"No More Bandaids"

Members of the National Press Club

Guests

Friends and colleagues.

I am here today to talk to you about the health system, which I believe is poised on a knife's edge. Health has the attention of the entire Australian population. The press devotes more headlines and more front pages to health than any other single area. Health matters to the people. And so it matters to politics.

I was elected as the AMA's Federal President a little over five weeks ago and in that time I have received a very large number of messages.

I've had messages from the public and patients - many touching messages of support and encouragement.

I've had plenty of messages from doctors as well.

They have urged me to continue to stand up for the profession we love and to fight for the interests of the patients we serve.

And I've had messages from politicians. Some have been welcoming, and have looked for common ground.

A few have been a little less welcoming and have suggested - some more subtly than others - that a boat rocker won't be welcome.

Well sorry. Too late for that! This is a boat that needs to be rocked.

And that's why I'm here today.

By world standards, Australian doctors and other health care professionals provide a very high standard of health care to the community.

But they are doing so in increasingly difficult circumstances.

Everywhere we turn, we find increasing financial pressure to curtail the costs of health care, and under our present system there are only two ways to do that - greater efficiencies in the way the system is operated, or reducing the level of patient care.

Today, I want to look at some of the problems we're facing and suggest some solutions.

I want to look at the pressure on our public hospitals, the slow strangulation of general practice, and the problems confronting aged care, Aboriginal health and public health.

PUBLIC HOSPITALS

Over the past 12 months, I have spent a lot of time visiting public hospitals. I have spent a lot of time listening to patients and staff.

Everywhere I go, the story is uncannily familiar.

Serious financial pressures translating into long waiting times for elective surgery, long hours for junior doctors, a nursing workforce shortage, early discharge turfing patients back home quicker and sicker.

For decades, not enough money has been spent on capital improvements and technology upgrades.

There is increasing need for investment in high technology equipment to diagnose, cure disease, prolong and improve quality of life. Medicare promises ready access for all but fails to fund it.

The pressure on hospitals transmits itself to general practice, too. Just last Friday, the independent news magazine Australian Doctor released the results of a survey of 1,300 GPs asking them about the problems they experience with the public hospital system.

One in ten GPs said they had patients frequently sent home from a public hospital emergency department when they had been seriously ill and should have been admitted. Another 44% said it happened occasionally.

And 73% of doctors reported having patients prematurely or inappropriately discharged from hospital in the past 12 months.

It is a pleasant piece of rhetoric to say that patients would rather be recuperating in their home environment, but it smacks of the aftermath of the Richmond report which recommended the de-institutionalisation of mentally ill patients to have them 'cared for' in the community.

Then the institutions closed down without the community support services in place to cope with the fallout … people with mental illness, unemployable and unable to look after themselves living in abject poverty in inadequate hostel accommodation or homeless.

"Early discharge" presumes that a patient either has someone at home who can do some nursing, or they have the means to get a community nurse to visit. There will be someone to do the shopping and the housework and prepare meals. It's a bit hard if you are 85, widowed, your kids live in another city and you are recovering from a bout of pneumonia.

There is no question that we need to develop a level of lower cost "step down" care that sits midway between acute hospital bed and discharge home. But we cannot allow the cynical cost-cutting exercise that is going on at the expense of patient well being to proceed until such an alternative is in place and fully funded.

A further 56% said it was more difficult to get seriously ill patients into hospital than it was five years ago.

Unless you have been in the situation, you just cannot imagine how frustrating it is - as a doctor - to sit on the phone arguing with a hospital resident about the need for a patient to be admitted - and then being told that the hospital is closed to all but life-threatening cases.

Or being told that they will have to lie on a trolley in emergency for days until a bed can be found.

So, this is what GPs are saying about our public hospitals.

Our patients also know what is happening.

Last year, a major health care survey found that 71% of Australians now express specific concerns about the health system.

There's only so long you can keep a lid on these sorts of problems before people start to notice.

Two years ago, the main concerns about the health system related to cost. Now they have swung to public hospital waiting lists, poor public hospital service, lack of appropriate public hospital funding and shortages of doctors and nurses.

Of course these are opinions. But the survey provides some hard data, too. For non-emergency admissions, the average wait for acute treatment was 72 days - up 21 days on the 1997 figure.

