe that the Inquiry was flawed from the outset - not so much by the tight deadlines or the all-encompassing Terms of Reference - but by the way in which the Commission went about its task. In addition, the Commission found it difficult to handle the views of the vested interest groups and, in particular, those of the medical profession. From our perspective, some recommendations seemed to have been formed independently of the analysis and supporting data, they were not always costed and little attention was given to their im- plementation.25 The published material of the Inquiry therefore contains a number of inherent contradictions and lacks an overall conviction that complex issues had been thoroughly analysed.26

Volume 2: Supplement even contains a statement that:

‘because of time constraint for the pre- sentation of the Report imposed in the Letters Patent, this Volume is not in a form asrefined as the Commission otherwise would have amnged. Detailed editing and normal proof reading have not been possible.”

On balance, however, we believe that this statement hides a multitude of sins. The Letters Patent had made specific allowance for an extension of time for presentation of the final report. We believe that an extension should have been requested after publication of the Interim Report in June.

The Positive Side Despite these disappointments, there were a

number of positive aspects to the work of the Jamison Inquiry. For example, the Inquiry made a significant contribution to the store of reference material available to those working in the areas of health services planning, administration and research as well as health economics. Even the most strident critics of the Jamison Inquiry have acknowledged its contribution in these The data on admission rates to both teaching and non- teaching hospitals contained in Volume 2: Supplement have been of particular value to policy-makers.29

A1 though the quality of the submissions varied, they were, in the main, very useful. In particular,

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the submissions from the Commonwealth Department of Health and the State health authorities became reference points for membersof the research staff. They dealt with some issues, such as resource allocation, in great detail. Submissions from hospitals, dealing with issues such as utilization review, disease costing and man- agement initiatives, also proved to be very valuable.50 In addition, the Interim Report has been commended for demonstrating factors of significant cost escalation in hospitals over recent years and pointing out that many of them were outside their control.)’ The Interim Report also provides a useful overview of the quantitative and institutional aspects of the Australian health system and the problems with which i t is confronted.

Since the Commonwealth Government’s announcement of the new arrangements for the funding of public hospital services and health insurance on 29 April 1981, it has been rather difficult to independently assess the rontent of the published material of the Jamison Inquiry.)* While it is not the intention of this paper to consider the relationship between the re- commendations of the Jamison Inquiry and the Commonwealth Government’s response, it must be remembered that only 30 of the Inquiry’s 140 recommendations dealt with the funding of public hospital services and health insurance arrange- m e n t s . O n e h u n d r e d a n d t e n o t h e r recommendations, a long with addi t ional supporting material in Volume 2: Supplement and Volume 3: Selected Studies, remain to be acted upon.53

The discussion contained in Volume I : Report on the delineation of Commonwealth and State Government responsibilities for the funding, administration and provision of hospital and health care services has been commended, if not implemented?‘ State health authorities have found many recommendations extremely useful in ini t ia t ing new directions i n policy a n d adminisuation?5 Moreover, several recommen- dations were aimed at ensuring that at the State level:

‘the functions of planning and policy (were) more closely coordinated with those of financial allocation and management.’s6

Notable examples of other recommendations in Volume I : Report which have opened u p discussion on important issues are those roncerned with the need to improve health data sources at both the national and State level (Recom- mendations 5 , 14 and 80). the need to review the

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Medical Benefits Schedule in the dual interests of c o s t c o n t a i n m e n t a n d p a t i e n t r a r e (Recommendation 31), rights to private prartice for full-time salaried doctors in public. hospitals (Rerommendations 109-11 1) and the aged and handicapped (Recommendations 127-140).

In summary, then, the Jamison Commission produced much valuable reference and source material, provided a stimulusfor publicdebateand formulated some useful and sensible recom- mendations. It must be stressed, howewr, that the Commission’s published material represents only part of all the material accumulated by i t during 1979-80. An enormous amount of invaluable research material is contained in the unpublished papers of the Jamison Inquiry?7 Conclusions

There were many aspects of working with the Jamison Inquiry which we found confusing and at times demoralising. Of particular concern were the absence of any initial or developed hypotheses which could have been tested by a n integrated research programme, the timing and resources devoted to the public hearings and the restricted opportunities for the research staff to make use of so many useful submissions.

