Dr Andrew Pesce, Keynote Opening Address, AFR National Health Conference

SOFITEL SYDNEY

TUESDAY 17 AUGUST 2010

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The National Health and Hospitals Network

Good morning.

My subject today is the Government’s National Health and Hospitals Network.

If this speech was being delivered next week, it could possibly be a very different speech depending on the election result.

Labor and the Coalition have different views on the future of the National Health and Hospitals Network.

It is our job at the AMA to make sure both sides are serious about health reform.

For now, the Network is still a ‘live’ topic of conversation.

I will talk about the Network policy from a clinician’s perspective.

There are some specific areas I’ve been asked to speak about that are listed in your program.

I will speak about those issues in some detail, but first I’d like to talk more broadly about health policy and health reform.

What do doctors want?

Doctors want health to be the top priority of every Government.

But this is important, not just from a doctors’ perspective, but from everyone’s perspective.

Firstly, good health policy affects everyone.

Access to health care, and the quality of services, impacts on everybody.

Secondly, a healthy population makes good economic sense.

More people in the workforce means more people able to contribute to growing Australia’s economy.

Good health policy makes good fiscal sense.

Finally, good health policy wins votes.

Every voter can relate to needing more time with their family doctor, waiting endless hours in an emergency department, or living in pain while waiting for elective surgery.

That’s why this election has been so surprising for doctors.

And I’m sure for most of the delegates here today.

The current Government’s health reforms were a positive step in addressing many of the problems in our hospitals and the wider health system.

But there is still little detail about how these reforms will be implemented and work in practice.

This election period has not provided us with much more information.

We also haven’t seen any move by either party to significantly address gaps that the National Health and Hospitals Network reforms have left unplugged.

The AMA has published a list of what we think are the key health issues that urgently need Government support.

What has either party said about Indigenous Health?

Throughout the term of the last Government, it was heartening to see a bipartisan resolve to close the gap on Indigenous disadvantage.

At every election, the AMA calls for more concerted action, in partnership with Indigenous people to address this national disgrace.

Yet, here I am today, still saying that we haven’t done enough.

What has either party said about improving patient access to their family doctor, especially people with a complex or chronic condition?

The current Government has come up with a plan to improve care for people with diabetes.

But this plan will mean patients giving up their entitlement to Medicare rebates.

The plan doesn’t guarantee that patients will always be under the care of their usual family doctor.

The AMA has a better plan - one that would improve care for all patients with chronic diseases, not just diabetes.

This plan has the overwhelming support of GPs.

Our plan focuses on the patient’s clinical needs and ensures that more support is available to those patients who need it.

We’re not asking for more money for GPs, but better subsidies for patients to access the ‘other than GP’ services, such as podiatrists or dieticians, they might need to better manage their conditions.

We’ve asked both parties to get behind the AMA’s plan if elected.

The Opposition’s policy is consistent with our plan.  The Government says it will go ahead with its plan.

We ask that if a significant change in health funding is to be implemented, it should be done on the basis of evidence that it will improve access to services for Australians.

We ask that the Government ensures that changes are the best we can achieve by trialling its plan against ours to determine which is better and more cost effective.

For some reason, the Government does not want to find out - and so the debate remains a political, rather than a clinical, one.

In recent weeks, there’s been much said about the unacceptable state of mental health services in Australia.

The AMA has supported the Coalition’s announcement to commit an additional $1.5 billion to mental health services.

The AMA also welcomes the Labor Party’s commitment to invest more funds in suicide prevention.

However, both parties have missed the point.

Mental health reform needs a comprehensive and strategic approach across the whole health system to make a difference.

Mental health reform means more hospital beds, respite services and better access to specialist medical care in the community, and other social support.

It is also about providing employment and housing support.

The plight of those with mental illness needs to be tackled with as much, if not more, determination than the political parties are putting into the immigration debate.

I should also note that while the AMA is pleased to see evidence of the Coalition’s intended investment in mental health, it’s concerning that it would come at the expense of e-health.

A journalist asked me a few weeks ago whether I thought there were any areas in health where it was possible to make savings, given the current mood of fiscal constraint.

I answered that the best way to get savings is, overwhelmingly, getting our health care models right.

Investing in e-health is one way to do that.

It’s a terrible waste of money and time for me to have to reorder tests on a new patient, because I can’t get access to their health care records.

There’s a lot of unnecessary expenditure, just because of the inefficiency of our health system.

So e-health is an investment, not a cost.

It saves us money if we invest it wisely.

And I note here that Labor has made a significant commitment to invest in e-health and telemedicine.

The AMA welcomed that commitment as an investment in a modern health system.