The latest figures from the Australian Institute of Health and Welfare reveal that no less than 11% of patients admitted for elective surgery from the two MOST URGENT - yes the TWO MOST URGENT clinical groups were reported to have had extended waits in 1997-98.

I might add that waiting time figures used by state governments are probably under-estimates.

There is a bureaucratic sport called "category shift". To play this game, hospital administrators magically transform category one patients into category two patients with a star.

This game is most popular in states that impose a financial penalty on hospitals that fail to admit patients in certain categories within accepted time frames.

Shifting the patient's category without their condition actually changing is their creative way of avoiding the penalty.

Unfortunately, in this game there are no winners. Indeed, it is virtually impossible to keep score.

Another game is "Dodge the Waiting List". This is where you only count patients on waiting lists once they have been seen by a specialist in an outpatient clinic and assessed as requiring surgery.

There is …surprise, surprise… no mechanism for counting the number of patients on waiting lists to see specialists in outpatient clinics.

The conventional wisdom is that the number of people who haven't yet made it on to the waiting list, is about the same as the number of people actually on it.

So, the total number of people waiting could be double the official number.

Outpatient facilities are also stretched to the limit. A cancer specialist at a major hospital told me recently she cannot get X-rays done for her patients in the hospital, they have to be sent to a private facility.

And the budget will not stretch to providing information pamphlets for patients about to undergo chemotherapy. So she pays for them herself.

So, what's the AMA planning to do.

Politicians will only act when they know votes depend on it. That's how a democracy should work. But the prerequisite for that is a fully informed public who are engaged in the debate.

The AMA will be conducting an audit of public hospitals to identify the pressure points on our system and to find out accurately what forms of rationing are in place throughout the public hospital system.

It is information that is almost impossible to obtain through official channels and it will form an integral part of a campaign to get better funding for our public hospitals.

We are also conducting audits of junior doctors' hours as part of our 'safe hours' campaign. Young doctors have traditionally worked unacceptably long hours in public hospitals, a practice that puts the health of themselves and their patients at risk.

The working hours audit has commenced in New South Wales and Queensland and will shortly commence in South Australia, Tasmania and the ACT.

We will also conduct a survey of doctors working in public hospitals to find out the pressure points in the system and to find out where and why lack of access to essential medical services occur.

These audits and surveys will from part of a nationwide campaign for a better funding deal for public hospitals.

There is another issue we face in challenging the problems facing the health system, and that's the ability to speak out.

Historically, individual doctors are constrained from speaking out about problems facing patient care.

The constraint includes contract provisions, employment provisions and the fear of losing access rights to specific hospitals.

We also find organisations that accept government funding find it more and more difficult to say what they really think.

There has been something of a conspiracy of silence.

Doctors have spoken out in NSW in a campaign that commenced about a year ago. It was influential in the commissioning of a government inquiry and achieving extra state dollars into some areas of need.

The AMA will be speaking around the country. We will be applying pressure to secure improvements in the public hospital system.

And we will be providing doctors with an avenue for voicing their concerns about the pressures on our public hospitals.

COMMONWEALTH-STATE FINANCING ARRANGEMENTS

The Commonwealth has pursued a policy of not only restoring a balanced budget but also reducing public expenditure in real terms.

Of course, it is not just about more dollars, although that will help.

Everyone I talk to agrees on one thing - the current Federal-State funding process is grossly inefficient. "A dog's breakfast" is the usual analogy.

The States have elevated cost-shifting to an art form with schemes to shift cost back onto Federally-funded Medicare, claiming that the Commonwealth has not passed on agreed increases.

But the Commonwealth assures me it is all the fault of the States. So along with cost-shifting, we also get blame-shifting.

A national summit should be convened to bring all parties to the table to think these issues through and to build some consensus for the way forward.

The summit needs to turn the dog's breakfast into something that is far more palatable.

PRIVATE vs PUBLIC

Australia is lucky to have a dual health care system. The Australian model has an affordable and accessible private sector that helps keep the pressure off the public hospital system.

It is the defining aspect of our system and it is a model worth preserving.

But we don't actually have political consensus about how large each sector should be.

Such consensus is important.

While we support moves to get more people into private cover, we are very carefully watching the behaviour of the health funds.

We are deeply concerned about moves by funds to establish lists of preferred providers, moves to restrict patient care and access to services, and moves to interfere in the clinical decision making process.