From a personal viewpoint, we learnt a great deal about health care policy formulation in Australia from working with the Jamison Inquiry. For example, we came to recognise the importance of defining roles and objectives for the different levels of Government involved in the funding, administration and provision of hospital and health care services in this country. Secondly, we came to realise that it is important to define terms such as efficiency and effectivenessconsistently and have access to data that is relevant, timely, unambiguous and easily interpretable. Finally, we were made very aware of the power of the well- organised groups in the health field and, in particular, their predilection for the institutional mode of care and the key role played by the medical profession.

We have asked ourselves many times since 1980 whether or not the task set for the Jamison Inquiry could ever have been satisfactorily handled by such a body. In particular, should we haveexpected that complex issues in this area kould be resolved by a process that included a careful weighing u p of the evidence both for and against in the quasilegal setting of a public hearing? On balance, we believe that it was not so much the nature of the Commission but the way it went about its task that led to such an unsatisfactory outcome. Con- siderably more could have been achieved by the Jamison Inquiry under different circumstances.

The announcement of three major Com-

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monwealth Government inquiries into aspects of the Australian health care system within eighteen months of the completion of the Jamison Inquiry may seem to be a sad indictment of its work?’ Yet, does the Jamison Inquiry deserve to be completely dismissed? The value of any such Inquiry depends

not just on its immediate impact, but on the use to which it is put over the years for the purposes of criticism, argument and study. If the Jamison Inquiry gains new status in this regard, well and good, but we will be left to ponder at what might have been.

References

I . Four such critical reviews of the Jamison

0 The Report of the Commission of Inquiry i n f o the Efficiency and Administration of Hospitals, Volumes I - 3: A Review (Institute of Health Economics and Technology Assessment, Health Economics Monograph Series No. 2, Sydney, 1981);

0 S.J. Duckett and G.R. Palmer: ‘Jamisonitis: A Case of Inadequate Diagnosis, Faulty Prescription and Uncertain Prognosis’, New Doctor, No. 19, April 1981, pp. 10-14;

0 J. Goode: ‘The Road to Medibank Mark 1 0 Jamisonitis Revisited’, New Doctor, No. 20, June 1981, pp. 10-12; and

0 R. Harvey: ‘Unstated Assumptions, Partial Analysis and Unconscious Irony: T h e Jamison Report’, Communi fy Health Studies, Volume V No. 2, June

Inquiry are:

1981, pp. 165-71. 2. For example:

0 Report of the Committee of Enquiry into Health Services in South Australia (Chairman: The Hon Mr Justice C.H. Bright, 1973);

0 A Report on Hospitals in Australia (Hospitals and Health Services Com- mission, 1974);

0 Report of the Committee oflnquiry into Hospital and Health Services in Victoria (Chairman: Sir C. Syme, 1975);

0 Proposals for a Change in the Ad- ministration and Delivery of Programs (1977) and Consultative Arrangements and the Coordination of Social Policy Deuelopment (1978): Reports from the Task Force on Coordination in Welfare and Health (Chairman: Mr P. Bailey);

0 A Discussion Paper on Payingfor Health Care (Hospitals and Health Services Commission. 1978);

0 Report of the Committee on Ap- plications and Costs of Modern T e c h n o l o g y i n Medical Practice

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(Chairman: Dr S. Sax, 1978); o Through a Glass, Darkly: Evaluation in

Australian Health and Welfare Seruices (Report from the Senate Standing Committee on Social Welfare, Chair- man: Senator P. Baume, Vols. I and 11, 1979);

0 Reports from the Committee of Officials on Medical Manpower Supply (First Report, 1979 and Second Report, 1980); and

0 Report on Rationalisation of Hospital Facilities and Services and on Proposed New Charges - A Discussion Paper (Dr S. Sax, Mr M. Carroll, Mr B. Hennessey, et al, 1979).

3. The agreements between the Commonwealth and the States of South Australia and Tasmania were not due toexpire until 30 June 1985.

