AMA President Dr Andrew Pesce, speech to 'Australia's Health'
The Congress on National Health Reform, Parliament House of Victoria, 30 November 2009
Practical Immediate Health Reform
My thanks to Global Access Partners and the Australian Centre for Health Research for the invitation to be part of this important Congress.
You can't escape the term 'health reform' these days - it has become a signature tune of the Rudd Government.
Everybody has a view on health reform - what it means, what it should look like, and when and how it should happen.
If you want real reform that sticks and works operationally, and is supported, you have to bring along the key players in the health sector, including the doctors.
This means negotiating the changes with them and working through the operational detail, rather than just announcing them as a fait accompli.
This is the only way to get real reform embedded into the system and supported by those who have to implement and work within the system changes.
But the real problem with health reform is that it moves at glacial speed.
We have all seen the reports and we have probably all been consulted in some way or another - which is all very good.
However, there are problems in the health system that need fixing right now.
So, amid all the various health reform processes, the AMA released its own reform document.
The AMA Priority Investment Plan for Australia's Health System is all about practical immediate health reform - things that can and should be done right now.
I would like to share the AMA Plan with you now.
Ending the 'Blame Game'
Perhaps the biggest challenge for the Government is its health reform endeavours is the issue of governance.
There can be no argument that it is time to end the 'blame game' between the Commonwealth and the States over the funding of our public hospitals.
The AMA believes there should be a single public funder for public hospitals - and that funder should be the Commonwealth.
The Commonwealth should take total responsibility for fully funding the public hospital system.
The AMA does not support a takeover of the operation of the public hospital system.
The States can still own and run the public hospitals but there needs to be much better local governance arrangements for our public hospitals to ensure that the needs and the views of the local community and the local health workforce are properly responded to.
This system would provide transparency and would negate overt cost shifting.
It would also help to eliminate waste and inefficiency.
We see a single public funder for public hospital services, primary care and aged care.
This would ensure that the overall adequacy of funding in any one particular area could not be used as an excuse for poor patient access in other related areas of the health system.
This would be in conjunction with the continuation of existing fee for service MBS and PBS arrangements covering the cost of medical services and pharmaceutical costs for patients.
Can I just say at this point that it is ironic that academics and bureaucrats criticise fee for service for doctors as putting pressure on health funding and being the big flaw in the health system.
But at the same time, the proposal that is being mooted to increase efficiency of the hospital system is to fund them on a casemix basis, based on throughput.
Dare I point out that this is the hospital equivalent of fee for service!
The AMA believes that Commonwealth funding for public hospitals would need to cover the effective cost of care, not the efficient cost of care as proposed by the National Health and Hospitals Reform Commission - the NHHRC.
This would allow local flexibility and decision-making.
An effective payment arrangement must incorporate sufficient loadings, adjustments and flexibility to reflect the variable geographic and other circumstances of individual hospitals.
It must also include additional dedicated funding for research and development, training and education of the health profession, and capital funding for public hospital infrastructure.
This will require significantly more funding for public hospitals across Australia.
The AMA model for a single public funder with local governance would involve:
- The development of national targets and performance indicators through agreement with both the Commonwealth and State and Territory Governments;
- Service planning by State and Territory Governments, with clinician involvement, to take account of local needs;
- Allocation of funding by State and Territory Governments in accordance with the service planning;
- Purchasing and service provision at the local level with local clinician involvement in service level resource allocation;
- Monitoring of performance at the national level by both the Commonwealth and State and Territory Governments; and
- An independent audit process to make transparent and monitor over time the amount of public funding provided for clinical services, as opposed to hospital and health department administration, and the performance of the public hospital system against agreed national targets.
As a doctor who works in a major public hospital, I see great merit in this system of funding and governance.
Apart from the funding and governance issues, there are achievable practical things that can be done to ease the pressure on our public hospitals.
We need to ensure a maximum 85 per cent bed occupancy in public hospitals.
The Commonwealth has recently provided additional funding to the States for public hospitals.
And the Prime Minister has indicated that this could be used "to establish 3,750 new beds in 2009-10, growing to 7,800 additional beds by 2012-13".
The AMA's plan to increase bed capacity in public hospitals would ensure that we achieve this essential outcome.
