Dr Hambleton, Speech to National Press Club
AMA President Dr Steve Hambleton addresses the National Press Club as part of Family Doctor Week. AMA President Dr Steve Hambleton discusses health service in Australia and outlines the AMA's plan to get primary health care reform back on track.
SPEECH TO THE NATIONAL PRESS CLUB
WEDNESDAY 18 JULY 2012
AMA PRESIDENT DR STEVE HAMBLETON
***Check Against Delivery
The AMA - More Than Just A Union
I acknowledge the traditional owners and custodians of the land on which we meet today, and pay my respects to their leaders, past and present.
Ladies and gentlemen, the Federal AMA is 50 years young this year.
Of course, medical organisation in this country goes back a lot further than 50 years, with records of meetings of doctors going back as far as the early 1800s.
These groups had varying fortunes across the States.
Things started getting serious though from July 1880 when both NSW and South Australia gained formal recognition as branches of the British Medical Association – the BMA.
Other States followed suit over the next thirty years or so.
But it wasn’t until 1962 that the Federal AMA was born.
There are some wonderful characters and wonderful events in the creation of the local branches of the BMA and the eventual creation of the AMA that we know today.
The AMA has had a long list of distinguished Presidents since 1962. It is more than a little daunting to be standing in their shoes.
The success and achievements of the AMA Presidents would not have been possible without the work of the founding fathers – those who went before.
From the doctors who established hospital services in the new colony …
To the doctors who worked in the goldfields of Victoria …
To the doctors who had early skirmishes with government authority …
And even the doctors who met in each other’s houses in the early days of forming branches of the BMA.
It is upon their shoulders and achievements that the Australian medical profession now stands.
It is a fascinating story. A fascinating history.
In our 50th year and as the 22nd AMA President, today it is my great honour to launch ‘More Than Just A Union: A History of the AMA’.
You will note that it is called a history, not the history – and there is a very good reason for that.
The researcher and author of this history, Dominic Nagle, has spent many months piecing together fragments of the AMA past from many sources to create a seamless narrative.
In many cases, the source material has been patchy in places.
Poor or incomplete record keeping, lost files, missing files, and fading memories made it difficult.
In other cases, some Branches of the AMA (formerly the BMA) have kept excellent files and archives.
The National Library of Australia was another handy resource.
But this history is based on the records, recollections, and resources of some of the players and observers.
Others will have different memories or different slants on what happened in AMA history, from long ago to more recent events.
This publication also includes some personal recollections from previous AMA Presidents.
But this particular AMA history does not end here …
It is the beginning. It is a living history.
It will be posted on the AMA website and we invite people to provide comment.
We invite people to add their version of events, or add episodes of AMA history that we may have missed.
We want to build on this history, round it out, fill in the gaps.
As it stands, though, this is a fascinating account of the role that the AMA has played on the medico-political stage in Australia.
Copies will be available as you leave here today.
On behalf of the AMA, I wish to publicly thank Dominic Nagle for all his efforts over many, many months in drawing all the loose threads of the AMA’s past into a fine publication.
Dominic is here today. I am sure he is glad that this history … is now history.
Let’s now talk about health reform …
Ladies and gentlemen, the pace and extent of health reform in this country has slowed considerably.
To be fair, this does not mean that good and significant changes have not occurred.
The AMA acknowledges that the Labor Government has done many good things in health since coming to office.
The tobacco plain packaging legislation is world leading and a public health milestone in this country.
The AMA strongly endorses the Government’s intention to introduce a National Disability Insurance Scheme, which appears to have bipartisan support.
We do not want to see the momentum for this Scheme slowed down.
The Government has invested strongly in Indigenous health.
We now have to work together as a nation to make that investment deliver its full potential.
This will involve capacity building in local Indigenous communities and concerted efforts to address the social determinants of health.
This is a big challenge and a big opportunity for us all. It is not just the job of Government.
After the usual heavy tussle, we now have a COAG Agreement between the Commonwealth and the States … but the blame game is alive and well.
This Agreement will continue to come under immense pressure as new State Governments attempt to flex their muscles.
The Federal Government’s promise to deliver clinical leadership to Local Hospital Networks has come under threat from the States already.
The Government has provided a significant increase in medical training numbers, including in general practice.
This is a great investment in our future medical workforce.
We now need to see all our governments cooperate to ensure we have the right number of intern places to ensure these doctors of the future can finish their training.
And we now have the Australian National Health Prevention Agency dedicated to prevention. We welcome this.