The AMA supports informed financial consent where possible. Though it should be said that there are circumstance where it will simply not be possible to do this.

Some suggest that too much emphasis has been placed on the private sector. I don't share that view.

The Federal Government has done a lot of work on the private sector. That's true.

The challenge now is to apply the same level of care and attention to the public system. We should restore the balance… not by rolling back the private sector initiatives, but by now doing more for the public sector.

There are very sound reasons for this, even if the numbers of privately insured people recover to pre-Medicare levels, some treatments are best provided or only available in the public sector.

Moreover, there will always be a significant section of the community that will always need to rely on the public sector.

Without an appropriately funded public sector, the only research that will be done will need to demonstrate a commercial bottom line.

And we need to remember that it is the public sector where we have the infrastructure for teaching our next generation of doctors and nurses.

All of the evidence points to a compelling case for a larger as well as a better-cut cake.

In the recent World Health Organisation report on the performance of the world's health systems, France came first. France spends some 9.8% of GDP on health care - we spend around 8.5%.

There is not always a direct link between high health expenditure and good health outcomes.

But there is a strong case that can be made for lifting our expenditure to 9.5% or 10% of GDP. Well-targeted funding and reform of our financing arrangements will go a long way to lifting our health system performance.

Contrary to what many believe, Australians care about their public system strongly enough that they are prepared to pay more for it.

That would ensure better access, better care and a flexible health system that was more responsive to the needs of patients and more considerate to the professional needs of staff.

GENERAL PRACTICE

Ill turn now to general practice.

In 1996 Federal Health Minister Dr Wooldridge told a group of GPs;

"It strikes me as a disaster to have a large part of Australia's general practice population disillusioned, disengaged and progressively deskilled. I will do what I can as Minister to turn that around."

Since then, patient rebates under Medicare have effectively gone backwards and there has been no respite in the disillusionment and demoralisation experienced by GPs.

It takes ten years of training to become an independently practising GP. That's a lot of life invested in a single career.

In 1995, a survey by the National Centre for Epidemiology and Population Health found that 35% of GPs would leave general practice immediately if they had somewhere else to go.

It also found 95% felt the contribution of the GP was not valued by government.

What is more concerning now is that many GPs are telling me that they are feeling less appreciated by their patients. It is as though a so-called "free" service is expected, but not valued.

On top of this is the mounting weight of red tape and paperwork and extra unpaid work expected of GPs.

The much-debated Memorandum of Understanding between the government and three GP groups (not including, I might add, the AMA) did nothing to address the real problems in general practice.

FUTURE OF GENERAL PRACTICE

Australia needs its GPs more than ever to deal with the growing burden of chronic disease in an ageing population.

Most Australians will succumb to some form of chronic disease in their lifetime. General practice has a major role in preventing the onset of disease and, where disease occurs, preventing the development of disability and suffering.

That's why GPs should be rewarded for spending time with patients. Counselling patients about preventing illness and managing chronic illness takes time.

And that brings me to bulk-billing.

Universal bulk-billing has been one of the most insidious and damaging features of our current health system.

On the one hand it provides a safety net for people in genuine need. But on the other hand, it has become a case of doctors subsidising the system at the expense of traditional general practice. This has had devastating effects of the way doctors practice.

When it started, it looked attractive enough. Let the government take care of all the administration for you and you never have to discuss money with a patient.

Many practices agreed to accept the patient's Medicare rebate as the discounted payment for their services. This was despite the fact that the schedule of fees disadvantaged GPs against other specialists, particularly specialists who performed some sort of procedure.

For doctors who privately bill, their patients have had to shoulder more of the burden of cost for general practice because their insurer - Medicare - hasn't been keeping up.

And for GPs who bulk-bill, the Medicare Schedule has fallen further and further behind the increased cost of running a practice and making a living… it did not even index with inflation.

So there was only one place to go. See more patients. Deal with only one complaint in a consultation. Reduce the time you spend with each person.

Enter the world of six-minute medicine. Under the current schedule the fee is the same for five minutes as it is for 25 minutes. So it took about six minutes to figure out the most cost-effective consultation time.

Everyone knows that the current system puts GPs who bulk-bill under great pressure to churn patients through. However, common sense tells us that it is not in the best interest of quality general practice.

What is at stake? The future of general practice as we know it, and the survival of bulk-billing. Let me explain.