Currently there is no evidence that there is a comprehensive and coordinated strategy to open and staff the required beds.
There have been some ad hoc announcements of new beds in particular States but no comprehensive strategy where the Commonwealth holds each State orTerritory accountable.
And there is no evidence that the States aren't closing beds as quickly as the Prime Minister announces ad hoc funding for new ones out of the additional Commonwealth funding.
The AMA plan for our public hospitals involves:
- First, undertaking a stocktake of the actual number of beds needed in each hospital to ensure no more than 85 per cent average occupancy;
- Second, undertaking a stocktake of the number of sub-acute beds needed to take pressure off acute hospitals in each area;
- Third, obtaining formal intergovernmental agreement on the timeframe for their establishment and evidence that the States have also provided the additional required funding in each institution's recurrent budget;
- Fourth, implementing a robust accountability system so that the Commonwealth can be assured unequivocally that the funding it is providing under the new National Healthcare Agreements is used to establish these new beds within agreed timeframes - say, within the next 18 months; and
- Fifth, implementing an ongoing monitoring system - Bed Watch - that would transparently report on the number of new and existing beds that are available in public hospitals. Bed Watch would also monitor other important factors related to hospital occupancy such as access block in emergency departments. We need to achieve a target of 10% or fewer patients who wait more than 8 hours in emergency departments before reaching an inpatient bed or being transferred to another hospital for admission.
Taking advantage of the e-Health revolution
Another important area of health reform is E-health.
We must accelerate the national uptake of e-Health and the benefits it offers.
The AMA fully supports the roll-out of e-Health initiatives in order to integrate systems, reduce fragmentation, streamline service delivery, reduce duplication, and improve quality and safety.
The roll-out should start with e-prescribing and sharing of essential patient health information between health care providers through electronic records.
Priority needs now to go to funding and rolling out the infrastructure for e-Health - especially electronic medical records - given that investment to date has mainly focussed on the development of standards and technical specifications.
Remote communities should be 'wired' for e-Health service delivery such as telehealth and Internet consultations and advice, as recommended by the NHHRC.
And finally on e-Health, there is a need for more education and support for health professionals to get them ready to be participants in the e-Health revolution.
The NHHRC's focus on providing access to multidisciplinary primary care services has significant merit.
General practice can lead the way in the development of such services, but lacks the necessary infrastructure to do so.
For prevention advice, sickness, injury, or chronic disease management, people want to be able to see a doctor, usually a GP.
With over 7000 general practices across the country, the Commonwealth could significantly enhance patient access to general practice and allied health services through a broad infrastructure support program targeting existing general practices.
This would allow existing general practices around Australia to evolve and develop into GP Primary Care Centres, similar to the Comprehensive Primary Health Care Centres (CPHCC) envisaged by the NHHRC, or to provide specific additional services tailored to local needs and to train our future GP workforce.
Better infrastructure could support more community-based training, support more on-site collaborative care, support more virtual consolidation and coordination with other services, support more practice nurse services and the integration of nurse practitioner services on site, and support more person-specific preventive health care through primary care services in the community.
Above all, the central and leading role of the GP in primary care must be protected and promoted.
The AMA was pleased with the Government's recent amendment to the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009.
The amendment specifies a formal requirement that midwives and nurse practitioners must work in collaboration with medical practitioners.
The AMA had been negotiating with the Government for this vital change to the legislation for some time.
We made it clear to the Government that without a requirement in law that there be collaborative arrangements between midwives, nurse practitioners and doctors then the legislation did not have any safeguards to ensure continuity of patient care, nor did it have any protections against the fragmentation of patient care services.
The change creates a framework of quality primary care delivery that supports team-based care and ensures that the role of medical practitioners, particularly the patient's usual General Practitioner, is not undermined.
There is a significant mismatch between the number of pre-vocational and vocational training places and the training infrastructure available and the number of medical school graduates expected to graduate from medical schools around Australia who will need these training places in the next few years.
To address this problem and to ensure that we have sufficient doctors in the future, there is an urgent need to expand the number of medical training places and training infrastructure in our health system so that we have a training position for every medical school graduate.
The Government should actively and genuinely work with the medical profession to determine how many of each medical discipline or craft group is required and what we are going to do to get them.