From our perspective, the dream of health reform that began in 2007 has not been realised.
Let’s be clear. Real health reform for doctors, patients, nurses, and allied health professionals means more resources at the hospital bedsides, in the surgeries, and in community health services.
The AMA is determined to ensure that the grassroots experience of medical practice is not drowned out in the health reform debate.
Our patients mean too much to us to let that happen.
But we still have many changes. We have to now manage those changes. And hopefully we can do that together.
Ladies and gentlemen, as you know I am a proud GP and this week is AMA Family Doctor Week.
It is our traditional celebration of the hard work and dedication of the nation’s family doctors.
These are the GPs who serve local communities in the cities, the suburbs, the rural centres, country towns, and remote areas of Australia.
As you read our publication, you will see that family doctors, our GPs, have not only been an important part of the AMA’s history, they have made a huge contribution throughout the nation’s history.
GPs have always been, and remain, the foundation upon which our health system is built.
To many Australians, GPs are the health system – the first stop every time. Throughout life.
I want to spend the rest of my time here today talking about GPs and primary care and the way ahead.
GPs are the first point of call in the health system when people are sick.
GPs deliver around 120 million consultations each year for patients.
They already deliver high quality, comprehensive care for patients, and they save the health system money.
The care that GPs deliver is not only clinically effective, it is cost effective.
Any changes to the health system must add to this record, not subtract from it.
General practices – our family doctors – are key to ensuring that any changes deliver the best possible health care to patients and communities.
It does involve significant investment in challenging economic times – but it is the right investment to make.
I have just returned from a trip to New Zealand, where I visited a number of their primary health organisations (PHOs) – which are their version of Medicare Locals.
It wasn’t that long ago that New Zealand was the place to look if you wanted to see what not to do in general practice and primary care.
I have to say that things have changed considerably. They have learnt from their mistakes. And that is an important lesson for us.
Patients value the care that they receive, and bulk billing is not seen as a measure of how well the health system is performing.
Co-payments are a fact of life in New Zealand general practice with targeted initiatives in place to ensure affordable access for disadvantaged patients and for young children.
General practice in New Zealand has embraced team-based care – with GPs and nurses working closely together.
Most practices have at least one nurse for every GP working in the practice.
It’s the delegated model of care that that the AMA has recommended.
It sees many nurses working to their full potential in a well-supported general practice environment.
General practice is quite rightly relied upon to deliver population health in New Zealand.
I want our Government and the Opposition to make general practice an even stronger priority in the health policies they take to the next election.
At this stage we have seen very little detailed health policy from the Coalition.
There is a pledge to abolish Medicare Locals. But we have not been told what will go in their place.
There is a commitment to cut red tape and bureaucracy, but no detail about where and how much.
The AMA wants to see a competitive policy battle on health at the next election.
There can be no complacency from either side.
The current Government has already made primary care a major part of its health reform strategy.
While a lot of its big health reform agenda has been watered down or put on hold because of the nature of minority Government, and the changes in governments at the State level, much of its primary care reform direction remains.
However, the AMA has some points of difference about the way some of this policy is being rolled out.
I am concerned that the Government is getting some poor advice on what really happens on the front line of primary care.
It seems that a lot of the reform is being brought in around GPs – through Medicare Locals and other health professionals, for instance – rather than being led and coordinated by GPs – as it should be.
The most cost effective health reforms are investments in general practice and reducing red tape, not taking savings from general practice or increasing complexity.
You just have to look at the last few Federal Health Budgets to see that savings have been made at the expense of general practice, rather than increasing funding for GP services.
Let’s look at the list …
Cuts to the Better Access mental health program.
Cuts to incentive payments for immunisation.
Cuts to incentive payments for cervical cancer screening and specialised diabetes care.
Cuts to joint injection rebates.
The loss of Medicare practice nurse rebates.
And incentive payments for GP after-hours services are soon to go.
Instead of building and supporting general practice, there are cuts after cuts.
Instead of consulting GPs, there has been too much insulting GPs.
No wonder morale is down in the GP workforce.
But it does not have to be this way. We have shared our concerns with the Health Minister Tanya Plibersek. She has been prepared to have the conversation with us.
We can learn from the New Zealand experience, especially in regard to Medicare Locals.
Medicare Locals will only succeed with GP leadership and majority GP decision-making.
They got it wrong In New Zealand before they got it right. Disenfranchising GPs set them back years.
We still have the chance to get it right first time … but we have almost blown it.
GP Super Clinics are fine if they provide services where they are needed and they do not compete with established GPs.
