Dr Hambleton, speech to the National Press Club, Wednesday 20 July 2011

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Fixing Health: Unfinished Business

I acknowledge the traditional owners of the land on which we meet, and pay my respects to their elders, both past and present.

Indigenous health

So much more needs to be done to improve the health of Indigenous Australians.

There has been more funding from the Government and through COAG – this is very welcome.  The key now is to ensure that the money is well spent.

We must continue to build the capacity of Aboriginal community-controlled primary care services so they can do more at the local level.

We must also address the social determinants of health in Indigenous communities - things we take for granted such as housing, education, water and sanitation.

This is a big job for all of us – governments, non-government organisations, the health professions, and others.  We must do everything possible to Close The Gap.

Just as there are challenges in Indigenous health, other areas of our health system also need attention.

We must support the health professionals who provide the care.

Family Doctor Week

This week is AMA Family Doctor Week.  It is a time when we remind everyone about the important work carried out by GPs.

Family Doctor Week activities are highlighted on the AMA website.  I recommend you take a look and support your local family doctor – your GP.

I stand here today as a proud GP – a GP still burning with a passion to help people both through my practice and through my work with the AMA.

Just over six weeks ago, I was honoured to be elected unopposed as the Federal AMA President.

This job carries a heavy responsibility – none more than being a voice for doctors.  All doctors.

My advocacy must echo the daily experiences of doctors in the many and varied ways and places that they practise medicine.  Not only do the situations and environments vary, so do the challenges and the risks.

The vocation of medicine requires an unrelenting dedication and determination to do the best you can for your patient.

At times, that also means speaking up about things that could improve or might hamper medical practice.

This advocacy, in turn, will improve the care and treatment of patients.

It will improve the provision of accessible health services in communities all around Australia.

It is from this standpoint that I wish to discuss health, health policy, and health reform with you today.

I am going to talk to you about a heroic vision.

I am also going to present you with a sad reality.

And I am going to offer you some solutions.

Health reform

Two years ago, when my predecessor stood here, it was a time of promise, a time for Big Bang changes to health service governance.

It was a time when there was a vision for efficient and accountable health service delivery.

The Government was armed with reports and reviews, and feedback from countless community and clinical consultations.

The Government’s own polling told them that our public hospitals were suffering, and they needed a fix.

Then came the health reform rhetoric:

• End the blame game;
• Build more beds;
• Build computers to hold medical records that will actually talk to each other when we need them to;
• Central funding with local control;
• 60 per cent Commonwealth funding for hospitals and teaching and training;
• 100 per cent funding for primary care; and
• A commitment to allow clinicians to lead.

There were Labor governments from coast to coast.

Only Western Australia at the time had a Coalition government.

There was a rare alignment and a rare opportunity.

There was a heroic vision.

At this very podium two years ago, Dr Andrew Pesce committed the AMA to engage with the Government on this bold health reform agenda.

But he also said ‘come and talk to the AMA first’.

The AMA is the conduit to the frontline in hospitals, public and private.

The AMA is the conduit to the GP workforce.

The AMA can help make the reforms work.

But the talk didn’t happen.  All too often we were not asked what would work in local surgeries, hospitals, laboratories and community clinics.

So let’s talk about the elephant in the room – the sad reality.

Since then, we have a new Prime Minister, a Federal election, and now a minority Government - and State elections that have delivered feisty State Governments.

The COAG Agreement from earlier this year was the start of the end.

The States appear to be once again calling the tune - and the tune is pretty much ‘business as usual’.

Where once ‘no change’ was not an option, I fear ‘no change’ may well be the new masthead in health reform.

A single funder – gone.

Uniform public hospitals reform – gone.

Ending the blame game – gone.

100 per cent primary care funding – gone.

Any change now will be slow.  Good reforms will be rare.  Improvements will be at the margins.

So we are now talking about a health reform landscape that is far removed from two years ago.

There are still remnants of the Rudd reforms but they are not necessarily the good ones – at least from our point of view.

