AMA President Dr Steve Hambleton National Press Club Address 17 July
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SPEECH TO THE NATIONAL PRESS CLUB
WEDNESDAY 17 JULY 2013
AMA PRESIDENT DR STEVE HAMBLETON
***Check Against Delivery
Health Reform – Back To The Future
I acknowledge the traditional owners of the land on which we meet today, and pay my respects to their elders, both past and present.
Thank you to the National Press Club for giving me the opportunity to talk about health today.
I want to send a message to our politicians that Australians care about their health and their health system. They will be looking for well-reasoned policy and planning in the lead-up to the election.
I remind you that it is AMA Family Doctor Week this week – an event that the AMA has been running for more than 20 years.
It is a week when we pay tribute to the important work – often taken for granted – that is carried out by doctors in local communities around Australia every day.
The Family Doctor Week theme is Your Family Doctor – Your Medical Home. It is an important theme in the current primary care environment, and I will talk more about that soon.
These are very interesting times in Australian politics. In a way, we are heading back to the future.
We have seen many changes. We have a new Prime Minister who is also a former Prime Minister. We have new Ministers, and we have seen the resignations of a host of senior politicians. And there are incredible fluctuations in the opinion polls.
In health, we have seen many changes, too. Some good, some not so good, and some just plain dumb. Maybe in the current environment we too will have a chance to go back to the future to make sure the next changes in health take us somewhere meaningful.
Let’s set the flux capacitor to just after the election in 2007, rather than 1955, and see how this ‘future’ came about. Kevin Rudd came to power in 2007 thanks in part to a bold platform for health reform.
He promised to meet ‘the long term challenges in our system: duplication, overlap, cost shift, blame shift, ageing population, the explosion in chronic diseases, not to mention long term workforce planning.’
He established the National Health and Hospitals Reform Commission and, with then Health Minister Nicola Roxon, travelled the country consulting widely on his reform ideas.
The AMA shared Mr Rudd’s enthusiasm for much-needed health reform, and we supported much of what he wanted to achieve.
Unfortunately, Mr Rudd’s ‘big picture’ health reform vision looks more like a passport photo today – largely due to a shaky relationship with some of the States and the challenges of minority government.
Nevertheless, there are fragments of the Rudd reforms that survived in full or in part.
There is a changed public hospital funding arrangement. There is a greater focus on prevention, safety and quality and reporting. We have seen an expansion in GP and specialist training positions, and there is more funding for Indigenous health.
But the blame game that Prime Minister Rudd set out to destroy in 2007 is very much alive in 2013.
Did we get health reform or did we just get change? I think we got a bit of both.
Before I expand on that, let’s reset the flux capacitor to 2003. Opposition Leader Tony Abbott was Health Minister and served in that role till the 2007 election. He was also responsible for significant change.
The Coalition was not a natural supporter of Medicare, but Tony Abbott knew that the Australian people loved Medicare. He knew that Labor was usually considered the best party to run the health system.
He set out to turn that view around. He increased the general practice Medicare rebates to 100 per cent of the scheduled fee in response to declining bulk billing rates.
He routinely called the Howard Government ‘the best friend that Medicare ever had’.
He presided over the introduction of graphic health warnings on cigarette packets, against the wishes of Big Tobacco. He also put in place measures to dramatically increase medical student numbers – a trend continued by the current Government.
The community is now seeing the benefits of this, with 1287 graduates in 2004 - and this figure will rise to 3970 in 2016.
To the medical profession, though, he is perhaps best remembered for delivering a solution to the medical indemnity crisis. That was a genuine crisis that threatened to force many doctors out of the system – or out of high-risk specialties at the very least.
Once again, we saw some necessary change with definite elements of needed reform.
So we can see that both the men who would be Prime Minister after the next election – whenever that may be – have a strong past in health policy. The AMA would like to see that past dedication reflected in their future actions and promises over the next few months ahead of the election.
We would like to see the next Prime Minister be a champion for the health system. We need to see more health champions in politics.
I pay tribute to the commitment of Health Minister, Tanya Plibersek, and Nicola Roxon before her, and Shadow Minister, Peter Dutton. They have all given the AMA a fair hearing. They have not always agreed with us – on both sides of politics – but they have remained engaged with us.
I note also the strong contribution to the health debate from Dr Richard Di Natale from The Australian Greens. Dr Di Natale has been an active and informed voice in the Parliament, especially on public and environmental health.