The shared electronic health summary will only work if GPs are supported for the work they need to do to make it happen.
And on it goes. The key to getting primary care right is to work with and for GPs, not around or against us.
The AMA has a plan to turn things around and get health reform back on track.
1. Improved coordination of primary care services
First we must improve coordination of primary care services.
The AMA Council of General Practice understands the need for primary health care organisations to improve the coordination of primary care services.
They can help to break down the silos, build better links between the hospital sector and primary care, support improved population health, and address gaps in the delivery of primary care services.
The Australian Government has called them Medicare Locals.
The Government has established 61 Medicare Locals across the country.
Although they have been operating since 1 July and been in the planning since 2009, few Australians have heard of them or understand what they do.
The Government is pursuing the wrong model by substituting the role of GP leaders in Medicare Locals and in their decision-making structures.
The Government is making the same mistakes that New Zealand made in 2001 when it decided to implement ‘skills based boards’ that excluded GPs.
These boards were initially made up of people who, while experienced in governance, did not understand the complexity of health care delivery.
Clinical leadership was absent in many areas in New Zealand and the models failed to deliver.
The leadership role of GPs has now been restored and the PHOs in New Zealand are now playing a more meaningful role in support of improved health outcomes for local communities.
In New Zealand, the PHOs are:
- Supporting GPs to focus on population health;
- Supporting improved quality in general practice by facilitating information sharing among GPs;
- Supporting pro-active management of chronic disease;
- Supporting e-health initiatives;
- Funding specific initiatives to keep people out of hospital; and
- Helping support more sustainable general practice by building improved IT and delivering business support.
These are initiatives that are being built from the ground up and led by GPs, not imposed from the top down.
Our Government must urgently rethink its Medicare Locals model.
They are not local enough.
They will not be responsive to local health needs unless they are fully engaged with GPs. GPs need to be at the helm or it just won’t happen.
2. Complex and Chronic Disease
We know that complex and chronic disease represents a huge challenge to the health system.
Chronic disease now accounts for about 70 per cent of the allocated health expenditure on disease and it is estimated to increase significantly in the immediate future.
Current Medicare funded chronic disease management arrangements are limited, can be difficult for patients to access, and involve considerable red tape and bureaucracy.
We need a much better way.
We need less red tape and more streamlined arrangements allowing GPs to refer patients to Medicare funded allied health services.
We need a more structured, pro-active approach to managing patients with complex and chronic disease.
The Department of Veterans Affairs is doing some great work in this area with its Coordinated Veterans Care (CVC) Program.
DVA is supporting GPs to provide comprehensive planned and coordinated care to eligible veterans with the support of a practice nurse or community nurse contracted by the Department.
The CVC program is a comprehensive approach to the management of chronic and complex diseases.
It supports GPs to spend more time on these patients on a longitudinal basis.
It recognises the non face-to-face work required, including regular follow-up to see how patients are going.
We need to look at how we can roll out this type of pro-active approach more broadly.
We could be investing in a healthier future with better disease management, and prevention of avoidable costly hospital admissions.
We also need to support better infrastructure in general practice to improve access to multidisciplinary care.
The Government has invested over half-a-billion dollars in 64 GP Super Clinics – with only 25 operating to date.
But there are problems across the board – and inequities.
Modbury in South Australia, for example, received $25 million in State and Federal funding, yet has no GPs.
There are more than 7000 general practices across the country.
The Government’s spend should have focused on supporting many of these practices to expand the services they provide to patients.
Investment in these practices would deliver better IT, new treatment rooms, space for a practice nurses and other health professionals.
Access to care would improve and multidisciplinary teams would be encouraged.
A recent Australian National Audit Office report showed that the Government’s modest investment in its Primary Care Infrastructure Grants Program was delivering good results by investing in existing practices – with many projects being ‘shovel ready’.
We need to see this program expanded dramatically, with the AMA wanting 575 more grants on top of those already made available.
4. Teaching and Training
General practice is a great place to learn.
GPs provide comprehensive care to patients from the cradle to the grave and the work is both challenging and rewarding.
Australia has also more than doubled medical student numbers and our public hospital system simply cannot provide enough training places for these students.
There are also training gaps in the years beyond when they have graduated and are looking to complete specialist training.
This presents a great opportunity to build the GP workforce.
By investing in a strong GP workforce, the health system saves money. GPs do a great job of treating illness early, recognising and managing chronic diseases, and keeping people out of expensive hospitals.