Another area of huge potential to generate savings across the health system is preventive health care.  Keeping people away from hospitals is the best investment.

Everyone in this audience is well aware of the modelling that shows waiting until someone is sick enough to need hospital care is much more expensive that investing carefully in preventive and primary health care.

I’ve talked briefly about Indigenous health, mental health, managing chronic illness, e-health and preventive health care.

These are a sample of the key health areas the AMA believes Governments should be investing in as part of the broader health reform agenda.

We think they are no-brainers for any Government.

Let me now address the particular topics listed in the program: the new funding split between the Commonwealth and the State Governments, access to elective surgery, national access targets for emergency departments, and transparent hospital performance reports.

The AMA would have preferred that there was a single funder of hospitals.

The sixty/forty, forty/sixty or any other funding split will not end the blame game.

It will just provide different opportunities to cost shift and avoid responsibility for whole of hospital system outcomes.

And that’s just within the hospital system.

How will health services be coordinated across the primary care and hospital systems without a single funder who has to pay - no matter in which part of the health system the care is provided?

As a doctor, I want to know who will be responsible if a Local Hospital Network doesn’t deliver on the services the community needs.

I want to know who is responsible for ensuring coordinated transfer of care from a GP’s surgery, into a hospital, and then back again.

And I want to know that care is organised for the benefit of the patient, not individual health budgets.

Who will be responsible for fixing things that aren’t working well?

Which Minister will I write to when there is a problem that needs to be fixed?

Under the new system agreed at COAG, the States will essentially continue to have control over services provided by hospitals via service contracts to be negotiated with local hospital networks.

Funding will be activity based, but the number and mix of services funded is still determined by the State.

Local Hospital Networks will be run by Governing Councils - but the Governing Council is chosen by the State Minister of Health.

Some Ministers - Carmel Tebbutt in NSW and John Hill in SA - have acknowledged and support the appointment of local clinicians to Governing Councils.

Victoria opposes local clinician involvement, and other States and Territories are yet to decide.

It is imperative that clinicians re-engage in decision-making at all levels in the health system if we are to work together to improve our hospital and health system.

The Opposition has committed to renegotiate the COAG Agreement to institute Community Boards of related hospitals, and devolve the National Framework Responsibilities to existing national bodies.

It doesn’t look as if the Commonwealth will have enough power or control over public hospitals to fix parts of the hospital system that aren’t working well.

We have seen the compromises that the Commonwealth made to get the States to sign up to at COAG.

If the States remain in the driver’s seat on the rollout of these reforms, it could be ‘business as usual’ in our hospitals.

Now what do doctors think about targets and hospital performance reports?

There’s nothing wrong with setting targets and measuring performance.

Targets set us goals that motivate us to achieve.

Measuring performance keeps us accountable and transparent.

The AMA fully supports the development of national standards and reporting.

If they are implemented well, they can be used to inform improvements in clinical practices.

Hospital performance reports can also ensure all levels of Government are held to account for the funding and services provided.

A poor performance report can help identify hospitals that are struggling because they don’t have sufficient funding or equipment.

Used wisely, these reports can help ensure that hospitals are properly resourced for the services they are asked to provide.

We do have to be careful, however, not to use these reports to name and shame hospitals themselves.

If hospitals are not working well, Governments are ultimately responsible for ensuring they are in a position to improve.

Similarly, we have to be careful when setting targets.

Just because you set a target, it doesn’t automatically follow that the target is achievable, or even meaningful.

Targets, when they are met, are great for politicians.  But you never hear from politicians when targets aren’t met.

Let me use the example of the four-hour national access target for emergency departments that has been agreed by COAG.

The proposal is that all patients presenting to an emergency department of a public hospital will be treated, referred for follow-up treatment, or admitted to hospital within four hours.

This target will be phased in over the next few years, with the most urgent category of patients coming under the target from the beginning of next year.

From the patients’ perspective, this sounds great.

They want to spend the shortest time possible in an emergency department.

From the doctors’ perspective, they will always treat their patients quickly and effectively if the hospital has the capacity to allow this.

 

In Western Australia, where a four-hour target is being phased in already, doctors have reported that the target motivates them and hospital managers to think differently about how hospitals operate.

For example, smarter and more timely discharge planning in the rest of the hospital can free up beds more quickly for patients in emergency waiting to be admitted.

I’ve heard about a hospital where beds were only available after 2.00 in the afternoon – even if the bed was empty in the morning – because that was when the cleaning contractors would have them ready.

Once the target was introduced, hospital management changed the cleaning contract so that, once a bed was empty, it was available for a new patient much more quickly.

So, there are early signs that the targets are driving improvements in hospital systems, which in turn is helping reduce overcrowding in emergency departments.