The Australian health system
So, what is the real state of the Australian health system at the moment? How is it coping with demand? How does it compare internationally?
I have been fortunate over the past year to meet with leading doctors from all over the world in Thailand, China, Canada, the United States, and the United Kingdom. I have been given first hand accounts of what works and what doesn’t work in these very different systems.
Some – like the US – are attempting major reforms. Some – like the UK – are seeing their outdated system struggling under growing demand for services.
There are many similarities to what we are experiencing here in attempting to meet the needs of an ageing population with chronic and complex health needs.
If we want to drive real health reform, we must first define the problem.
It has been said that our health system is perfectly designed to get the results that it gets. The problem is, it was designed for a different set of problems. It is currently focused on acute care needs - with the ability to rapidly escalate to secondary and tertiary services.
We do this very well. If you are going to get seriously unwell, Australia is a great place to do it. You will get world-class care.
Australians are far more likely to survive a heart attack today than they were a decade ago. In fact, the mortality rate from a heart attack has fallen 39 per cent since the turn of the century.
Heart attacks claimed 9,811 lives nationally in 2011 - down from 14,443 in 2001.
As a result, more Australians are now living with coronary heart disease and the disability that follows an attack.
Real health reform must be about recognising the changing needs of our society and redesigning the system to meet the new challenges.
Let’s not wait for the heart attack and the ambulance. Let’s not rely on the emergency department, the catheter lab with the latest stent, the coronary care unit, and the cardiac rehabilitation. Let’s fix the lifestyle and prevent the heart attack instead.
We need to see that seismic shift.
The National Health and Hospitals Reform Commission observed the following things:
· “Australia has a rapidly ageing population with changing disease patterns.”
· “We have a health system skewed to managing sickness rather than encouraging wellness.”
· “There is no nationally coordinated mechanism to deliver prevention and health promotion services on the scale required to impact significantly on the cost of chronic disease.”
· “We have a fragmented health system with a complex division of funding responsibilities and performance accountabilities between different levels of government.”
The Commission’s observations mirrored international thinking. The recurring theme internationally is the need to bolster primary health care.
As we know, hospital care is very expensive. Our current focus of getting people in and out of hospital fast is just not good enough.
It is far preferable to keep them from ever getting there with health maintenance and prevention programs. There is a bigger bang for the health buck in primary care.
General practice is the cornerstone of primary care. It is high quality, comprehensive, and value for money. And this is very much the case here in Australia. That is why our Family Doctor Week theme is Your Family Doctor – Your Medical Home.
Let’s look at total health spend. Against most measures in the OECD Health Data 2013 report, Australia sits close to the average - but are we spending it in the right place?
We are in 21st place on health spending as a percentage of GDP at 8.9 per cent. That is, 20 countries spend more than we do.
Our New Zealand colleagues are sitting in 10th place with 10.3 per cent. The United States, of course, is way out in front of the pack at 17.7 per cent. Canada is at 11.2 percent.
The UK is at 9.4 per cent. That’s right, the UK spends more than Australia. That will surprise many of you.
But percentage of GDP is not the whole story. The OECD reports Australian Government expenditure on health as a percentage of total health spending at 67.8 per cent.
As you might expect, this is about half way between the United States with 47.8 percent and the UK with 82.8 per cent.
The patient share of health as a percentage of health spending is 19.3 per cent in Australia and is growing, compared to 9.9 in the UK and 11.6 in the US. So, we must closely monitor the risk to access to care.
When we look more closely in Australia, our out-of-pocket costs are 6th highest – but the AIHW data shows that the highest spend is on discretionary products at the chemist. This might change.
We also know that expenditure growth is flatlining with government revenues down, which the OECD attributes to the financial crisis.
If we want our health system outcomes to stay above average, we need to spend smarter.
As I said, internationally our health problems are strikingly similar – namely ageing populations and increasing non-communicable diseases. There is a tsunami of sickness on its way – but, with the right treatment, it will recede.
Also, like the rest of the developed world, Australia has worrying levels of obesity and cancer incidence rates. Internationally, we are rating pretty well on treatment and mortality.
So, our current system is doing a great job - but we know it is under pressure. We cannot be complacent. Further health reform is still needed. Doing nothing is not an option.