One of the outcomes of the pressure on general practice is the emergence of the concept of corporatised medicine - a variation on the theme of the US-style HMO, or Health Maintenance Organisation.

It has emerged as an option in Australia because GPs have become disillusioned, the value of good will in their practice all but disappeared, and the administrative load to run the business side of a practice has become an ever-increasing burden.

So many have welcomed corporate buy-out offers, leaving the GP to get on with medicine and not worry about the responsibilities of being an employer.

You may ask why a corporate entity, particularly a publicly listed company might be interested in general practice as a business if the profits are so marginal? The answer is vertical integration.

When the same company owns the general practice, the radiology, pathology and even hospitals, then referral up the line is where the profits lie.

Traditional, community-based practices are not allowed to provide all of these services in their practice because referrals are supposed to be "at arms length".

So this will make it even more difficult for these practices to survive.

Hopefully, general practices owned by the doctors who work in them will continue to operate. The question is, what will corporatisation mean for quality and continuity of patient care?

There is a very strong case for practice ownership to be limited to doctors working in the practice. If it is the right thing for pharmacies, why should a different principle apply to the GP?

There is no question that in either environment with things continuing in their current direction, bulk-billing is on the way out.

FUTURE OF BULK-BILLING

Practices have hung on to bulk-billing for a variety of reasons. Many started years ago when it made some economic sense in the short term.

As the rebates fell further and further behind, they were forced to see more patients for shorter consultations to maintain their practice incomes.

These doctors are now reassessing their situation. Other doctors who work in predominantly disadvantaged areas continue to bulk-bill because their social conscience dictates that they provide that service to their needy patients at the discounted rate.

So what happens from here?

Later this year, we will see the conclusion of the Relative Value Study, a five year effort commenced by the ALP and continued by the Coalition with the cooperation and goodwill of the profession in an attempt to renovate the Medicare Benefits Schedule.

I would like to see an emphasis on changing the schedule to acknowledge the important role of general practice and encourage longer consultations.

If there is any intention to acknowledge the problems of general practice, there will inevitably be a recommendation to increase patient rebates.

The big question is whether the government will be prepared to fund it.

I am often asked if I want to get rid of bulk-billing.

My answer is this… If it is supposed to be a universal insurance scheme it is sadly failing its customers.

We need to provide a safety net for people in genuine need… the disabled, the unemployed, aged pensioners, the poor.

What are the possibilities?

1. Increase Medicare rebates for everyone. This would mean a ten-year catch up to the full value of the RVS, or around $44 for a 15 minute consultation instead of the current $22.50

2. Do nothing, or claim that it is all too expensive. This will have the result of eliminating bulk-billing by attrition. Where doctors are more scarce, bulk-billing is already disappearing. For example, we know that bulk-billing in rural areas is down to about 55%. This would be an admission that Medicare is unsustainable as a universal insurer because it cannot properly fund medical services to their proper value.

3. Increase rebates for the genuinely needy only, in other words, introduce "differential rebates". The rebate goes up to the full value according to the RVS for the needy, but not for those who can afford to pay more. There would be an option to allow those others to privately insure for the gap. This concept preserves the safety net for those most in need. This option also requires an acknowledgement that we cannot afford to fully fund a bulk-billing system.

PUBLIC HEALTH

I see the Presidency of the AMA as having two parallel objectives. Advocacy for and on behalf of my colleagues in medical practice across the spectrum of the profession, and advocacy for public health issues.

In some areas, Australia is doing well. Immunisation rates, for example, have been addressed by the Federal Government with some energy.

But what are we doing to counter our leading cause of preventable death and disease - smoking? We have one good campaign that is getting results. But the funding devoted to addressing a problem that causes 18,000 deaths a year is dismal.

At the Federal level, there is just over $2 million a year allocated over the next three years. There are top up funds available from other sources.

But $2 million a year at a time when the Federal Government is collecting $4.5 billion a year in tax revenue from sales?

$2 million a year when the Government is giving half a million a year back to the tobacco industry for "research and development purposes"?

Research and development so that the industry can market more cigarettes which will kill more people.

You would have to say something is seriously wrong with this picture.

You only have to watch groups of high school age students to see the magnitude of the problem. Make no mistake. There is a war on, and the tobacco companies are still way ahead.

