GP ratios worsen for the suburbs

This an Australian story, for anyone who clicked a link thinking it was their country.

The Sydney Morning Herald is reporting that GP-to-patient ratios are worse in several suburbs than in rural areas (where, conventional wisdom has accepted long ago, such ratios are fairly shit).

…doctor-patient ratios are worse in many Sydney suburbs than in country towns. GPs are searching for up to two years to recruit a doctor to help in their practices.

Fifteen of the state’s 20 urban divisions of general practice have a higher patient-to-doctor ratio than the existing Federal Government benchmark of one GP for every 1100 patients, though the Government said it did not set targets.

The worst regions are the Central Coast and Hawkesbury-Hills districts, which have one doctor for every 1800 patients (this rises to one in 5000 in some parts of the coast); the Blue Mountains (1:1700); and Sydney’s south-west (1:1600).

…

GPs in metropolitan Sydney are also feeling the strain as doctors age faster than graduates can replace them. Liverpool’s ratio is 1:1200, Macarthur’s 1:1478, and Manly Warringah 1:1154.

The more affluent divisions of Eastern and Northern Sydney are faring better, with GP patient ratios of 1:763 and 1:400 respectively. Central Sydney division, which covers the inner west and parts of South Sydney local government area, is closer to targets, with one doctor for every 1093 people. But traditional general practice hubs such as the North Shore, inner west and eastern suburbs are having difficulty finding GPs.

…

In the Hunter Urban division, one GP services up to 4000 people in some areas such as the southern end of Lake Macquarie, where many GPs have closed their books and patients have to seek basic health services out of the area.

If the problem is systemic (ageing physicians not being replaced) then yes, there is indeed a problem. By contrast the UK, where ratios vary widely, the worst was one GP per 3,428 people. Sucks to live there. Our rural ratios do not reach that, although I believe they do push 3,000 in some areas. I suspect that last statistic is anomalous. Although it could well be that the southern end of Lake Macquarie is dead boring – one of the reasons why rural areas cannot recruit doctors.

The point is probably moot. Come winter, anything over 1,000 is going to cause some real trouble. What a shame we treated our last brown-skinned doctor the way we did – whoops.

Solutions? Few enough. Outside of monstrous expenditure on fading towns, to attract physicians (and, hell, other professionals), there isn’t much. Altering fee structures won’t work – increasing fees will not push the burden to the emergency ward, and not, ultimately, reward GPs. A British-style system, where GPs are funded according to the number of registered patients on their books, might not be a bad idea, if the GP is going to work purely publicly.

Here’s a solution. Australia’s immigrant cluster in one or two fairly dense urban areas – a product of bugger-all done by state or federal governments to help immigrants push further out to take advantage of more opportunities outside the immediate confines of their language skills. Not to promote self-segregation, but people from those cultures have doctors, too – who just might head out to expanding multicultural communities as well, along with their kids – re-establishing communities, community groups, community economies, schools, etc.

Right now Australia is in a fairly vicious cycle of oceanfront urbanisation, heading to the fringes of the continent and looking ever-outward – to what, one wonders. I’ve said for a long time that a lot of Australian communities face slow deaths from pushing too far into too dry a continent, but slow deaths starting much further away from now, surely (hopefully? If not, the whole problem is probably moot, now).

The problem is likely, therefore, two-fold: not enough doctors (or not enough practising as GPs), and not enough in certain areas. For the former, I’m not sure what else can be done – GPs make a fair amount of money (ABS statistics of a few years ago have practices running operating profit margins of 25% or so), but less than specialists (those same statistics: an average of AUD100,000 for GPs, as opposed to AUD180,000 for specialists) although you’d never convince them of that.

A change in funding – possibly something like an NHS list, possibly something else – might help. It’d also cost the taxpayers a bundle, though, and we might not be too disposed towards the idea. A change in funding to increase the fees GPs could charge would never work – GPs are scarce in exactly the areas where people cannot afford gap fees (a difference between what the doctor charges you for something, and how much the government will contribute. The whole point of public health in our Medicare system is that there is not a gap).