Again, I turn to the observations of the NHHRC, which stated:
· “There is an urgent need to resolve existing pressures, service gaps, safety concerns, inefficiencies and inequities … emerging challenges will lead to an increased but changed demand for health care.”
· “Now is the time for action if we want to safeguard the health and wellbeing of future generations at an affordable cost to our nation.”
Back to the future, indeed.
***Voting for better health
It is an election year, so let’s look more closely at what the Australian people are concerned about. The polls are telling us that voters want a real focus on health during this election campaign.
They also want a health system that looks after their needs and the changing needs of their parents. They want a health system that will look after their kids as they move through life.
Along with the economy, it is health and education that are the issues foremost in people’s minds. In a modern country like Australia, you would expect and hope that the Federal election would be fought on these issues.
It would be a source of great optimism if our political parties engaged in a battle of ideas and policies about the economic security, health, education, and employment of the Australian population.
Instead, some of our politicians and talkback hosts are fixated on immigration, asylum seekers, the carbon price or ETS, mining taxes, and personal attacks – the things that divide us, not the things that unite us.
Let’s shift the focus to the policies that will make us a healthier and smarter nation.
Health reform must be resuscitated urgently or Australians will find it more and more difficult to get access to quality affordable health care – where and when they need it.
These are tough economic conditions nationally and internationally, but the next Government must invest the best it can in the health of the Australian people.
It is important in this environment to get back to basics. We must protect and support the fundamentals of the health system. If new funding is limited, then it must go towards building on the things that work, the things that respond to our changing needs.
The AMA has put a lot of thought into the sorts of things that must be done to build a better health system.
Any change suggested by a political party - or indeed, a lobby group -must be tested against the reasons we need reform – our increasing burden of chronic disease and our ageing population.
Proposals should be moving us toward a joined-up, strengthened primary health care system built on team-based solutions. Any policy or proposal that does not work towards this goal should be shelved.
The AMA has benchmarks against which to judge health policies. We have collected them in a publication called Key Health Issues for the Federal Election 2013 – and I am releasing it here today.
Key Health Issues for the 2013 Federal Election
I will now outline for you some of our recommendations to respond to the key health issues. They are common sense, practical, and affordable.
***Healthier Australian families
Let’s first talk about wellness, not just about dealing with illness.
The wellness of Australian families is fundamental and must be a priority for the Australian Government. The wellness of families will be enhanced through measures including:
· curbs on alcohol marketing to young people, and appropriate minimum pricing for alcohol products;
· measures to improve environmental health, including better standards for clean air, and greater preparedness for the effects of climate change;
· measures to ensure that all existing coal seam gas extraction projects are regularly monitored for any adverse health effects and for the presence of air and ground water pollutants in their local environment;
· support for the 5-star food labelling system that has been agreed upon by Australian and New Zealand food ministers that will give consumers simple at-a-glance information about the healthiness of packaged food; and
· taking steps to control the exposure of children and adolescents to energy drinks that contain caffeine and other stimulants, and drinks with high levels of sugar.
These simple measures would strongly contribute to healthier Australian families.
***Affordable medical services
We must also ensure that health care remains affordable.
There were five measures in this year’s Federal Budget that together will wreak havoc on the affordability of medical services for Australian families.
These changes shift the cost of medical services onto the chronically ill, the elderly, young families, accident and trauma victims – patients who need medical care.
To restore affordability, the next Government must reverse the Budget changes by:
· immediately restoring indexation of MBS patient rebates;
· lifting future indexation of patient rebates to levels that are higher, and are set more realistically, to achieve a slowdown in patient out-of-pocket medical expenses;
· reversing the decision to raise the Extended Medicare Safety Net threshold from 2015;
· restoring tax deductibility of out-of-pocket medical and health care gaps; and
· reversing the decision to cap tax deductions for work-related self-education expenses.
Scrapping the cap will ensure that doctors can continue to improve their medical knowledge and skills through their training years and continue their professional development throughout their careers.
The AMA has been a founding member of the Scrap The Cap coalition. The cap is a dumb policy. It is at odds with the Government’s stated commitment to education. If this measure is not scrapped, many professionals – not just doctors – will be lesser skilled in the future.
That is not the hallmark of a clever country.
One of the pillars of our health system is our public teaching hospitals.
We have not included Public Hospitals in our election document, but I cannot leave them out of this speech today.