Our children are smoking in vast numbers. If they get hooked, and many will, they will go on to die prematurely in vast numbers from a variety of unpleasant diseases like lung cancer, heart disease and emphysema.

But there is hope, if we look at what's happening in the United States, where well-funded campaigns are getting impressive results in states like California, Massachusetts and Florida.

In Florida, we have seen an energetic campaign called 'The Truth'. It is run with young Americans and focuses not on health warnings, but on how the tobacco industry uses people for profit.

I call also on the film, television and magazine industry to be aware of the danger of depicting smoking in any sort of glamorous of positive context. There is no positive to come from smoking.

It is time to get serious with the leading cause of preventable death and disease in our society.

The same applies to alcohol. We have a $5 million campaign underway and a further $1 million a year has been allocated Federally to curb alcohol abuse.

That's $1 million a year for a $4.5 billion a year problem.

DRUG POLICY

I don't know about you, but I am over all the rhetoric about "getting tough" on drugs. Yes, it is one of our major public health problems, but surely we can see by now that the current philosophy has not been working.

I believe it is far better to "GET SMART ON DRUGS". "Getting smart" about drugs will mean looking for courageous and pragmatic solutions, being prepared to trial innovative ways of dealing with addiction and keeping the victims - but not the profiteers - out of the criminal justice system.

Getting smart means opening options like naltrexone maintenance, a trial of prescription heroin, allowing injecting room trials to go ahead, and diverting funds from jails into rehabilitation.

We will never succeed with a one-size-fits-all approach. The more options we have, the more chance we have of making a difference.

We must not lose sight of the fact that a "junkie" is a person with a drug problem. Person first.

I find it hard to understand that if we are being so tough on the drug problem, then why we are still turning people away from rehabilitation and treatment programs.

I've been told that one leading centre had 10,000 requests for placements last year…and had to turn down 7,000 of them.

Until we make treatment and rehabilitation places as easy to get as heroin in the street, we are not going to get on top of this problem.

ABORIGINAL HEALTH

If I could highlight the one area of public health that needs the most urgent attention, it is the state of Aboriginal health.

Why is it that Canada, New Zealand and the United States experienced major improvements in life expectancy of indigenous people over the past two or three decades, yet Aboriginal people - on best estimates - still die 20 years younger than the rest of the population? That's where the non-indigenous population was a century ago.

A policy of gradualism is not appropriate for the scale of the problem. The answers to indigenous health are there. They are not, contrary to what some people think, intractable.

In fact, the answers are largely the same for indigenous people in Australia today as they were for the general population in Victorian Britain.

It's about decent housing, good primary health care, better food, good education, employment opportunities and better living standards. It's about good sanitation and fresh water.

It's about strong communities accepting what needs to be done and making decisions about their own futures.

We also need to destroy a few myths.

We need to destroy the myth that it's always going to be bad and that putting money into Aboriginal health is throwing good money after bad.

There are projects that are working, like the health project in the Tiwi Islands of the Northern Territory, where a low cost project has turned the tide on appalling rates of renal and cardio-vascular disease.

To succeed, programs need to have a strong sense of community ownership and control.

More money is needed to provide the infrastructure and fund programs. The AMA commissioned a report from Professor John Deeble to find out what level of additional finding would be needed using a conservative needs-based formula.

Professor Deeble concluded that an additional $245m a year is required.

We were able to find hundreds of millions of dollars to run a promotional campaign for a new tax system. We should be able to find an additional $245m a year to accelerate the rate of change in indigenous health.

In discussions around Aboriginal health, the issue of reconciliation often arises. The argument is often put that reconciliation is a prerequisite to improvements in health status. I have a different view.

While reconciliation is an essential part of progress, we cannot wait for it to happen. Health improvements can and must proceed independently of it.

AGED CARE

I turn now to one area where it's painfully obvious that we're trying to ram a square peg into a round hole.

In aged care we need to be doing more and we need to be doing it now. When legislation governing aged care was changed in 1997, it removed the requirement for any staffing ratios for aged care facilities, regardless of the level of dependency of the individuals.

This has led to a situation where residents needing nursing attention from a registered nurse may not get it because there are not enough skilled hands on deck.

Emergency department nurses tell me that often nursing home patients end up in Casualty for simple procedures like change of catheters. In the past, these would have been done by the nursing home staff.

This adds to the burden in public hospital emergency departments - not to mention the stress of the transfer and waiting time for the patient.

