STAYING IN TOUCH WITH OUTREACH

Good morning fellow doctors.

After a busy election campaign for the AMA, it is nice to be back in the real world, Queensland, and one of my favourite places - Townsville.

My friends, we are about to enter a very important time for the health system and our profession.

As we look at the very real prospect of the Howard Government having control of both houses of the Federal Parliament, the opportunities for reform are limitless.

An unfettered Federal Government can now make changes to Australia's social and economic landscape in a way that could last a generation.

Policies that would have been chipped away by the Opposition and the minor parties in the Senate will now find easy passage.

And one of those policy areas will be health...undoubtedly.

It is a credit to the profession - through the work of the AMA and other groups - that patients and communities were winners from health policy at the election just gone.

But they were election promises in an election environment...and at a time when there were no economic storm clouds on the horizon.

But in the week since the election, we have seen Peter Costello take off his rose-coloured economic glasses and put on his Men In Black shades - all very serious.

And economic forecaster, BIS Shrapnel, has warned of higher interest rates and possible recession.

What a difference a week makes.

Well, therein lies a challenge for our profession.

We have to defend the hard-won gains for our patients and our communities and work with the Government to put in place health policies that can survive a tougher economic environment.

We must not be complacent.

We must determine our agenda and sell it to the Government.

The AMA's medico-political agenda must come from you - especially you.

After all, it is the patients in remote Australia who do it toughest.

I can assure you that the AMA's policy agenda will be built on the advice we get from the grassroots.

I'm not here to preach.  I'm here to learn.

Any sustainable health policy must be built on five key planks:

Independence of the profession

Quality care

Access to quality health services

Affordability of quality health services, and

Choice - our patients must have choice of health services.

If it is to deliver in these areas, the first challenge for the re-elected Government is to get the medical workforce right.

Some years ago, the AMA identified medical workforce shortages as a major health issue.

At the time, the health bureaucrats said we were wrong.

It's just a maldistribution, they said.  More like a malfunction on their part, I say.

Anyway, they now agree with us.  Every one agrees there is a national medical workforce shortage.

And that is not news to anybody in this room.  You have been living with that reality for years...and so have your patients.

Not only is there a nation-wide shortage of doctors, the overall distribution of doctors is skewed heavily towards the major cities.

And this means that regional, rural and remote areas shoulder a disproportionate workforce shortage burden.

And the patients do it tougher in the access, affordability and choice stakes.

Around 34 per cent of Australians live outside major cities - yet only 20 per cent of the medical workforce lives in these areas.

This picture becomes even worse when you look more closely at the specialist workforce.

Around 15 per cent of specialists live outside the major cities.

In remote and very remote Australia, less than 0.4 per cent of specialists live in these areas.

Put simply, there is a strong preference among much of the current medical workforce to live and work in major cities - with particular preference for the inner suburbs.

Given the educational background and the demographics of the current medical workforce, his should come as no surprise.

Doctors are no different to any other professional group.

Evidence throughout the western world shows that attracting young professionals to rural and other locations is extremely difficult.

In times of general workforce shortage, these problems cannot be solved overnight.

Strategies to increase the bush's permanent medical workforce will take many years to deliver results.

It is good news to hear that around 25 per cent of the current medical school intake is represented by students from rural backgrounds, compared to 8 per cent less than 10 years ago.

The limited evidence available shows that these students will be 2 to 3½ times more likely to practice in rural areas than other doctors when they finish their training.

However, for someone who aspires to be a specialist, it will be around 15 years before they can realise that ambition.

The potential for specialists to work in the bush will always be limited by available infrastructure and the need to treat a minimum number of patients in order to maintain their skills.

Faced with these problems and limitations, innovative solutions are therefore required, in the short to medium term as well as the longer term.

Outreach programs are one of the most effective solutions to provide rural communities with access to specialist treatment.

Since 2001, the Commonwealth has operated the Medical Specialist Outreach Assistance Program (MSOAP).

This program is designed to improve access to specialist services in regional, rural and remote areas.

MSOAP's original objectives were to:

Increase specialist services in areas of identified need

Facilitate visiting specialist and local health professional relationships and communication about patient care, and

Increase and maintain the skills of regional, rural and remote general practitioners and specialists.

Like any other section of the community, rural people prefer to have their treatment close to home - where they can be with family and friends.

And they like their post-operative care to be in the hands of their local health professional.