They are currently covered by the National Healthcare Agreement between the Commonwealth and the States. Given recent events, Agreement is probably not the right word.
The blame game continues and it must end.
Our public hospitals must be strongly supported with funding and resources. We still need to build capacity in our public hospitals.
Funding must be better targeted, patient-focused, and clinician-led.
This will require unprecedented cooperation between the Federal and State Governments – something we are not seeing at the moment.
***Medical workforce and training
We also need all governments to work together on medical training.
Last year, we saw the blame game play out over intern places - with a last minute deal struck between the Commonwealth and some States and Territories. Crisis management is not a good approach to long-term health workforce planning.
The AMA calls on the next Government, through Health Workforce Australia, to urgently finalise a five-year medical workforce training plan and for the Council of Australian Governments to:
· reach agreement on the number of quality intern, prevocational and specialist medical training places needed, based on the analysis provided by HWA;
· reach agreement on the respective financial contribution of each government; and
· agree on robust performance benchmarks to measure achievement against Health Workforce 2025 targets and COAG commitments, with regular reporting by HWA on progress against these targets.
Some of our governments also need to renew their commitment to improving Indigenous health.
Closing the gap and achieving health equality between Aboriginal people and Torres Strait Islanders and other Australians is a national priority that requires long-term funding and political commitment.
The next Federal Government must continue to show leadership so that all governments sign up to a new COAG National Partnership Agreement on Closing the Gap.
The Partnership Agreement is for another five years starting this year, and there must be at least the same level of funding as allocated in 2008.
Some States are slow in signing up. They must do it now. That would be genuine health reform in action.
***Providing medical care for dementia, palliative and aged care patients
As stated earlier, we must also be looking to our ageing population and their special health needs.
Medical care for dementia, palliative and aged care patients requires the regular attention of doctors.
And it requires ongoing doctor management of the patient with the patient’s family and carers, mostly outside the doctor’s surgery.
Australia’s system for funding medical care for these patients is inadequate. It does not appropriately recognise the time that doctors spend assessing patients, organising services, and providing support and working with the patient’s family and carers.
Medicare rebates for services provided by doctors and practice nurses must reflect the time and complexity of providing ongoing dementia, palliative and medical care in the community.
How much more cost effective would that be, compared to spending day after day in an acute hospital bed?
***Tackling chronic disease
Likewise, we need specific solutions for the dramatic increase in chronic care needs across all age groups. GPs are already increasingly treating older patients with more complex needs.
The management of chronic and complex disease is a key part of general practice, comprising more than a third of all problems managed.
The chronic problems most often managed by GPs are hypertension, depression and anxiety, diabetes, cholesterol-related disorders (brain and heart attacks), chronic arthritis, oesophageal disease, and asthma.
Many older patients suffer from two or more such chronic illnesses simultaneously, and this significantly complicates diagnosis and management. This is also true for Aboriginal people and Torres Strait Islanders.
Australia has moved to implement more structured arrangements through Medicare to tackle chronic and complex disease, but more needs to be done.
The Department of Veterans Affairs (DVA) has initiated the Coordinated Veterans Care (CVC) program. It provides additional funding support to GPs to provide comprehensive planned and coordinated care to eligible veterans with the support of a practice nurse or community nurse.
This program is designed to reduce avoidable hospital admissions and deliver overall savings to the health system. The DVA CVC program was developed with strong clinical input and has broad stakeholder support.
We need a broad coordinated care program to tackle chronic and complex disease based on this model.
***General practice infrastructure
We also need a coordinated plan for general practice.
For starters, the AMA wants to see the end of the GP Super Clinics program. It has been an expensive failure.
In contrast, the smaller and more modestly funded Primary Care Infrastructure Grants Program has been evaluated by the Australian National Audit Office and shown to be excellent value for money.
For an investment of just $117 million over four years, the Commonwealth has been able to support around 450 practices.
These practices have been able to expand services for patients and become more involved in teaching and training the next generation of GPs.
The next Government must increase GP infrastructure grants funding by an additional 600 grants at the level of the existing grants. This would enable a third round of GP infrastructure grants to support quality primary care through general practice.
In regard to broader primary care reform, the AMA has, at times, been critical of the role of Medicare Locals.
The AMA generally supports the Medicare Locals concept to improve the interface between hospitals and primary care and to help GPs to give their patients better access to services.