There is also no minimum level of education for personal care attendants for aged care facilities.

This is the fastest growing category of aged care worker because they are cheap. There is no need for them to have any qualification. There are a few courses available but they are patchy and inconsistent.

There need to be changes, and soon:

Clearly the issue of quality control has been dealt with recently but

The Federal Government should amend the Aged Care Act to require minimum levels of staffing.

The AMA believes that Personal Care Attendants should be qualified and registered.

We are also proposing a concept of teaching nursing homes, where research into ageing can be fostered, and where undergraduate and postgraduate teaching can be done. These facilities would also help to teach carers how to look after their aged relatives at home.

CONCLUSION

Politically, we are at a crucial point in our history. States around Australia and countries around the world are trying to find the right balance between economic responsibility (some would call it rationalism) and social policy.

It is not good enough to say that social progress will just happen if we get the balance of payments right and keep interest rates down.

Don't get me wrong...like everyone, I love the low interest rates and economic growth.

BUT the medical politician and the doctor and the person in me sees a void in social policy and economic reality.

For too long the health system has been put in the "too hard" basket. Too hard because the Medicare rhetoric has been around for long that Medicare became an "untouchable" with dire threats of political ruin for any party that tampered with it.

The clock is ticking fast. When I look at out health system I see the lessons of history from the education system. Teachers are a couple of decades ahead of doctors and nurses in demoralisation stakes because they have already seen it all. For years our schools were used as an experimental laboratory for the ideologies of a succession of politicians and bureaucrats who for some reason decided that literacy was an optional extra, and teachers a bunch of radicals who needed to be controlled to keep them out of trouble. What the changes did was to ensure that truly talented potential educators chose a different career. Why go into a profession where you were unappreciated, not listened to, underpaid and over-controlled? Where instructions that made no sense were dictated by people who paid no heed to the outcomes of these experiments until we ended up with a generation of semi-literate high school graduates who wouldn't know the difference between a verb and a proverb?

We have been seeing the same thing happening to the medical profession.

Doctors being cut out of the decisions about health care because we kept saying things nobody wanted to hear, bureaucratic interfering in medical treatment, the same complaints about doctors being self-interested greedy whingers. If things keep going in the same direction, there will be a similar outcome. Nobody will want to be seen dead in a public hospital…or alive for that matter… and I don't just mean the patients…and the cream of our young academics will take their talents elsewhere like merchant banking or information technology.

Inappropriate political meddling in critical areas like health and education is eroding the pursuit of excellence in the professions. I do not want to see the health system used as an experimental laboratory for political gain.

So what is the right balance….informed debate is the place to start. And I stress informed. Ill-informed rhetoric does nothing to advance social progress and is ultimately viewed by the electorate with extreme cynicism. Ditto for short-term politically motivated changes.

The other essential ingredient is political change.

There is no doubt in my mind that inaction is more politically dangerous than acknowledging the problems and fixing them.

The medical profession in Australia, as in other countries in the developed world, is built on a solid foundation of core principles. There include caring, compassion, an unending search for the truth (which some call evidence), and the pursuit of excellence. As a profession we set the standard of practice based on these care values.

Only the medical profession has the ability to decide what is best practice for our patients, based on experience, insight and scientific evidence.

While we must always be mindful of the realities of cost-effectiveness and health budgets, we must not allow our professional standards to be hijacked by vested interests like governments or private health insurance companies who do not have the same priorities as we do.

We have to be on guard to protect our professional independence for the sake of our profession and for the wellbeing of our patients.

The problems in our health system will force us to face the question:

"What kind of health system will we be leaving to our next generation?"

There are serious warning signs. Morale in the profession is at low ebb.

Many of our brightest high school graduates are not choosing Medicine. Medical indemnity insurance is blowing out.

Health insurance funds are taking a more aggressive stance than at any time in our history.

Public hospitals are in trouble in every State of Australia.

The time for wishful thinking is past.

Under my Presidency the medical profession will be taking a leadership role in the debate about where our health care system in Australia is headed.

Doing nothing will lead to disaster and the public is now demanding something to be done.

Bandaids won't do the trick when corrective surgery is what is required.

I intend to fight on until we get a health system that is fair and affordable and with a healthy blend of private public sectors, and a public hospital system that delivers on its promise to look after the health of the people of Australia.

Thank you.