For the latter, the problem is not how to move GPs to certain areas, but how you can move many elements of a community to areas that used to have them, making them communities again. Not something for which Australia’s governments – at any level – will ever be famous. Something will have to be done – Howard has already, apparently, lost his battle for the battlers.

Americans, here is a lesson to learn from us or the Brits: when you fund health care from general taxation, it becomes political fodder for a sitting government. Equity, levels of service, etc. If you’re a taxpayer, you get the right to expect health care (including GPs). And you get the right to dump the government that can’t give it to you.

Two years mild, then: hot

So say the folks at the British Meteorological Office’s Hadley Centre in Exeter:

Using powerful computer models, scientists at the British meteorological service’s Hadley Center predict that at least half of the years after 2009 will exceed temperatures during 1998, the warmest year currently on record.

The year 2014 is likely to be 0.3° Celsius (.5° Fahrenheit) warmer than 2004, the Met Office scientists predict.

This forecast means that while it has taken a century for the global temperature to rise 0.8°C (1.44°F) it will take only 10 years for the planet to heat up half again as much.

The paper is in today’s Science (Improved Surface Temperature Prediction for the Coming Decade from a Global Climate Model).

When I wrote about this yesterday (climate change), apropos a story in Newsweek, a commentor who I’m sure was doing the WordPress rounds mentioned recent corrections to past estimates – using American data, which I criticised in turn, in my response. I believe the historical high temperature – globally – may still be 1998. It really doesn’t matter – arguing over when a historical high may have occurred is more than a bit of a furphy, these days. But whatever the sweaty optimists think will help their non-cause is fine, I guess.

The authors’ abstract:

Previous climate model projections of climate change accounted for external forcing from natural and anthropogenic sources but did not attempt to predict internally generated natural variability. We present a new modeling system that predicts both internal variability and externally forced changes and hence forecasts surface temperature with substantially improved skill throughout a decade, both globally and in many regions.

Our system predicts that internal variability will partially offset the anthropogenic global warming signal for the next few years. However, climate will continue to warm, with at least half of the years after 2009 predicted to exceed the warmest year currently on record.

The “at least half” comes from a year-on-year probability of around-to-over 50% that any given year will be a record breaker, relative to the – global – record from 1998.

They also used a word – “hindcast” – that I’d not, previously, seen. What a great word. Their model, through a combination of shorter-lead forecasts (less room for error) and better modelling/initial conditions, seems to map historical trends (out-of-sample) very accurately. Making their immediate forecasts for the next few years fairly reliable. The error on their hindcasts was within a degree or so, Centigrade.

Remember, surface temperatures refers to Oceans, not some uniform increase for the globe (I feel obliged, now, to add that caveat. You know, just in case).

From the paper, itself (subscription required, non-academics. Unless you know an academic, who can email you a copy…):

It is very likely that the climate will warm over the coming century in response to changes in radiative forcing arising from anthropogenic emissions of greenhouse gases and aerosols (1). There is, however, particular interest in the coming decade, which represents a key planning horizon for infrastructure upgrades, insurance, energy policy, and business development.

On this time scale, climate could be dominated by internal variability (2) arising from unforced natural changes in the climate system such as El Niño, fluctuations in the thermohaline circulation, and anomalies of ocean heat content. This could lead to short-term changes, especially regionally, that are quite different from the mean warming (3–5) expected over the next century in response to anthropogenic forcing. Idealized studies (6–12) show that some aspects of internal variability could be predictable several years in advance, but actual predictive skill assessed against real observations has not previously been reported beyond a few seasons (13).

Global climate models have been used to make predictions of climate change on decadal (14, 15) or longer time scales (4, 5, 16), but these only accounted for projections of external forcing, neglecting initial condition information needed to predict internal variability. We examined the potential skill of decadal predictions using the newly developed Decadal Climate Prediction System (DePreSys), based on the Hadley Centre Coupled Model, version 3 (HadCM3) (17), a dynamical global climate model (GCM). DePreSys (18) takes into account the observed state of the atmosphere and ocean in order to predict internal variability, together with plausible changes in anthropogenic sources of greenhouse gases and aerosol concentrations (19) and projected changes in solar irradiance and volcanic aerosol (20).

