Speech to Catholic Health Australia National Conference - AMA Vice President, Dr Steve Hambleton, Hobart, 18 August 2009

There is one area where there is agreement, however, and that is the topic of our session today — the need to improve the bond between primary, acute, and sub-acute care.

The AMA has long advocated for improvements in the continuity of care.

And we have long advocated the need to have people in the right place at the right time for the right care or treatment for their condition.

Systemic change is needed.

What doctors see every day is that:

• there is not equal opportunity to essential health care in Australia;
• there are too many scarce health dollars caught up in the games that governments play and the bureaucracies that they create;
• the system is confusing and uncoordinated for people coping with chronic conditions, with severe disabilities and with very tenuous social support;
• the safety nets for frail elderly Australians are frayed and, at times, elusive; and
• there is a lack of attention and concerted effort given to people with mental illness.

So, it is not surprising that governments are looking at reform.

Medicare is 25 years old, but looking and performing as though it is much older.

It was supposed to be a universal health system for all Australians supporting Public Hospitals, primary care, and community care.

What we have ended up with is health silos - all with insufficient funding, and all suffering from poor communication.  

Cost shifting has become an art form.  

In Government, instead of cricket or rugby or Aussie Rules being the preferred national pastime, we have had the 'blame game' in which each side seems to be allowed to have an unlimited number of spin doctors.

The winner is the one with the least number of hits on the front page of the newspaper.

One of our State Health Ministers said yesterday that he blamed G's and Specialists for letting patients stay on the waiting list for years.

He was more interested in getting the elective surgery done than keeping a tally on who was waiting for it.

There is frustration at the litany of undelivered promises from governments of all persuasions.

The major problems in the public hospital system are the practical difficulties of better resourcing and better results for patients.

Medication errors alone are responsible for 'jumbo jet' loads of patients crashing into the ground each year as a result of poor communication systems between General Practice, acute and sub acute care.

Much has been made of the Prime Minister’s election pledge to take over public hospitals if the States don’t lift their game.

Whether or not the States have lifted their game, the States are showing little enthusiasm for a Commonwealth takeover.

I do not think the Prime Minister and the Health Minister are keen about a takeover.

That is why the Prime Minister is taking six months to discuss the Reform Commission’s recommendations with the community.

It is notable that the key target group for the PM’s talkfest is hospitals — and the doctors, nurses, other health professionals and administrators who work in those hospitals every day.

This is a challenge and an opportunity for groups like the AMA and Catholic Health Australia.

For the public, however, good health care is about going to their doctor and getting a diagnosis, advice and treatment and moving smoothly through the system.

We need to look at access to quality primary health care.

We need to look at sub-acute care.

We need to look at aged care.

And we need to look at care for people at the end of life.

I’m pleased to say that the AMA has ideas and solutions across this continuum of care — and I’ll share some of those with you now.

Lets go back to President Obama's 'Fix what is broken and build on what works'.

The fix in health reforms must be a shift to be patient-centric and respond to the needs of patients not bureaucracies.

The process of building on what works in health reform must further recognise the importance of doctors - and in particular General Practitioners - as the foundation of quality health care teams.

It should not come as surprise to you that the AMA sees general practitioners as the lynchpins and the leaders in primary care.

All the evidence and community opinion supports this.

Australia has an excellent primary health care system that is the envy of many countries.

The key to the success of primary health care delivery in Australia is the provision of comprehensive, continuous and coordinated patient-centred care by general practitioners.

According to a joint Australian Institute of Health and Welfare/University of Sydney report, general practice provides all the care needed for more than 90 per cent of all health problems that GPs encounter.

The Australian community values the role that GPs play in their health care.

Eighty per cent of people visit a GP at least once a year and evidence shows that Australians spend more time with their GP than in most comparable countries.

While GPs still play a key role in the management of acute conditions, more than one-third of problems now managed by GPs are classified as chronic.

In addition:

• 20 per cent of GP patients are daily smokers.
• 30 per cent are 'at risk' consumers of alcohol; and
• 60 per cent are overweight or obese.

These will become the frequent flyers in the acute and sub acute sectors.

In the face of workforce pressures and the growing burden of complex and chronic disease, GPs have embraced GP-led team-based care.

This will give patients better access to other primary health care services after diagnosis and assessment and the consideration of an appropriate management plan.

More than 60 per cent of general practices have a practice nurse and GPs regularly refer patients to other primary health care services such as psychologists, specialised nurses, physiotherapists, dietitians, and occupational therapists.

GPs are clearly adapting to changing needs of the population.  Patient-centred care delivery considers the needs of the whole patient.