The AMA has consistently called for genuine medical consultation with frontline doctors on any health reform.

When reforming anything, it is Management 101 to consult with those in the front line.

They will show you the efficiencies, and they will tell you what works and what doesn't.

It seems the Government’s commitment to consult with doctors before rolling out new policies is rapidly disappearing.

Let’s have a look at the reforms that are still alive and answer the question: are they the result of consultation or are they not?

GP Super Clinics

One of the programs the Government remains most passionate about is GP Super Clinics.

The evidence shows that it is misplaced affection.

If GP Super Clinics were a movie, it would be Field of Bad Dreams – “if you build it, they will not come”.

The facts speak for themselves:

• A promise of 64 GP Super Clinics at a cost of $650 million;
• 11 are fully operational;
• 11 are partly operational; and
• nine are under construction.

The Department of Health and Ageing has said it will not conduct any assessment of the impact of the clinics on neighbouring general practices.  So we will never know if services are duplicated or if they are simply replacing existing services.

Twenty five GP Super Clinics are not even in designated districts of workforce shortage - but these 25 clinics will cost taxpayers $190 million.

At Clarence in Tasmania, let’s look at the recipe.  Take one State government-funded general practice of eight doctors, add a chunk of Super Clinic money, and open five months late with only three GPs.

The Queanbeyan Super Clinic in New South Wales is simply a re-branding of a long established clinic with 17 GPs.  It cost taxpayers $5 million.  Is that value?

The $2.5 million allocated for the Mt Isa GP Super Clinic isn’t enough to buy the land to build it on.

In Wallan, Victoria, there is no land available to build the promised GP Super Clinic.

The Modbury GP Super Clinic, South Australia, is costing $25 million.  It opened last year with no GP – it now has one full time GP.

The AMA has a solution.

Take all the remaining GP Super Clinic money and redirect it to improving infrastructure in existing practices.

These practices could expand the services that they provide with improved facilities, up-to-date technology, and better multidisciplinary care.

They could provide more teaching facilities in general practice.

The original $650 million could have provided every GP practice in the country with around $90,000 in infrastructure grants.

Instead, we have a GP Super Clinics program that is not based on patient or community health needs.

We have GP Super Clinics competing with local doctors, not supporting them.

Medicare Locals

Another Government priority is Medicare Locals.

We are told they will integrate and coordinate the range of organisations and service providers that operate within primary health care – a good idea.

We are told they will better link primary health care and other sectors – another good idea.

If done well, and in a manner that is supportive of general practice and GPs, this approach could provide benefits to GPs and their patients.

However, taking money out of general practices already delivering quality services for their patients – that’s a bad idea.

Medicare Locals, as currently framed, could waste a lot of valuable resources and disenfranchise the GP workforce.

The AMA has a solution.

To succeed, Medicare Locals need careful planning and a clear vision.

To succeed, they need strong consultation with local GPs who are the frontline of primary care and the first point of call for most people when they are sick.

To succeed, they need GP leadership on their boards.

The first 19 Medicare Locals have been announced, but there is no evidence of any of these key elements of success being part of their make-up.

We are still no closer to understanding how Medicare Locals will be structured and what services they will provide.

What we do know is that funding is being diverted from general practice.

We do know that Medicare Locals are not really local – they are remote.

There is talk of fundholding over and over again.  This must stop.

Overall, we desperately need to see some detail about exactly what they will be doing and how.

It is a big ask for the AMA to support this vacuum.

The Australian community cannot afford this to be an experiment.

This exact primary care model initially failed in New Zealand.  It was rescued when doctors were brought in to run the boards.

Again, the AMA has a solution – a better way to go.

The Government must learn from the New Zealand experience and get it right the first time.

We thought this message was getting through.

Health Minister Nicola Roxon made the following commitments at the AMA National Conference in May:

She said that: ‘…Medicare Locals will support and assist GPs to provide better care for their patients.’

