Dr Hambleton speech to CEDA on health reform

Health reform – from ‘big bang to a whimper’

Just a few short years ago, we were in the middle of what was being called the biggest reform of the Australian health system since Medicare.

There was excitement in the air.

And, of course, there was caution and concern and consultation … lots and lots of consultation.

There was a mood for change, but change to ‘what’ and ‘how’?

Like most groups in the health sector, the AMA was supportive of ‘big bang’ reform, just as long as it was the right ‘big bang’ reform.

A lot of the plans – many of which had been recommended by the National Health and Hospitals Reform Commission – had the conditional support of the AMA.

We were firmly engaged in the reform process.

We supported the idea of a single funder, the end of the blame game, greater responsibility and accountability, enhanced safety and quality, less waste, and a guarantee of clinical input to decision making.

Then political circumstances changed and political courage fell away.

The unique ‘once in a generation opportunity’ for genuine health reform fell away.

State Governments changed complexion and COAG became a battleground once again.

The Government changed leaders and faced a tough election with the polls working against it.

And then we had minority Government … and chaos.

The ‘big bang’ became a ‘small bang’ and then all we had left was a sparkler.

To be fair, the Government has pushed through some pieces of the original health reform big picture.

There are Medicare Locals and Local Hospital Networks, a Pricing Authority, a Performance Authority, a Safety and Quality body, and a national funding pool.

The AMA likes some bits, dislikes other bits, and is seeking changes where there is insufficient input or management from doctors.

It will be some time before these changes are fully bedded down, and even longer before we know the impact on patients and communities.

But, in a difficult and dramatically altered political environment, we must be thankful for some change.

So where does that leave us?

Realistically, the biggest element of health reform now confronting us is electronic health, with the biggest headline item being the Personally Controlled Electronic Health Record – the PCEHR.

I want to concentrate on e-health today.  It is the health reform ‘news’.

As a busy general practitioner, I am personally always interested in improving productivity in health care. 

A key productivity tool in health is the electronic health record.  While it will take longer in general practice, it should save both time and lives in the rest of the health system.

The PCEHR – due to commence implementation from 1 July this year - holds the promise of reducing adverse events and reducing duplication of treatment.

Most AMA members are enthusiastic about the shared electronic health record vision.  They know that, with the right system, they can improve the patient healthcare experience. 

And hopefully save themselves some time in quickly and accurately understanding the nature of the patient’s problem based on ready access to reliable health information.

The right sort of shared record system will help doctors deliver better care. 

They will have important information about their patients to help them make good clinical decisions.

We know that if we just share an accurate medication list, lives will be saved.  Some of my elderly patients can only tell me the colour and size of their tablets. 

These days it is very important to know whether those little blue pills they take at night are round or diamond shaped.  One makes the heart stronger, the other might wear the heart out.

With new patients to the practice it often takes quite a while to work out that medication list.  Often there is no choice but to phone the last pharmacy to piece the information together.

With a properly constructed e-health record, I could confirm my assumptions by reading the medication prescribed by the last doctor.  Or even see what has been dispensed by the last pharmacy.

This would be an improvement over the current situation, and would save time.

A good system will save extra costs for duplicate tests when the originals can't be found or retrieving them would take too long.  Treatment can happen more quickly and better decisions can be made.

The proposed system could be improved to make it much more useful to treating doctors.  A past AMA President, Dr Mukesh Haikerwal, has tried to facilitate this through NEHTA by engaging Clinical Leads.  They need to be listened to.

The introduction for this forum today notes the importance of getting the technological landscape right for e-health. I agree.

But today I also want to point out that introducing technology reform needs the right policy setting.

It needs an e-health policy environment that recognises that health care providers are keen to implement e-health for their patients – but only in a ‘light touch’ regulatory environment.

If the burden looks too great in time, cost and resources needed for the task, very few will adopt the new system.

The reality of patients having to opt-in means that, when doctors look for a patient’s record, they will often find there isn’t one. 

The PCEHR has been designed from an ideological point of view. 

Patients will decide if they want one. But there is no information about what the opt-in rate will be.  We might have fast take-up by patients, or it might be very slow.

In the meantime, in clinical practice there are only so many times that doctors are going to stop and look to see if their patient has opted in and given them access to their PCEHR.

If doctors were to find that most of their patients had a PCEHR, they would be more likely to keep using the system.  We hope that the opt-in feature proves successful. 

We know that, from 1 July, patients will be able to register for their PCEHR.

Just last week the Government launched the e-health.gov.au website.  Through that website, the Government is encouraging patients to register an interest in having a PCEHR.

But there is still much work to be done to roll the system out to hospitals and general practices.

There is still uncertainty about when and how well the system will be connected to health care providers.  There is a lot of technical work being done behind the scenes. 

And there is still a long way to go until we have appropriate, interoperable, tested, and affordable practice software to connect doctors and nurses to the system.  Every practice will need an upgrade.

At this stage, the Government strategy appears to be a ‘build it and they will come’ approach to supporting healthcare providers like me to tool up to use the PCEHR.

As announced in last week’s Budget, the Government will require general practices like mine to participate in the PCEHR in order to attract e-health practice incentive payments.

The Government is going to force us to make an investment in terms of redesigning our practices’ processes to integrate a system that, at this stage, we have relatively little information about.  This is a ‘stick’ to encourage us to do more for the same reward.

There is plenty of commentary recognising that general practice will have to make the most investment in the PCEHR both in time and money and will realise the least amount of benefit from it – and that is a real concern for us.

It will be interesting to see how non-GP specialist medical practices warm to the PCEHR without any incentives at all.

The legislation underpinning the PCEHR carries a lot of new obligations for medical practices, hospitals and other organisations providing health care. 

There is a large administrative impact on medical practices.

Medical practitioners who decide to use the system will have to adapt their clinical workflows and train their staff to work within the requirements of the legislation.

Doctors will have to consider the impact of this additional workload, and the changes to clinical workflow, on the fees they charge their patients.

As I said, the biggest impact will be on GPs.

GPs will take on the role of “nominated healthcare providers” and create and maintain the “shared health summary”.  This is a key feature of the PCEHR.

But without specific MBS items for this work, it will have to be absorbed into the standards consultations.

As things stand, GPs are being asked to provide a new service for free.

Providing a shared health summary is a very specific task requiring clinical skills.

GPs will work with their patients to ensure that a complete and accurate summary is available to be used by other health care providers in their clinical decisions. 

It is only reasonable that patients should receive an additional Medicare rebate for this very important additional service.

There needs to be some investment by Government to support medical practices that are private businesses – to invest in the infrastructure that is needed to make the PCEHR work.  There needs to be a business case.

Doctors need greater support than that what is on offer if the PCEHR is going to truly work to improve patient care and reduce waste and risk in health care.

The AMA is a great supporter of, and advocate for, accurate electronic communication.  It is the future.

We support the introduction of the PCEHR – but it has to be the right PCEHR.

At the moment, we do not think the proposed PCEHR is the right PCEHR.  And the Minister knows our view.

The implementation process may start on 1 July but the completion of the implementation will be some time off, unless there is genuine consultation and agreement on the final product.

16 May 2012

CONTACT: John Flannery 02 6270 5477 / 0419 494 761

Kirsty Waterford 02 6270 5464 / 0427 209 753 

Follow the AMA Media on Twitter: http://twitter.com/ama_media

Follow the AMA President on Twitter: http://twitter.com/amapresident