But.  And there’s a big ‘But’…

It isn’t as easy as that.

Just because a target is set doesn’t mean it’s achievable or even meaningful.

In the example of emergency departments, it is easy to see that premature transfer of a patient to a ward prior to adequate diagnosis and stabilisation may be detrimental to the quality of care received by that patient.

Especially if admitted to a ward where care is overseen by an overworked and inadequately supervised junior doctor.

We have seen examples of ED waiting time targets being achieved by blowing out on stretcher times, rather than genuinely improving access to treatment.

What doctors don’t like are policy decisions without evidence.

There is no evidence in the literature that supports any specific time-based target, whether it is four hours or six hours or eight hours.

There is no peer-reviewed data yet available that show actual improvements in patient care or health outcomes as a result of setting time-based targets.

The UK Government’s decision to introduce, and then this year remove, a four hour target for emergency departments was not based on any rigorous evaluation or evidence.

As for being achievable, the literature around the world shows that delays in emergency departments, particularly for hospital admission, are mainly due to capacity constraints elsewhere in the hospital.

Delays happen because there aren’t enough free hospital beds, because there isn’t enough access to diagnostic procedures, and because there aren’t enough senior or specialist doctors to provide the care or supervision needed.

The bottom line is that if we don’t increase overall hospital capacity, time-based targets only set emergency department doctors and nurses up to fail.

That’s why it’s vitally important for doctors practising in the area to be consulted before policy is developed, while policy is developed, and particularly about how policy is implemented.

We’ve made it clear that if time-based targets are implemented, not only does there need to be sufficient resources, but patient safety must come first, targets must be consistent with clinical guidelines, and the policy needs to be rigorously evaluated.

I acknowledge that the current Government has announced significant additional funding for emergency departments and to increase the emergency medical workforce.

And we will be interested to see if this funding will provide enough support for hospitals to achieve these targets.

The new, improved performance reporting framework should let us see this more clearly.

It will be even more important for State and Territory Governments to make a real commitment to nationally consistent collection of accurate and comparable data so that we can see an honest picture of what’s happening.

It is no longer satisfactory for States to measure their own performance and not be accountable to national standards.

The quality of data, or rather the lack of it, is a particular problem for elective surgery waiting lists.

I think we all appreciate how unreliable elective surgery waiting lists are.

Firstly, the length of time a public patient waits to be seen by a specialist after they have been referred by their GP is not measured.

Sometimes the wait to see a specialist is longer than the wait for surgery.

The AMA believes that public elective surgery waiting times should start from the time a patient is referred by their GP.

Secondly, there are still problems with the definitions and categories used by State Governments, despite efforts to bring them in line with national standards.

This makes it hard to interpret changes in waiting lists from year to year.

Thirdly, there seems to be a mismatch between what some of our members are telling us about waiting lists and what the official figures say.

There’s a serious problem if doctors don’t have any confidence in the official statistics.  If doctors don’t believe the statistics, nobody else will or should.

I think the Government’s policy of improving access to elective surgery is commendable.

I’m hopeful, but not certain, that the commitment to independent national reporting will mean we’ll be able to accurately measure the impact of extra funding to see if it really makes a difference.

In closing, I want to emphasise that we believe the National Health and Hospitals Network Agreement provides great potential for improving our health system.

It will be necessary for the Coalition, if elected, to move quickly to replicate the functions of the announced National Authorities within existing statutory bodies to ensure that progress on national standards, safety and quality and pricing of Activity Based Funding is not slowed.

As an organisation, we’ve been fully involved and engaged with the Government and the Opposition in trying to produce reforms that benefit patients.

But this is just the beginning.

For the Government and bureaucrats, it might seem like most of the work is over once their reforms are agreed and announced.

For doctors, we understand the work is just beginning.

Making the good ideas work as they should.

And trying to make sure those ideas we don’t like so much are implemented in a way that reduces their risk, and still provides some benefit to patients.

That’s why it’s so important for doctors to be consulted every step of the way.

Doctors are at the coalface of the system and constantly see the impacts of Government decisions.

Doctors know how to make the system work best for patients.

Health policies that don’t reflect consultation with the medical profession will not work.

Apart from our belief that our input improves policy, it is obvious that where local doctors have real input into policy development and management decisions, they will work better at implementing those decisions.

The Government has made a commitment to productive health reform.

I believe there is goodwill and momentum for ongoing productive health reform.

I hope whoever wins the election this weekend will continue with this commitment.

Our hospitals and our health system need fixing.

We have to fill the gaps – in mental health, in Indigenous health, and so on.

The system must change -  no change is not an option.

 

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17 August 2010

 

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