She said that: ‘…Medicare Locals are not intended to and will not displace the central role of the GP in the primary care system.  They will need to include local GPs in their governance and board structures – we are crystal clear on this.’

She said: ‘…And we have absolutely no plans to cash out Medicare benefits and have these funds held by Medicare Locals.’

And she said: ‘…We don’t want to usurp the role of the GP.’

We welcome these comments, but we need evidence that they are being turned into action.  We haven’t seen it yet.

We have written to the Minister expressing our concerns about the way things are going.

We have written to the Chairs of the first 19 Medicare Locals expressing our concerns.

Our view of Medicare Locals is that, if they are implemented correctly and with the right intentions, they can work.

But doctors have to be core parts of the process.

I announce today that the AMA will create local GP consultation groups in each of the first 19 Medicare Locals districts.

I will travel to each of these Medicare Locals and assist these groups to get the AMA primary care message spread throughout these communities.

The AMA will do all it can to empower local GPs to have a leading role in Medicare Locals.

The AMA will stand up for doctors to help them get the services they need for their patients.

Mental health

This is exactly what we are doing at the moment with mental health.

The Government has slashed $400 million in Medicare funding for GP mental health services under the Better Access Program.

In some cases, patients will have their Medicare rebates halved.

The Better Access program provides access to GPs and psychologists for over one million Australians each year.

But this didn’t seem to matter when the Government claimed a $2.1 billion mental health package on Budget night.

Better Access got the chop.  A successful mental health program was cut to pay for an untested one.

Closer examination of the Government’s claim shows that, in the standard four-year budgetary framework, the net new mental health spending is only $390 million.

The Government’s package does not match its rhetoric.

The Centre for Health Policy and Programs independently reviewed the Better Access Program.

The Review said that the program has:

• improved patient access to mental health services;
• achieved positive outcomes for patients with mental illness; and
• provided affordable access to GP mental health services, with little or no out-of-pocket costs.

The same review also found that the program was cost effective.

The Government has maintained that people in disadvantaged groups are not getting access to Better Access services.

This is simply not the case when you look at the facts.

According to the Review authors, 150,000 people in the most disadvantaged areas across Australia received services in 2009.

This is far more than prior to the Better Access program - and it is the fastest growing subset.

The Government’s decision will affect vulnerable patients and make access to vital GP services less affordable.

It is important for the community to appreciate the signal that these cuts send to people with a mental illness.

Medicare will now treat people with mental illness less favourably than people with a physical illness.

Despite involving more work and responsibility, rebates for GP Mental Health Plans will be between 10 per cent and 50 per cent lower than GP Management Plans for other chronic illness.

This devalues the importance of tackling mental illness.

We surveyed more than 700 GPs over the last couple of weeks to gauge the reaction to the cuts.

We are releasing the survey results today, and here are some of the key findings:

• 85 per cent of GPs surveyed think the budget cuts will reduce patient access to mental health services;
• 58 per cent of GPs think that the Budget cuts will lead them to spend less time with patients with mental health problems; and
• 28 per cent of GPs stated that they would stop using Medicare GP Mental Health Treatment items.

And here are some of the more telling comments from the surveyed GPs.  They said …

‘The Government is once again devaluing the service of GPs and making it a less inviting profession. In the long term, patients will suffer both from a monetary stance and a lack of doctors.’

‘I am very upset about these changes.  I feel I am being financially penalised for having an interest in mental health and a readiness to bulk bill patients from low socio-economic groups.’

‘This has been one of the most valuable changes the Government has made to encourage GP management of mental health problems.  I can’t believe they would be so stupid as to put the program at risk in this way.’

‘As a headspace doctor, this will impact the service there dramatically.  Patient access to services will be limited and recruitment of staff for the proposed new sites will be extremely difficult.’

I think, in summary, we can say that the GPs are not happy.

Over the past two weeks, the AMA has also been running an online petition to have these cuts reversed.