The problem, to date, with many Medicare Locals has been inefficient implementation, which has been characterised by poor engagement with GPs and the loss of GP involvement in decision-making structures.
This must be addressed if the AMA is to become more supportive of Medicare Locals.
***The Personally Controlled Electronic Health Record (PCEHR)
The same can be said about the approach to electronic health.
The AMA has been a strong supporter of the concept of a shared electronic health record.
An e-health system that connects patient information across health care settings, and which can be accessed and contributed to by treating medical practitioners and other health practitioners, will improve the safety and quality of medical care in Australia and underpin the reform that Australia needs.
The benefits of e-health in making the best use of existing health care services and avoiding errors, duplication and waste are well known.
To treating doctors, e-health means being able to access all of the clinically relevant medical information about a patient at the time of diagnosis or treatment.
We note that the roll-out of the Personally Controlled Electronic Health Record (PCEHR) has been slow and patchy across the country. The AMA is not surprised.
The design of the PCEHR means that its use is limited for doctors in terms of accessibility, content, accuracy, and the comprehensiveness of information.
Health care of the patient is best served when the doctor has access to the most basic information that is critical to patient care.
This includes pathology and diagnostic imaging results, hospital discharge summaries, information on prescribed medications, and GP health summaries.
Doctors want to use the PCEHR to enhance clinical care.
If the Government wants to see increasing use of the PCEHR, it should be a reliable source of the information that makes a difference to clinical care.
We urge the next Government to consult more closely with the profession to overcome these hurdles.
The AMA wants to see the benefits of e-health flow on to efficient and effective patient care.
***Appropriate health care for asylum seekers
Another issue of great concern to the AMA is the health of asylum seekers. We have raised our concerns regularly in political forums.
The arrival of asylum seekers to this country has been politicised to the extent that it has become an ugly, bitter and divisive matter in the community.
I will not go into the politics of it, but I will go into the health and social justice elements of it.
The AMA believes that once we take responsibility for people seeking asylum in Australia, they should have access to an appropriate level of health care, whatever the detention arrangements or location in which they are placed.
Those held offshore inherently have poorer access to specialist health and medical care than those held onshore.
Asylum seekers typically have multiple health conditions that require complex treatments, and health emergencies need to be treated quickly – but being offshore makes it harder.
The prospect of indefinite detention poses a great risk to the mental health of detainees, often resulting in self-harm and attempted suicide.
The stress and trauma of indefinite detention has life-long health effects on children. Community detention is much less likely to cause harm.
We need independent and systematic monitoring of the health of asylum seekers. There are currently no Commonwealth agencies that are free to report on this.
The Commonwealth Ombudsman and the Australian Human Rights Commission periodically undertake inspections of immigration detention facilities, but their expertise does not extend to assessing the health of asylum seekers.
The hamstrung Detention Health Advisory Group – DeHAG – has become the Immigration Health Advisory Group – IHAG. Unfortunately, IHAG – despite its best intentions - is also severely constrained in its ability to monitor or speak out about these issues.
The next Government must establish a truly independent medical panel to oversee, and report regularly on, the health services that are available to asylum seekers in immigration detention facilities, both onshore and offshore.
This would be a true sign of a compassionate country.
In closing, let me reiterate that to achieve health reform you must first define health reform.
We have a new set of problems that require a new set of solutions. This is the challenge for governments.
In pursuit of genuine health reform, it is fair to have opposing views … on some things. That is the nature of politics. But there are times when all sides of politics can work together on shared goals.
We have seen it in health with high immunisation rates, plain packaging for tobacco products, and the National Disability Insurance Scheme. These are great outcomes that deliver significant public good. There should be more of it.
I look forward to a compelling political contest over the coming months as we head to the election. I hope it is a contest of ideas, solutions, and optimism for a better future for our great country.
I repeat what I said earlier - the health policies at this election must be judged on whether they are genuine health reform or politically opportunistic short-term change.
Any change must be tested against the reasons we need proper health reform – our increasing burden of chronic disease and our ageing population.
Proposals should be moving us toward a joined-up, strengthened primary health care system built on team-based solutions. Any policy or proposal that does not work towards this goal should be shelved.
And that is how the AMA will judge the competing health policies at this election - and that’s how you should judge them, too.
17 July 2013
CONTACT: John Flannery 02 6270 5477 / 0419 494 761
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Published: 17 Jul 2013