Outreach programs that work in collaboration with local communities can deliver these benefits in a cost effective fashion.

Since its inception, around 1,100 specialist services have been developed with the support of MSOAP.

In the May 2004 Budget, continued funding for a further four years was confirmed.

MSOAP funding is administered both through state/territory governments as well as "fundholders" such as the Queensland Divisions of General Practice.

The pool of specialists prepared to provide outreach services is relatively small - but it is certainly very committed.

Motivation ranges from the need for more diversity in their usual practice, altruism or a sense of ethical responsibility, or just the fact that they get to treat a very grateful group in the community.

MSOAP has been widely supported and is recognised as having delivered strong results.

That said, it has not been without problems. 

Outreach specialists can have a negative impact on local specialists if they are not properly integrated with local healthcare services.

Proper consultation and a strong knowledge by the fundholder of the requirements for the delivery of each service - including the necessary support services - is essential.

While the program is committed to up skilling local practitioners, the implementation of this has been very uneven.

The paperwork involved in complying with the program's guidelines is often seen as a burden - to the point of discouraging participation.

The program did not offer funding to established outreach services, except where they proposed new services.

Medical specialist outreach programs have demonstrated benefits for the community.

Let's have a look at an evaluation of a Specialist Outreach Service formed in 1997 by Darwin-based specialist staff in Surgery and O&G.

This service focused on indigenous groups.

Over the period 1997 to 1999, 3647 procedures and consultations took place in remote community clinics.

This was five times more than took place previously when patients were transferred to Darwin Hospital.

Staff and patients reported much better doctor-patient communication in the community setting compared to outpatients.

Indigenous communities were far more comfortable when they were around familiar people with familiar culture.

They also had access to family members.  This meant they could discuss grave decisions with family members.

All of these factors combined to engender greater trust - which is essential when discussing treatment options.

There was a modest, but sustained, drop in-patient assisted travel.

There was a fall in the average cost of each consultation - with reductions of up to 40 per cent when compared to what it would have otherwise cost had the patient been required to travel to Darwin hospital.

Many people would have otherwise decided not to pursue diagnosis or treatment had they been forced to travel to Darwin hospital.

Problems with the MSOAP program are being addressed, but we must look at the overall benefits in any assessment.

The May Budget delivered an additional $6 million to support existing outreach services that had been previously overlooked.

How far this will go, however, is not clear.

There is already a feeling that funds earmarked for existing services will be exhausted very quickly.

MSOAP funding guidelines and processes are also being examined in order to see what processes can be streamlined.

The fundholders are being asked to review their existing services prior to February 2005 in order to ensure that:

there is still a community need, and

the services properly integrate with other local services and planning initiatives

Overall, outreach programs are a worthwhile and cost effective means of delivering healthcare to rural and remote areas in particular.

They must focus on working with local healthcare providers.

They must focus on up-skilling as well as service delivery.

They must allow for proper continuity of care.

And they must genuinely satisfy an unmet need.

Then they will have the capacity to:

reduce metropolitan and regional hospital waiting lists

improve patient satisfaction

improve rural healthcare resources, and

support the ongoing social and economic viability of rural communities.

The lessons learnt from outreach must be applied to the broader health system if we are going to build a system that looks after us when we get older, our kids, and their kids.

Before I conclude, let me clarify my references to, and use of the term 'fundholding'.

As many of you know, the AMA is a strong opponent of the practice of fundholding as a central principle and practice in the Australian health system.

One of the few areas where we condone the practice is in specific areas like the provision of outreach services and in Indigenous health.

So, before anyone runs off to say that Bill Glasson and the AMA have crossed the fundholding Rubicon, forget it.  It's in for Outreach: it's out elsewhere.  Full stop.

When it comes to outreach services, I practise what I preach.

I derive enormous personal pleasure and professional satisfaction getting out to Longreach and Birdsville and those other great places that are the essence of Australia.

They are great people out there and they deserve the equal in health care that people get in Brisbane or Sydney or Melbourne get.

These services illustrate that good policy and vision can deliver on the principles of independence, quality, access, affordability and choice.

The secret is to learn from the local level and build it up.

The task ahead for the AMA and the medical profession is to apply these lessons to the big picture.

Working together we can build a quality affordable health system that is fair and equitable - a system that will last the distance to serve the next generation of Australians.

Thank you.