But true patient-centred care can only be delivered within a framework that enshrines medical diagnosis and assessment.

The specialised training of GPs is vital to the evolving primary care system — especially in today’s health reform environment.

A strong GP-led primary health care system can relieve pressure on hospitals in areas such as mental health and the treatment of chronic and complex disease.

A stronger primary health care system is unlikely to make a significant difference to the workload in emergency departments, reduce waiting times or relieve the need for more hospital beds.

GP-type presentations in emergency departments consume less than one per cent of resources.

The ultimate key to improving waiting times in public hospitals is the provision of more beds so that hospitals can achieve a bed occupancy rate of 85 per cent.

This includes the operational capacity to take care of the patients in those beds — doctors, nurses, support staff and equipment.

This will improve patient safety and allow hospitals to operate with much greater efficiency.

I note that the National Health and Hospitals Reform Commission made a recommendation along similar lines.

I quote from their Final Report:

“Our proposal involves building and funding major public hospitals with emergency departments so that they operate at closer to 85 per cent occupancy.

This would allow public hospitals to have ‘spare’ or ‘stand-by’ bed capacity and on-call staff available.

“For patients, this would mean quicker access to a hospital bed if it is needed in an emergency and less crowded emergency departments with care being provided more quickly and safely.”

As well as building more beds in public hospitals, the AMA supports the call from Catholic Health Australia and now the recommendation from NHHRC that the number of government-funded aged care places be calculated on actual need so that older Australians who should not be occupying acute beds get the care they deserve in an aged care facility.

High quality continuity of care requires that the care provided by hospitals be well coordinated with the patient’s general practitioner.

Most hospital episodes begin and end with general practice.

The patient’s usual GP brings his or her knowledge of the whole person into consideration in planning and managing the patient’s pre- and post-admission care.

General practitioners have established within their practices systems and processes that can improve communications with hospitals.

More than 90 per cent of GPs are computerised today and have the capacity for secure electronic communications today.

The trouble is most of our health sectors cannot talk to each other, rendering our IMIT infrastructure useless.

There is a major department at my local public hospital, the Royal Brisbane and Women's Hospital, who won't even accept a fax – they will only accept snail mail.

With the reinvigoration of NEHTA to set communication standards, we must overcome these difficulties.

The first step is a unique health identifier which must have built-in patient privacy but still allow practical access to appropriate providers of health services.

Over 80 per cent of Australians support the introduction of a national e-health record.

My hope is that the e-health record will give us access to the complete patient history at a glance - with demographics, current medications, allergies and drug side effects, medical and surgical history, vaccinations, allergies and test results.

Everything will be there with the patient in control of the record.

This will not only enhance the efficiency of health services, reducing unnecessary referrals and duplication; it will also help us better serve our patients and save lives.

The AMA policy on General Practice and Public Hospital Integration builds on this theme.

Appropriate integration of general practice, public hospital and sub acute care can lead to improved patient health outcomes through better clinical management, improved continuity of care, and reduced readmissions.

Over the past decades, GPs have increasingly been excluded from the provision of hospital based care.

Barriers between these two sectors have grown as hospitals have become focussed on providing acute care to high need patients with little input from GPs.

Divisions of General Practice have helped us in this area but more needs to be done.  

My own Division - GP Partners - was not prepared to wait for the rest of Australia.  They have set up their own electronic communication system – Health Record Exchange.

All major hospitals and the Care Coordinators can get access to key clinical data 24 hrs per day, 7 days per week.

The experience of Australian general practice in accessing timely and relevant patient information from hospitals is generally very poor also.

The provision of discharge summaries or letters from specialist outpatients  is patchy at best in terms of quality and timeliness.

The absence of this information reduces the ability of the GP to provide the highest quality continuity of care for the patient following a hospital admission.

The direct provision of information in the discharge summary is particularly important in relation to the discharge of patients to Residential Aged Care Facilities, given the complexity of care involved.

It is the AMA’s view that much more needs to be done by governments to facilitate GP visits to aged care facilities.

This will involve greater effort from aged care providers to establish safe clinical rooms for the GPs to see residents and must include access to computers with links back to their surgeries.

The real beneficiaries from measures that improve GP hospital and sub acute  integration are patients.

It is thus essential that the links between GPs and hospitals and sub acute care are strengthened and supported through adequate funding by Governments who must end the 'blame game'.

GPs are key players in linking primary care, acute and sub acute care.

As I said earlier, the AMA believes that any health reform process must respect and preserve this role.

I look forward to questions a little later.

Thank you.

 

_____________

John Flannery
02 6270 5477 / 0419 494 761
Peter Jean
02 6270 5464 / 0427 209 753