Those numbers, for the non-Academics, are references that I did not remove – that’s 20 references in what was originally a single paragraph. Bloody scientist show-offs.

The Henry stopped there

The Daily Show has added another…white guy (I suspect it is deliberate, now). Senior historial perspectivist (and sometime actor, writer, comedian, etc.) Buck Henry:

To be honest, that last piece with Murdoch and the underwear slightly ruined an otherwise very clever segment. The idea that Murdoch could make the Wall Street Journal lean right is laughable. They could probably teaching him a thing or two.

HowTo: Dirty floats

I figured I’d write this one, since I talk about it so often, albeit in passing. A ‘dirty’ float is a managed float. Why it’s called dirty I don’t know, but I’ll bet some free-market monetarists were behind it.

In principle, most developed OECD countries have floating exchange rates – the value of your currency fluctuates freely, and according to various factors such as interest rates, economic activity, export activity, etc. In the case of the US dollar we can add to that the demand for greenbacks as operating cash by small governments, NGOs, multinationals, etc.

Typically, we allow our currencies to float freely between certain bounds – our dollar can swim, but only between the flags (that might only work with Australians, actually). China, for example, had a – very unpopular – fixed exchange rate up until fairly recently. Even now, the degree to which is manages its currency is still unpopular.

The key to managed floats is that, with a floating dollar, one’s domestic economy is exposed. In Australia, for example, our currency:

Did fairly well, up until around a month ago when speculation died down and/or the speculators took their profits. I used a longer time trend in my previous post – it was much more impressive. The pressure has died off a bit, now that we have had the interest rate increase.

Now then, what happens if the Australian dollar gets too high? Australian exporters take a big hit, because our prices become too expensive on the world market. Our macroeconomy slows down some as those declining export incomes kick in. Meanwhile, if speculation is the cause of the appreciating currency, there can be a liquidity problem, because foreign companies are borrowing up all of our money, rather than domestic firms and households. If they drive interest rates up, that too slows down our macroeconomy via consumption and investment. Our Current Account Deficit also deteriorates.

So the Reserve Bank of Australia steps in to manage our floating currency. Specifically it will sell off reserves of Australian dollars, lowering their value on the ForEx market.

If, on the other hand, the Australian dollar were to depreciate too far (as per the Asian currency crisis), we have trouble attracting foreign capital because the return on those loans are too low. Our Current Account Deficit benefits but our debt becomes much worse (if it is in, say, US dollars, which is often the case). In this case the Reserve Bank enters the ForEx market and buys up Australian dollars, so that its value appreciates.

The key to a managed float is market invervention (as opposed to interference) designed to prevent external pressure getting through to a domestic economy. As a rule, this ‘getting through’ is considered bad when the domestic economy would be thrown out of whack. In the case of China, for example, their economy was already out of whack – prospering from a low Renminbi, which is being kept low to keep exports selling. Managed floats that are designed to sustain non-equilibrium conditions for a domestic economy relative to the rest of the world are the ‘dirty’ kind. Given the level of international trade these days, almost all domestic economies are exposed to currency fluctuations (the other big factor in the AUD appreciating has been the commodities boom, driving up legitimate demand for our currency, in order to buy our commodities). As a result most floats are managed.

This, finally, is where my comments about US borrowing come in. With a level of debt equal to USD29,551.77 per citizen, and a Congress continually raising the debt cap (feeling fat? Let your belt out!), more and more money needs to come into the country as lending. For the US a depreciating dollar helps their debt, kind of, but they have to pay it off with predominantly US dollars anyway, so. Along the way, a depreciating dollar makes getting loans more difficult (except from China, who can extend lines of credit to the US all day long, if they’re buying their plastic crap. Same with Saudi Arabia and their oil), necessitating interest rate increases to attract capital. However, at the moment, those interest rates are under a hell of a lot of fire from financial and housing markets.