4. In 1978-79, health expenditure in Australia was 7.9 per cent of GDP, having been only 5.4 per cent in 1968-69. By comparison, health expenditure in the United Kingdom was only 5.5 per rent of Gross National Product (GNP) in 1975.

5. Fourteenth Report from the Public Accounts C o m m i t t e e re ferr ing t o F i n a n c i a l Management of the Hospitals Department (Chairman: M r C.J. Wells, Adelaide, 1979).

6. For example, 450 new beds were about to be opened at the Westmead Centre in the western metropolitan area of Sydney. This was to necessitate a rationalisation of hospital services in New South Wales because at the same time that i t announced the Jamison Inquiry, the Commonwealth Government announced that its contribution to the operating costs of public hospitals for the 1979-80 financial year would be held at its 1978-79 level.

7. A manifestation of this concern was the issuing of Letters Patent by the Tasmanian, Queensland and Western Australian Gov- ernments over and above the Letters Patent issued by the Commonwealth Government.

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The Inquiry was therefore required to submit its Reports to three State Governments as well as to the Com-monwealth Government.

8. Other significant tasks included the pre- paration of some forty topic papers (January- February), the Commission’s sample survey of recognised hospitals throughout Australia (April-May) and the seminars held on health insurance and funding of public hospital services (October - November).

9. The research staff who joined the Inquiry in Sydney in January 1980, saw little of Mr Holmes ‘a Court.

10. The submissions varied in size from less than one page to more than 700 pages.

11. This ‘keyword system’ was adapted from the one used by the research staff of the Committee of Inqurry into the Australian Financial System (Chairman: Mr J.K. Campbell). It was not, however, used much in the preparation of the Final Report.

12. Not all those called to a public hearing had prepared a submission to the Jamison Inquiry. Moreover, key Commonwealth De- partments such as those of Treasury, Social Security and Finance neither submitted to the Jamison Inquiry nor were called to give evidence at one of the public hearings.

13. The data supplied by the Commonwealth Department of Health was published at the same time as the Interim Report in a publication entitled: Australian Health Expenditure 1974-75 to 1977-78: An Analysis.

14. J.S. Deeble: ‘A Review of the Interim Report of the Commission of Inquiry into the Efficiency and Administration of Hospitals’, Community Health Studies, Vol. IV No. 3, 1980, p. 244.

15. The frameworks proposed at this stage included ones based on:

relating the analysis, conclusions and recommendations of the Final Report to the goals of the health care system and those of the Inquiry - e.g. to improve efficiency, to allocate resources effectively and to constrain costs;

0 dividing the Final Report into three sections - viz. finance, administration and efficiency; and

0 dividing the Final Report into six sections - viz. the policy framework, costs, rational information systems, rational service provision, rational resource allocation and real cost constraint.

16. This proposal resulted from a staff

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meeting held on 1 July to discuss the Final Report and the setting u p of a research programme.

17. The Commissioners were also involved in this ‘team approach’.

18. A proposal to analyse the extent to which health care could be considered different to privately produced g d s and services was also formulated. It was thought that such an approach might highlight the scope for cost control as well as an appropriate role for Government involvement in the provision of health care services.

19. The journalist was Mr R.J. Curtis, seconded from the Australian Infor- mation Service.

20. These three reports - viz.: Productivity in Hospitals (Cruickshank Management Resources Pty Ltd), Accounting, Re- porting and Budgeting (C.H.S. Con- sulting Pty Ltdand Price Waterhouse Pty Ltd) and Issues of Public and Private in the Health Domain (C.H.S. Consulting Pty Ltd) were not commissioned until October and were, by and large, prepared without any input from the research staff.

21. The Executive of the Jamison Inquiry comprised the three Commissioners, the Secretary and the Director of Research. The original Secretary resigned in April and was not replaced for several weeks.