So far, we have collected more than 2000 signatures.

A lot of people are not happy with the cuts.  These people are voters.  Their numbers are growing.

The AMA has a solution.

Reverse the cuts.  Invest in mental health and do not devalue the engine room of our health system – the GPs.

The AMA will be enlisting the support of our members, the profession, and the general public to force changes to the Government’s mental health package. 

Doctors will charge the same.  The Government has cut the Medicare rebate.  Patients will have to pay more.

This is not health reform.  This is bad policy.

The sad reality of missing health reform is not just limited to primary care.

Public hospital funding

The great 2007 election pledge to fix our hospitals remains undelivered.

In November 2008, then Prime Minister Rudd announced a $64.4 billion investment in health and hospital funding.

The National Health Care Agreement provided an extra $4.8 billion for public hospitals.

The Prime Minister's press release at the time said this investment could support an additional 3,750 beds in 2009-10, growing to 7,800 additional beds by 2012-13.

Let’s look at the scoreboard.

Only 378 new public hospital beds were opened in 2009-10.

These new beds did not go close to making up the lost ground of the previous year when only 11 new beds were opened.

These numbers show that our public hospitals still do not have the capacity to meet the acute care needs of sick Australians – not just now, but in the years and decades ahead.

We have a growing population and an ageing population.

GPs know about this bed shortage when they try to get elderly and medically sick people into hospital where they should be.

Unfortunately, it is still too easy for decision makers to blame someone else.

The blame game lives on.  This is why the AMA has called for a single public funder to be responsible for hospitals.

People want timely elective surgery and they don't want to be cancelled at the last minute.

They want timely emergency care and, if they need admission, they don't want to languish on trolleys in corridors waiting for a bed.

That is why the AMA is vigilant in monitoring the capacity of public hospitals.

That is why we watch how Governments are performing in providing public hospital services under the Health Care Agreement. 

Our Public Hospital Report Card for 2011 is currently being drafted.

I can tell you now that it will not show much improvement for the additional investment that has been made.

For starters, the median waiting time for elective surgery is 35 days.  Five years ago, the median waiting time was 29 days.  The capacity of public hospitals is not keeping pace with demand.

Another key measurement of hospital capacity is the percentage of elective surgery patients who are seen within clinically recommended times.

The current Health Care Agreement has a benchmark of 95 per cent.

When the Commonwealth last reported this data - for 2008-09 - only 78 per cent of category two urgency patients were seen within the clinically recommended time of 90 days.

The percentage across all three urgency categories was 86 per cent.

The Minister is now reported as saying that this benchmark will be 100 per cent.

This is a very big call when we know that public hospital capacity has not increased to the extent that it needs to.

It is curious that the Government has not published this data for 2009-10.

The danger is that the community is being misled through a combination of overly ambitious targets and a lack of transparency around the real capacity of the hospital system to deliver those targets.

A case in point is the ‘hidden waiting list’.

Every AMA member working in the community or in public or private hospitals knows about the ‘hidden waiting lists’ for elective surgery.

When patients are referred to a public hospital for surgery, most of them have to wait several months to get an appointment with the surgeon to be assessed.

This waiting time is not counted.

It is hidden - but it is often the longest part of the wait and the most important for the referrer and the patient to know.

Just recently, one of my Queensland colleagues referred a patient to a public hospital for specialist care.

He received a letter from the hospital informing him that: ‘The waiting list was lengthy’ and the patient ‘would not be seen in a reasonable time’.

It seems that even the clerks in that hospital know that there is a problem.

Is that the result of a heroic vision or is that a sad reality?

The AMA has a solution.

We need fully operational hospital beds for people to have their elective surgery when they need it.

We need 85 per cent bed occupancy.

This would allow surge capacity so that elective patients don't need to be cancelled and we would have the capacity for teaching, training and research.

We need honesty and transparency with statistics.

We realise that there will be some priorities, but GPs and their patients need this information so that we can consider alternatives. 

