There is no doubt government officials are sometimes left in the unfortunate position of having to defend the indefensible.
Sometimes, that is the job.
That is certainly the case for Department of Health officials who have been left in the position of having to publicly defend the woefully unfair and discriminatory arrangements for people accessing PBS-listed treatment for opiate dependence.
Of course, officials have their own responsibility for the plight of these people, many of whom must feel close to abandoned once they choose to want to end an addiction that in many cases has been fully funded by the government through Medicare and the PBS.
Health minister Greg Hunt has delegated his powers over this program to officials. As a result, they must take significant responsibility for the failure to lawfully enforce the 'special arrangement' under which this one group of patients is denied the protections every other Australian takes for granted.
Under the Opiate Dependence Treatment Program (ODTP), the federal government pays the manufacturer for the medicine, but it does not fund the cost of wholesale distribution or pharmacy dispensing fees. It also removes patient protections in the form of PBS co-payments and the safety net. Patients are forced to pay uncapped and unregulated private dispensing fees for PBS-listed medicines.
At Friday's Senate Estimates hearing, officials appeared frustrated in their responses to questions about the ODTP.
At one stage, Department of Health deputy secretary Penny Shakespeare vigorously defended the situation by listing the other services provided to people recovering from drug dependence.
The argument went that the government spends almost $900 million on these services every year and that a comprehensive review is appropriate given the existing arrangements have been in place since 1974.
The existing arrangements have been in place since 1974 but they have significantly evolved. Having started as a program operating solely through state and territory hospitals and clinics, around three-quarters of treatment for opiate dependence is now dispensed through community pharmacy.
They have not evolved in a vacuum. This evolution has been significantly driven by the decisions of successive governments, specifically the reimbursement of new treatments. It is just that these successive governments have failed to contemplate the patient experience to the extent the program is not even lawfully enforced.
The government has known for several years that community pharmacy dominates dispensing of ODTP medicines and that patients have been struggling to access these treatments because of cost. The Pharmaceutical Benefits Advisory Committee publicly acknowledged this reality in an outcome almost three years ago.
"I understand the concerns, but we really need to look at making reforms to this program on the basis of a comprehensive review of how it should work," said Ms Shakespeare.
"Because making changes that have been suggested by some of the stakeholder groups do not take into account that opiate dependency medications are not just distributed to people through community pharmacies at the moment. There are other delivery mechanisms and we need to consider fully the implications before we move away from a commonwealth funded medicine state and territory delivered program to make sure that we do not end up with unintended consequences."
Would any other patient group be expected to accept this defence?
It is exactly the same as saying cancer diagnosis and treatment is based on a complex set of arrangements involving federal, state and territory governments, as well as private providers, so any concern over patients being denied the basic protection of PBS co-payments and safety-net needs to be set aside while the government takes two years to find a solution.
Cancer patients would not be expected to simply accept such a discriminatory arrangement. Would cancer advocacy groups accept being told to sit, wait and hope for a positive outcome and in the meantime face monthly uncapped and unregulated prescription charges of over $200 for their PBS-listed treatment? Of course, cancer patients face their own challenges, but they are not denied something every other Australian takes for granted and they would not be expected to simply accept it while the government takes two years to contemplate a solution.
In fairness to the officials, what other defence is possible given the apparent absence of a commitment for change? It was a buying time defence.
This entire situation is also the clearest evidence anyone needs of why advocacy is so important. The health system appears simply unresponsive in the absence of advocacy.
The ODTP arrangements have been in place for several decades. They have not even been legally enforced for many years, if at all, with the failure to lodge a legislative instrument.
It is hard not to draw the conclusion that the failure to properly administer this program, let alone make it work for patients, is related to the fact those impacted are amongst some of the most stigmatised and marginalised in Australia.
The deafening political silence of all but one senator might be the best indicator of this sad reality.
This group of patients has been given so little consideration over the years that when the issue was first raised at Senate Estimates, in October last year, Department of Health officials did not even know the details of the program they administer. Or, worse still, they did and pretended otherwise.
The recently announced post-market review is an inadequate response to these years of failure but does anyone really believe it would have happened in the absence of advocacy leading to scrutiny in the Senate?
Decision-making that reflects community expectation requires actual advocacy - not compromised government-funded 'consultation' and advocacy, but actual advocacy targeting elected politicians.
In the absence of advocacy and scrutiny, the current arrangements for people trying to recover from opiate dependence would have almost certainly continued unscrutinised, possibly even without a legislative instrument with all the related consequences for patients, including preventable deaths.
Governments and their officials often complain about stakeholders advocating for change. Sometimes they even vituperate groups in response to their advocacy. Yet surely the situation with the ODTP is evidence of why advocacy is so important because, in many cases, it is the only way to achieve change or at least the hope of change.