It can become a mess very rapidly. In a managed float, the Federal Reserve’s incentive is to go and buy up US dollars to shore up their value. The trouble with that is the downward pressure is fairly strong these days, and a central bank cannot manage a float forever (usually – even China’s will be unsustainable, eventually). If China really does go through with diversifying it’s portfolio, that pressure will certainly increase.

Basically there’s only so much tide a central bank can hold back. Immediate crises? Fixable. Long-term pressure? Not so fixable, but softenable, at least. Hence my comment on the previous post, that we’re seeing aggressive central bank activity, but not float-managing. Principally, this is because currencies are not the vector for this contagion – international trading of frankendebt CDOs among companies is. If it carries across to currency, these banks will need some more fancy moves, but for now they just have the much more difficult task of trying to manage liquidity drying up because everyone’s selling debt that nobody wants.

An age of dirty floats?

Not yet, at least. But Central banks are getting aggressive, it seems.

Aug. 10 (Bloomberg) – The Federal Reserve joined the European Central Bank and policy makers in Asia to add temporary cash to the banking system, aiming to stem a collapse in credit markets as lenders try to protect themselves against losses.

The Fed said in Washington it is providing reserves to “facilitate the orderly functioning” of markets, in a statement unprecedented since the aftermath of the Sept. 11, 2001, terrorist attacks. The European Central Bank loaned 61.05 billion euros ($83.6 billion), keeping most of yesterday’s record injection of funds in the system.

…

The BOJ added 1 trillion yen ($8.5 billion) today and the Reserve Bank of Australia lent $4.2 billion, the most in more than three years. The Fed added $24 billion in temporary reserves yesterday, the most since April. Central banks in Canada, Norway and Switzerland also injected money into the financial system and countries including Denmark, Indonesia and South Korea said they’re ready to provide cash.

To some extent I agree with this: market stability is a key priority for central banks. However, a lot of the instability we mere mortals have been seeing is in the reporters, not the markets. Even Jim Cramer’s meltdown (the man does indeed have balls for going on Colbert’s show. I’m impressed) follows the loss, not the volatility. Stock exchanges seem to have fairly consistent – with some rallies, they’ve been going down. The job of central banks is not to make the stock market a one-way street. Stocks go both ways, and sometimes traders and shareholders take a bath. That’s just the way it goes.

This strikes me more as central banks trying to force a bottom into the fall. We’ve been hearing time and time again that the sub-prime problem is contained, that it will not affect other markets, that housing has already recovered, etc. The promised bottom, the promised containment, just hasn’t been there, and attempts to talk the market out of their doldrums have had no more success than any reasonable person should have expected.

Can the Fed save your house?

Even, returning to Cramer, to the extent that the real victims of this are people sold mortgages that they couldn’t afford. Central banks can’t fix that. Getting interest rates that far down will (a) mess with the exchange rate, and debt financing, and (b) really only perpetuate the bubble, by letting households refinance their way out of the problem on the backs of appreciating house values (if the policy were to work). Which is to say, postpone the problem. The current infusion of liquidity is also (or should be) too short-term (the ECB’s loans were for a day, but the US Fed’s might be more generous).

Here’s one: you’re up to your neck in credit cards and credit card debt, and just about out of options. Will giving you a new line of credit solve the problem? If the new line of credit is at least as great as your debt, just maybe. Otherwise, I should be surprised – it will really only be the equivalent of a payday loan. Those wolves know where you live. The problems have been systemic: terrible treatment of debt by companies and brokers that should bloody-well have known better (and did know better, but saw a monster pay-off. I just read about those Bear Stearns fellows). The problem wasn’t liquidity or a credit-crunch: that has been the result.

I don’t see how giving brokers, etc. more to play with is going to help. What I see is giving them just enough room to maneouvre themselves out of their trouble – you and your neighbour and your cousin are still going to be neck-deep in yours.

Paul Krugman has written a brief explanation, of this and why monetary tools are fairly limited in what they can do about it. I get the impression that the US Fed is trying to flush liquidity into the market on more of an ongoing basis than the ECB.

It’s sure going to make teaching macroeoconomic policy interesting, this semester…