AMA Transcript - AMA Public Hospital Report Card

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BRIAN OWLER: Okay. Well, thank you very much everyone for coming out to the AMA this morning to talk about funding of our public hospitals. The AMA is very pleased to launch the 2015 Public Hospital Report Card, which looks at our public hospital system right across the country. It focuses on both capacity but also on the performance in terms of emergency departments and in terms of elective surgery. A perfect storm is how the AMA describes the current situation for funding of our public hospital system. We have seen improvements in the performance in terms of access to our emergency departments, in terms of waiting times for our emergency departments, access to elective surgery in some states. But unfortunately, all of that is under threat.

There's a long way to go before many of the states reach the targets that were previously set in order to get 90 per cent of people admitted or discharged from an emergency department within four hours, and to get patients to have their elective surgery within the clinically recommended wait times. So, while doctors and nurses have put in an enormous amount of effort in terms of trying to meet these targets, and there has been investment in our public hospital system, we are very concerned about the funding of our public hospital system going forward.

Last year, in the 2014-15 Federal Budget, there was a change to the funding of our public hospital system. The National Health Reform Agreement, which tried to end the blame game between State and Commonwealth governments, ended. [The Budget] took $1.8 billion out of our public hospital system over the next three years. There was also a change in the MYEFO [Mid-Year Economic and Fiscal Outlook] from 2014-15, which took another $941 million out of our public hospital system for states and territories. The biggest problem, though, comes in 2017. Up until that point, we will have been under a system of activity-based funding where there was a commitment of the Commonwealth to meet at least 45 per cent of the growth funding. But in 2017 we're going to see public hospitals funded by the Commonwealth on the basis of CPI and population growth only. That is an enormous difference to the current funding arrangements.

Now, funding of public hospitals under that circumstance will be reduced…to an increase of only about three per cent or maybe four per cent per annum. For many states and territories, this leaves an enormous black hole in their budgets, not just for health, but the whole State or Territory budget. [NSW Premier] Mike Baird has described this as the biggest single financing issue for state governments across the country. We know that many states and territories do not have the economies, do not have the ability, to raise the revenue that's necessary to meet this shortfall. At the end of the day, it is the patient that suffers. It's not good enough for the Commonwealth Government, for the Treasurer, to throw their hands up in the air and say it's all the responsibility of State and Territory governments. It's a responsibility of all governments to make sure that our patients get the right access, the timely access, to health care that they need and deserve.

With these changes, we are going to see a situation where hospitals are scrambling to just provide the basic clinical services that patients need, to make sure that people can get into an emergency department, let alone trying to reduce waiting times, let alone trying to build capacity in our public hospital system. Now, there's variation among states and territories, and I'm happy to take questions in relation to our state and territories, but also in terms of future funding arrangements. I have Steve Parnis who's the Vice President of the AMA. He's also an emergency physician. Steve, would you like to say a few words?

STEPHEN PARNIS: Thanks very much Brian. I'm an emergency physician, I'm based in Melbourne and I have to say that the story is not a good one as far as the facts that the AMA has been able to glean from the Australian Institute of Health and Welfare, Budget papers and other sources. I have to say that there has been, I think, tremendous work in innovating, particularly in the emergency sector, as well as across the hospital system. You talk about increased flow and increased numbers of patients. In the last 12 months alone, seven per cent more patients treated in emergency. But the bar becomes harder and harder to climb when you look at resources being taken away.

The measures are there for all to see - short stay units, team-based care, early streaming, decisions about disposition of patients from the minute they come into the ambulance bay or the triage door - but with the sorts of changes that are being proposed for 2017 and beyond, let alone the cuts that have occurred in the last 12 months, there is a brutality about them, I have to say and, in fact, I believe an abdication of responsibility when it comes to the Commonwealth Government and their commitment to hospital funding.

These things have a human face and a human impact. They can't just be measured in terms of dollars on a balance sheet. I worked in emergency yesterday and I'll be back there tomorrow, and every day there are cases that I and my colleagues see which make things more difficult for the patients that we care for, and make it harder to do the work that we've trained so many years to do. Examples that come to mind are a patient who was dying, who needed a bed in a private area to be with her family, and that bed, despite the best efforts of the nursing and administrative staff, was not going to be available for five hours or more. Patients staying on trolleys because there simply was ‘no room at the inn’ to get them in quickly, and these are patients that have complex needs that could not be managed in the community.

So, these are the sorts of cases that are our daily bread in emergency medicine. We know that these things can be avoided with the right flow, with the right capacity, because without that, what we see is elective cases becoming emergency [cases]. So, this is the dilemma, this is the threat that we see facing hospitals across the country. We know that if things continue in the vein that the Federal Government has proposed then it will get worse, that the aspirational targets that we have will become a pipe dream, and patients will suffer. So, this is the message that we are putting ahead of tomorrow's meeting of the heads of government and also the Health ministers. Thank you very much.