The hospital managers need to know this as well, so the problem can be fixed and not swept under the carpet.

AMA members working in public hospitals know that public hospitals have diminishing capacity.

This has happened in parallel with doctors being disenfranchised from the decisions about hospital services.

Clinicians are being hindered in their treatment of patients because of the bureaucratic ‘top down’ approach.

Most of the Rudd health reform announcements were about funding structures.

But there was always an overarching promise to deliver real results on the ground for better health and better hospital services across the country.

The catchcry was ‘health and hospital services funded nationally and run locally’.

Lead Clinician Groups

The medical profession was promised that ‘run locally’ meant new structures called Lead Clinician Groups.

These Groups would guide Local Hospital Networks on ‘service planning and the most efficient allocation of clinical services within the Network’.

It seems that, apart from NSW where doctors are involved in hospital decision-making, our aspirations for doctor engagement have not been realised.

The big promise has become the convenient compromise.

We now have a proposed national structure that puts Local Lead Clinician Groups as the go-between for Local Hospital Networks and Medicare Locals.

We hear about clinical standards, not clinical governance.

The AMA has a solution.

The State and Territory Governments must enshrine medical participation in governance structures.

We want the Commonwealth to force the issue by making Commonwealth funding available only when structures that guarantee local doctor involvement are in place.

That would get things back on track.

This may come as a surprise to you, but we don’t think the health agenda is all bad or coming apart at the seams.

Plain packaging

While the AMA is greatly disappointed by the lack of BIG health reform, the Government has managed to deliver some significant and welcome policies.

Thanks mainly to the tireless efforts of Health Minister Roxon, Australia is set to lead the world in tobacco control with plain packaging.

This is a mighty achievement that is backed 100 per cent by the AMA.

Smoking kills – it is as simple as that.

Policies that stop people smoking and policies that discourage people, especially young people, from taking up the killer habit must be supported.

Similarly, we strongly support the creation of the Australian National Preventive Health Agency.

The Government has made the right decision in allowing GP MRI referrals, creating new GP training places, providing GP infrastructure grants, and new funding for practice nurses.

These initiatives will make a difference – but we still need the big reforms to come on through.

Health reform is vital – and it is still possible.

AMAs health reform plan

The problems I have outlined today are not terminal.  They can be fixed.

The AMA has a plan for health reform.  It is based on clear and achievable principles:

• Innovation needs to be simple and practical;
• Changes need to be transparent; and
• Service improvement must be informed by clinical competence and must improve patient outcomes.

Here is our plan …

One, public hospitals must be financed by one public funder.

That means one level of government funding and one level taking real responsibility.

This will result in less blame shifting and better value for money and accountability to the community.

Two, we need a watchdog to make sure that resources dedicated to open more hospital beds genuinely open more hospital beds.

Three, we need to better support general practice.

This means ensuring that the GP’s patients can access well-integrated support from nurses and other allied health services without the red tape.

Four, we need an overarching medical workforce plan for the next decade.

It is simply not enough to graduate more medical students.

They need jobs and training that meet the needs of the community.

We need to know that the full range of medical services will be available across the country. 

So far, there is no certainty and no plan.  But we know that one is coming - so we are all watching this space.

Five, we need medical involvement in hospital and primary care governance.

Evidence shows that where doctors run the management of hospitals, results improve and morale is better.

Unless the Medicare Locals are governed by GPs, they will fail - and failure should not and cannot be an option.

In closing, I make this pledge to the Government.

I will tell you what doctors think about your health policies.

I will provide you with a conduit to the frontline of health service delivery.

I will disagree with you when your deeds and actions are bad for doctors.

Because if they are bad for doctors, they will be bad for our patients and bad for our health system too.

I will offer solutions.

I ask a simple pledge in return – talk to us first.

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20 July 2011

CONTACT:         John Flannery                     02 6270 5477 / 0419 494 761

                       Geraldine Kurukchi              02 6270 5467 / 0427 209 753

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