22. For example: 0 Care of the Aged (Social Welfare

Commission, 1975); 0 Report of the Committee on Care of the

Aged and the Infirm (Chairman: Mr AS. Holmes. 1977); Report of the Working Party to the C o m m i t t e e o n A c c o m m o d a t i o n , D o m i c i l i a r y Care and M e d i c a l Rehabilitation for the Elderly (South Aus t ra l ian H e a l t h C o m m i s s i o n , Chairman: Mr J. Joel, 1978); and Relative Costs of Home Care and Nursing Home and Hospital Care in Australia (Commonwealth Department of Health, Monograph Series No. 10, A. Doobov, 1979).

23. Report on State Tax Sharing Entitlements 1981 (Commonwealth Grants Commission, Chairman: T h e Hon Mr Justice R. Else- Mitchell, CMG, Volumes 1-11]). The Grants Commission produced a second report in 1982 entitled: Report on State Tax Sharing and Health Grants 1982 (Volumes I and 11).

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24. The Commission also failed to comprehend the extent to which health insurance arrangements in Australia had changed over the past thirty years. The Report of the Commonwealth Committee of Enquiry into Health Insurance (Chairman: Mr Justice J.A. Nimmo, 1969) and The Report from the Senate Select Committee on Medical and Hospital Costs (Chairman: Dame I. Wedgwood, 1970) were, for example, not studied in any great detail.

25. Moreover, the recommendations in Volume I: Report do not all correspond to those in Volume 11: Supplement and vice-versa.

26. For example, the Commission’s attitude to health ‘insurance was very confusing. Universality was promoted at thesame timeas was a voluntary scheme. Recommendations aimed at increasing the number of people with health insurance would probably have resulted in an increase in utilisation and thus in the mst of providing the services. There was also a marked discrepancy between the treatment of expenditure deflation in the Interim Report and in Chapter Iof VolumeII: Supplement.

27. Volume 11: Supplement pp. (iv) and 646. 28. For example, see Institute of Health

Economics and Technology Assessment: op. cit. pp. 8 and 18-20 and S. J. Duckett and G.R. Palmer: op. cit. p. 14.

29. The 1970-79 hospital utilisation and cost statistics listed in Appendix 2A of Volume 11: Supplement have since been separately published by P.R. Schapper: Measurement and Analysis of Australian Hospi tal Expenditure 1970-71 - 1978-79 (Unit of Clinical Epidemiology, Department of Medicine, University of Western Australia, 1980).

30. We found the submissions from the Queen Victoria Medical Centre (Melbourne) and the Royal North Shore Hospital (Sydney) particularly useful on these matters.

31. See E. Pickering in: What Next for Health Care in Australia? Proceedings of a National Conference on the Jamison Report (WEA,

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Adelaide, 1981) pp. 82-3 and H. Lapsley: ‘Hospital Efficiency’, Australian Health Rmiew, Vol. 4 No. 3, September 1981, pp. 3-5.

32. The new health insurance and funding arrangements came into operation on 1 September 1981.

33. In his statement to the House of Representatives on 29 April 1981, the then Commonwealth Minister for Health, the Hon M.J.R. MacKellar, said that some of the Jamison Report’s recommendations wen? still to be considered by the Commonwealth, some were still to be considered by the States and some required further Commonwealth-State negotiations.

34. See Institute of Health Economics and Technology Assessment: op. cit. pp. 8 and 23- 4.

35. Recommendation 78 in Volume I: Report that: ‘the States move as a matter of urgency toward the implementation of output related methods of budgeting’, has been pursued in South Australia, New South Wales and Victoria. Recommendations 37 - 49 deal with the public sector in general.

36. Volume 11: Supplement p. 124. 37. The unpublished papers of the Jamison

Inquiry are held by the Department of Administrative Services in Canberra.

38. These three inquiries are: 0 In a Home OW at Home: Accommodation

and Home Care for the Aged (Report from a Sub-Committee of the House of Representatives Standing Committee on Expenditure, Chairman: Mr L.B. McLeay, October 1982);

0 Joint Parliamentary Committee of Public Accounts Inquiry into Payments under the Commonwealth Medical Benefits Schedule - Medical Fraud and Oversemicing (Chairman: Mr D.M. Connolly, Progress Report published in December 1982); and Senate Select Committee on Private H o s p i t a l s and N u r s i n g H o m e s (Chai rman: Senator S. Walters, established November 1981).

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