BRIAN OWLER: Happy to take questions.

QUESTION: [Indistinct] elective surgery [indistinct] life threatening?

BRIAN OWLER: Well, I think first of all we need to remember what elective surgery actually means. I mean, elective surgery's not cosmetic surgery. No one chooses to have elective surgery. Elective surgery is any surgery that can wait more than 24 hours. So, unless it's absolutely life threatening at the time, everything else is elective surgery. So, when we're talking elective surgery, we're talking about people with cancer, we're talking about people that are waiting for bypass surgery, we're talking about children with congenital heart defects, we're talking about children with congenital spine problems. We're also talking about people with gross disability, people that can't walk because they have a spinal condition or they have arthritis of the hip or knee, and so these sorts of wait times can not only influence people's lives and provide an inconvenience, but they actually increase the chances of them having further complications. They experience deterioration in their health, and all of this adds to the rate of poorer outcomes, it adds to the rate of other morbidities and other co-morbidities that people experience.

So, these sorts of factors are very, very important when you start to talk about elective surgery. As I said, we are focused on the capacity of our public hospital system with our Report Card over many years, but I don't think we've ever been in the circumstance where the capacity issue has to be almost thrown out the window as we start to talk about the ability of our state hospitals to provide the very basic services.

If the $57 billion comes out of health funding between 2017 and 2025, which is what Treasury's evidence was to the Senate Economics Committee, that means that State and Territory governments will not be able to make up the shortfall. We will not be able to fund our hospitals to provide the standard of clinical services that they provide now, let alone build further capacity to improve the performance of public hospitals in the future. We will see the improvements that have been made under the reform process go backwards.

I can't overestimate or over-state the amount of effort that people, such as doctors and nurses in our public hospitals, have put in to reform to make our hospitals more efficient, to reduce unwanted clinical variation, to actually get a better system of funding through activity-based funding. We wanted that system to have the opportunity to work. We want to see it make a difference yet, from 2017, without any discussion, in the last Budget the Government threw out that system of funding, and we will go back to being funded solely on the basis of CPI and population growth.

There's been no discussion about how we're going to make our hospitals more efficient, simply the hands of the Treasurer thrown in the air, and the states and territories told that it's up to them. That's not good enough. We're weeks out from another Federal Budget. We want to see the funding for our public hospital system restored, so that we can have hospitals that deliver the care that our patients need and deserve.

QUESTION: What demographic probably are under the greatest threat? I notice that the report points out that the [indistinct] population really hasn't improved in real terms, and we're facing a growing problem with elderly populations. So what kind of impact might that have in the years to come?

BRIAN OWLER: Well, it is across the board, but certainly, with an aging population, we know that older people use a greater amount of our hospital resources. And I want to say that we are very supportive, as I've been saying for the past 10 months about the co-payment, to make sure that we get people better treatment, better management in the community, to hopefully keep them out of more expensive hospital care.

But, at the end of the day, I can't do brain surgery in someone's lounge room. You can't have a hip replacement in the garage or in the GP surgery. You've got to have the capacity in the public hospital system to deliver the sort of care that is only appropriate for a hospital. So you need to have both a proper public hospital system and good community care. It's not good enough to just take one sum of money out of acute hospitals to put it into the community. And we've seen a discussion about that in terms of mental health services in the last few days as well. We need to make sure that the Commonwealth lives up to its responsibility. I thought we'd ended the blame game between the states and the Commonwealth with the reform agreement, but that blame game is now back in full swing. And, unfortunately, the Commonwealth seems to have walked away from its responsibilities to provide Australians with proper hospitals, public hospitals, to meet the care needs of the future.

QUESTION: [Indistinct] result in this report underlines [indistinct] I notice that none of the states and territories reached the national emergency access target.

BRIAN OWLER: Well absolutely, and I think one of the other things that people need to understand is that demand on services in public hospitals has been increasing, Steve mentioned that before, I think, a 7.2 per cent increase in the number of presentations to our emergency departments. And, when you drill down on that number, these are not GP-type patients; these are category two and three patients; these are patients that cannot be managed in the community, that actually have very significant illnesses, and need very timely treatment. So, our doctors and nurses are trying to cope with an ever-increasing demand. But the fact that we are struggling to meet that demand, struggling to meet the targets, underlines the issue of capacity.

I mean, most of the problems with the emergency department performance are not the treatment of the lower category patients, it's actually those patients that need to be admitted into an appropriate bed for appropriate care in the hospital, because the beds aren't there. That's the part that we always struggle with. So, we've been outlining the issues about capacity for years, and we've seen a decline in the number of beds. We're much better at managing people in the community, there's no doubt about that, but there is a limit to how far you can push that. And we will be well beyond the limit with the budget initiatives announced in the last Budget. We need this Government to step up to its responsibility to provide proper funding to the public hospitals in the future. We need sustainable funding for the public hospital system.