However, many GPs are not engaged in teaching and training.
They may not have the facilities to place students, prevocational doctors and registrars.
They may have no way of recovering the significant opportunity cost to become involved in teaching and training the next generation.
The current subsidies for teaching medical students, for example, have not changed since 2005 - and are estimated to only cover around 30 to 60 per cent of the costs of taking on a student.
Only 14 per cent of general practices are involved in teaching medical students and we know that the GP training program is reaching saturation point.
Around 15 per cent of GPs are accredited to teach GP registrars meaning that there is enormous potential to get more GPs involved in teaching and training.
The fact is the subsidy for teaching medical students should be doubled and indexed annually.
This would be a great start in recognising the costs of teaching and would allow more GPs to get involved.
Similarly, an expansion of the GP infrastructure grants that I referred to earlier would support essential upgrades to GP practices.
This could allow them to take on a student, a prevocational trainee, or even a GP registrar.
5. Mental Health
The AMA recently conducted a survey on the impacts of the 2011-12 Budget cuts to funding for GP mental health services.
The results – which will be released later this week – show that patients are missing out on important care as a result of these cuts
GPs are at the front line every day in helping individuals and their families through traumatic events, family crises and ongoing mental and other health conditions.
According to BEACH data, there are around one million GP consultations involving a mental health issue each year.
Prior to last year’s Budget cuts there was significant trend growth in the use of Better Access mental health services accessed through GPs.
That growth has gone. It must be restored. That is part of our plan.
6. Team-based care
General practice in New Zealand has embraced team-based care – with GPs and nurses working closely together.
As I said earlier, most practices have at least one nurse for every GP working in the practice.
Through medically-delegated nurse clinics, patients have improved access to care - and patient safety is assured.
We need to reinstate the highly successful and effective ‘for and on behalf of’ Medicare patient rebates as the foundation of team-based care.
Team-based care is a more effective approach than promoting a fragmented model of care where health professionals, such as nurse practitioners, work independently in isolation of the GP.
A current concern for the AMA is the pressure being placed on the Health Minister to change the collaborative requirement for midwives so that they only need to have arrangements with hospitals, rather than with a medical practitioner.
This approach is not good for patient care. It simply encourages new silos and diminishes a well-supported team based approach.
The Government has decided to take the responsibility and the funding for the provision of after-hours services away from individual general practices.
It has given that responsibility to Medicare Locals.
Taking more than $100 million in funding from existing successful general practice after-hours services is not the way to go.
It is far too early to give this responsibility and this funding to Medicare Locals. They barely exist.
The UK tried this model and it has failed. The upshot of this was that many UK GPs then decided that after-hours was no longer their responsibility.
We need a guarantee that the successful Australian after-hours service providers will be supported by the new Medicare Locals.
Let’s support what works. Let’s build on success.
8. The Personally Controlled Electronic Health Record
The Personally Controlled Electronic Health Record – the PCEHR – is another speech for another time.
The AMA’s views are well known.
Health Minister Plibersek knows our concerns and is still considering some of our ideas to help the PCEHR implementation succeed.
We all want it to succeed but it has to be done the right way and it must be more supportive of GPs.
Without strong GP support, the PCEHR implementation will stall.
We need urgent clarity over when things will be rolled out.
We need to know how doctors will be funded to do the Government’s work.
Patients need to know what they can realistically expect to receive when they try to sign up at the doctor’s surgery.
We need a timetable for the rollout.
And we need a comprehensive public education campaign.
So there is our plan to get primary health care reform back on track.
1. Improve the coordination of primary care services.
2. Introduce better systems to deal with complex and chronic disease.
3. More GP infrastructure grants.
4. Provide more incentives for experienced GPs to provide teaching and training for the next generation of GPs.
5. Restore funding for GP services provided under the Better Access program.
6. Support medically-led team-based care.
7. Preserve existing after-hours services that work successfully based on local knowledge and experience.
8. Get the PCEHR right.
The key elements already exist. They just need recalibration – a new and better direction.
They need a guarantee of GP involvement and leadership.
The health system can only improve if all its essential parts remain connected and become better connected.
The glue that holds it together is general practice.
We urge the Government and the Coalition to look seriously at our plan for primary care. It will work.
Talk to doctors when developing your health policy. Talk to the AMA. After all, we are more than just a union.
18 July 2012
CONTACT: John Flannery 02 6270 5477 / 0419 494 761
Kirsty Waterford 02 6270 5464 / 0427 209 753
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Published: 18 Jul 2012