It can only be achieved through improved workforce planning - with doctors closely involved and advising - to ensure governments match demand for workforce with prevocational and vocational training positions.
As a nation, we must do all that we can to help close the gap in Indigenous health because this is both a symptom of, and a contributor to, the cycle of poverty in Indigenous communities.
The capacity to provide primary health care to Indigenous communities in rural, remote and urban areas must be significantly improved through expanding the workforce for Indigenous health, and building the capacity of Aboriginal Community Controlled Services.
This will require the following practical and immediate measures:
- First, additional grants to Aboriginal primary care services for enhanced infrastructure and services, and to allow Aboriginal Medical Services to:
- Second, grants to allow Aboriginal Medical Services to offer mentoring and training opportunities to Indigenous and non-Indigenous medical students and vocational trainees; and to offer salary and conditions for doctors wishing to work in Aboriginal Medical Services that are comparable to those of State salaried doctors;
- Third, funding for the development of Indigenous-specific medical training for hundreds of new Indigenous medical practitioners to work in Aboriginal health settings; and
- Fourth, new funding for community groups or NGOs for health-related capacity building in Indigenous communities.
These measures must be implemented as part of a long term national strategic plan for closing the gap in Indigenous health, which is developed in genuine partnership with Indigenous people and their representative organisations.
We must also do more for the other 'forgotten people' in the system.
We need an immediate increase in restorative services and sub-acute beds for rehabilitation and convalescence, as identified by the NHHRC, so that there are appropriate services for people who leave hospital but need further care. We support the NHHRC's recommendation in this regard.
he NHHRC identifies a number of important initiatives to improve care for people with a mental illness through expanded early intervention for young people, more sub-acute care, better links between acute care and community care, including through rapid response teams working from acute care settings in the community.
But their report is silent on the continuing unmet need for acute mental health care, often required on an inpatient basis.
There are many patients requiring acute inpatient care during initial diagnosis, stabilisation of their condition, or while they are under clinical supervision during a change in their medication to avoid a relapse in their condition.
The Government needs to undertake an analysis of the number of new psychiatric inpatient beds required in the public hospital system as part of the AMA's proposed stocktake on public hospital bed capacity.
There also needs to be an expanded integration of the role for psychiatrists in the provision of community-based care for people with mental illness.
This should include targeted funding for psychiatric nurses and psychologists to be able to work under the supervision of private psychiatrists, linked closely to the current referral system from GPs to private psychiatrists.
Long term care scheme
In addition to our national aged care program, which provides support for older Australians who need care, we support a national disability insurance scheme - which is 'no fault' and comprehensive in the care and support it provides - to cover the cost of long term care for people with serious disabilities.
The AMA has called for this for some time.
There has been progress in this area with the announcement last week of a Productivity Commission feasibility study into new approaches for funding anddelivering long-term disability care and support.
The Productivity Commission will report back to Government in July 2011.
Rural and remote
Australians in rural and remote areas need improved access to quality health services.
To address this, the Government should support the Rural Rescue Package developed by the AMA with the Rural Doctors Association of Australia.
The Rural Rescue Package would bolster the rural workforce and ensure that patients in rural communities have improved access to doctors.
The Package encourages more doctors to work in rural and regional Australia and recognises essential obstetrics, surgical, anaesthetic and emergency skills.
This funding would support further enhancements to rural isolation payments and rural procedural and emergency/on-call loading.
These reforms are all achievable and necessary and practical.
This is an AMA investment plan for the health of all Australians.
It is for immediate implementation.
We need this plan to improve productivity in the health system, place a greater focus on people and their health needs, and improve the quality and safety of health care.
To be successful, this plan will require upfront incentives, infrastructure, capacity building, and ongoing funding.
This investment is needed because a healthy community is a productive community. An effective health system reflects a compassionate society that has its priorities right.
We all know that good health care comes at a cost. Responsible governments and communities invest in health. The returns on the investment are huge.
Good health care allows people to contribute productively to society.
Australian Medical Association
Practical Immediate Health Reform - AMA President Addresses The Congress On National Health Reform, Melbourne
AMA President Dr Andrew Pesce, speech to 'Australia's Health'
The Congress on National Health Reform, Parliament House of Victoria, 30 November 2009