QUESTION: Can you just [indistinct] on how New South Wales has been performing [indistinct]?

BRIAN OWLER: Yeah. So, I think it's fair to say that Minister [Jillian] Skinner has been investing in terms of the emergency department. We've seen the improvements in terms of performance to over 70 per cent admitted or discharged within four hours, and I think across the state there's definitely been an improvement - still well short of the target, but overall an improvement.

As far as elective surgery is concerned, New South Wales has performed better than any other State and Territory in terms of getting people treated within the clinically recommended wait times. And having said that, we still know that there are problems with people getting access to the hospital, making sure that they can get an appointment to see a specialist to get on the waiting list. And we refer to the hidden waiting list in the report. I think that's still an issue, and we still need to be able to measure that so that we get much more accurate data. But I think New South Wales has done a reasonable job in terms of elective surgery. Again, a lot of clinicians have put in a lot of time and effort in making sure that that happens, but I think there are still improvements that we need to see.

QUESTION: When you look at New South Wales and Victoria, those two together [indistinct], is there a widening gap [indistinct] …

BRIAN OWLER: Yeah.

QUESTION: between the smaller states and territories? I mean, it does seem to be considerably behind some [indistinct] and particularly the waiting times for emergency.

BRIAN OWLER: And this is probably one of the biggest fears that I have, is that with this initiative, larger economies like New South Wales and Victoria may be able to find some of the funding shortfall. But when you look at economies like South Australia, Tasmania, which have been in trouble, they do not have the capacity to generate the State revenue to meet that gap. We already have gross inequities in the system, as you point out. The performance in some of the smaller states and territories has been a lot less. We are going to see greater inequity across the country. To me, I think all Australians should have access to the same level of health care, whether you live in Tasmania or whether you live in New South Wales, or WA, Queensland, wherever it might be. But we are going to see greater inequity, and it will depend on which State and Territory you live in.

QUESTION: [Inaudible question].

BRIAN OWLER: I think the same thing. They are funded on the same system. We know that regional hospitals, there's often no alternatives for the patient to seek treatment at. So, when we look at diversion from one emergency [department] to another, when we look at some hospitals being able to take up the slack, for many regional hospitals they don't have that luxury. And I think there's going to be much greater stress put on them.

QUESTION: What would you like to see come out of the COAG discussions [indistinct]?

BRIAN OWLER: Well, I think there's going to be a lot of discussion about how they deal with the funding shortfall. As I said, I know that Premier Mike Baird sees this as the biggest issue, finance issue, that's facing State and Territory governments. [Coughs] Sorry. I think what we're going to see is a discussion about that funding shortfall, and how … we need the Commonwealth to step up and provide funding.

I might hand over to you Stephen.

STEVE PARNIS: [Indistinct] Yeah, so this is an issue that has a direct impact on the entire country, whether you are in a capital city, whether you are in regional areas, whether you are elderly with complex needs or whether you are a parent of a child who needs to go to hospital. I think we can sum it up by saying we've made some big progress in recent years with innovative models of care. What we are concerned about is that this model, which I, I think, accurately describe as a brutal series of cuts, particularly from 2017, will put a lot of those innovations at serious risk and mean that Australians won't get the standard of care that they rightly, I think, expect when they visit a public hospital.

QUESTION: [Indistinct] everyone's finished [indistinct] just an aside here, I might need you Brian to argue this.

BRIAN OWLER: Yep. Sure.

QUESTION: [Indistinct] a few times there how significant [indistinct] Premier with regards to this issue. We've got the …

BRIAN OWLER: Yep.

QUESTION: … the, you know, the meeting tomorrow …

BRIAN OWLER: Yeah.

QUESTION: … to thrash it out. You'd expect the Health Minister today to [indistinct] to address your report? [Indistinct].

BRIAN OWLER: Well, I would expect Minister Skinner, yes, would be looking at the report. I know- I've met with a number of other State ministers around the country who are very concerned about the same issue. We've got some new State ministers as well, I know they're very concerned about the issue. I think we're going to see a much more robust discussion now between the states and the Commonwealth.

Okay. Any other questions, or?

QUESTION: I actually have one on vaccination if I could quickly ask you.

BRIAN OWLER: Of course.

QUESTION: [Indistinct]. Just, can you please just outline why it's so important for children to be immunised?

BRIAN OWLER: Well look, vaccination is the most effective public health measure that is available, there's no doubt about that. We see lives being saved in the order of millions through vaccination and immunisation programs. It's not just important for the individual, it's actually important for the rest of the community as well. Because we know that there are people who can't be vaccinated for medical reasons, or are sick. And so, if those people are exposed to viruses or other illnesses, then they are going to be much more susceptible. So, it is actually about getting that herd immunity, making sure that there is enough people in the system in the community to make sure that we don't actually allow diseases to get a foothold and spread from one person to another.

Okay, thanks very much everyone.

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