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Senate Select Committee on Health
05/02/2015

JUDKINS, Dr Simon, Councillor, Australasian College for Emergency Medicine

KILLEN, Mrs Alana, Chief Executive Officer, Australasian College for Emergency Medicine

CHAIR: I welcome representatives of the Australasian College for Emergency Medicine. Thank you for joining us once again. I invite you to make a brief opening statement.

Dr Judkins : Good afternoon. Thank you for the opportunity to speak today and discuss the concerns that we, the Australasian College for Emergency Medicine, have in relation to the proposed changes put forth regarding funding changes for health care in Australia. ACEM is a not-for-profit organisation responsible for the training and ongoing education of emergency physicians and for the advancement of professional standards in emergency medicine in Australia and New Zealand. As the peak professional organisation for emergency medicine in Australasia, ACEM has a vital interest in ensuring that the highest standards of emergency medical care are maintained for all patients across Australia.

ACEM remains significantly concerned that the introduction of any new co-payment mechanism for medical care will only further exacerbate the health access problems and ultimately lead to greater long-term financial and health costs for the Australian community. Australian consumers have already reported experiencing difficulty with costs, impacting on their ability to access the health care they need. ACEM contends that targeting primary health care for cost savings or revenue raising will be ineffective, as research has actually showing that the increase in rates of GP visits is more cost-effective than if these services were to be provided in others areas of the healthcare system. In particular those costs are for those patients with chronic illnesses who rely upon affordable access to primary health care much more than the rest of the population. They will likely be disproportionately impacted by an increase in out-of-pocket expenses. With an ageing population and subsequent increasing rates of chronic disease the need for effective community management of such illnesses will only grow further.

Many emergency departments across the country, as you would all be aware, consistently suffer from overcrowding and access block—that is, the inability for the ED to move patients to in-patient areas or theatre. It is a two-door hospital system which operates at maximum capacity most of the time. Any change which will lead to an exacerbation of this ongoing dire state raises grave concerns in the emergency medicine community. Emergency departments are designed for, and emergency staff are trained to, care for patients with acute illnesses and injury. Emergency departments not places for patients with chronic conditions who need ongoing care or for patients who can and should have the ability to be treated elsewhere in the health system. Compounding these proposed changes to the GP funding arrangements is the dismantling of the national partnership agreement, along with the National Emergency Access Target. We are concerned that the impact of this double whammy will see a significant deterioration in an already fragile state for many of our EDs and public hospitals. A robust and well-resourced GP community is one of the vital cogs in the healthcare machine and clearly has an impact on this ongoing problem.

ACEM contends that there are solutions within the health system to see a sustainable future. We acknowledge that the future challenges will necessarily involve balancing attempts to maintain or improve standards, without increasing per capita costs. ACEM considers appropriate resource stewardship needs to become a cornerstone of health system operations if sustainability is to be achieved. For example, as noted in a recent report by Russell and Doggett, there has been relatively little work done in identifying practices such as ordering tests, prescribing and procedures which are inappropriate and/or unnecessary. ACEM strongly believes that there are also significant gains to be made not only from a savings perspective but also with regard to quality of patient care and considering the value of various healthcare interventions. Choosing Wisely Australia, for example, is an initiative aimed at improving the quality of health care by addressing these very issues—that is, by identifying tests and treatment procedures where evidence shows that they have no benefit or, in some cases, cause harm. As a participant of Choosing Wisely Australia, ACEM is currently in the process of identifying such low value items for both patients and doctors to consider during their consultations.

ACEM and it fellows, the emergency physicians providing care in Australian and New Zealand emergency departments, understand the need for reform. We are strong advocates for reform that will see our health system robust, sustainable, effective and efficient. However, we also believe in a system that is just and socially equitable and a system that has a focus on prevention and maintaining health. We would strongly reject any change that would potentially see patients having to seek their care in an already overcrowded and stretched public hospital system, through lack of resourcing, access and care in other sectors. Thank you.

CHAIR: Thank you, Dr Judkins. Mrs Killen, do you want to add anything?

Mrs Killen : No. I think Dr Judkins has covered the points very nicely. Thank you.

CHAIR: Thank you for your submission and for your participation today. You have heard some of the evidence that has been given here this afternoon.

Dr Judkins : Yes.

CHAIR: One of the things that we consistently hear is that there is a myth that continues to be perpetrated about the sustainability of Medicare. On the back of that myth, if it continues and there is a co-payment, the articulation of our experts so far is that patients will end up in your field, in the emergency rooms across this country. Have you seen any shifts towards that already? Have you seen increasing anxiety about it? Could you speak to the concerns that you think are imminent, if a co-payment is required?

Dr Judkins : There is always concern and there has been concern for many years. We know about the issues of overcrowding and the stretching of emergency department resources. There is no doubt that there is a certain cohort of patients—there are a couple of different cohorts of patients—who do present to emergency departments when they could receive their health care in another place and there are those people who have been termed 'GP type patients', for want of a better term. But there are also those patients who, unfortunately, end up in our emergency departments because they have not been able to access appropriate care in another place, whether that is by a GP, whether it is by an aged care physician or whether it is by getting access to a surgeon or surgical outpatients. Whatever their chronic problem is, it becomes an acute problem, and they suffer a health crisis and end up in our emergency departments. It happens across a spectrum of specialties. It is not only GP patients; it is also surgical patients, oncology patients and, as we heard before, mental health patients. There is a big concern that we are seeing a growing number of mental health patients, a growing number of drug-affected and alcohol-affected patients. It is the combination of all these factors that I think makes most emergency physicians and emergency staff become gravely concerned when we hear there might be measures put in place that will exacerbate the problems that we already have.

Mrs Killen : Just with reference to your query about whether we would anticipate a co-payment impact on appearances or attendances, there is some anecdotal evidence that, following the announcements of the budget last year, there was a spike in emergency departments, because people assumed that it had already taken place. This is anecdotal. It was reported back to us that some emergency departments reported that patients were presenting there because they thought that they were going to have to pay already, so we know that there will be an impact. We have evidence that that is going to happen.

CHAIR: So you have had a trial run, almost.

Mrs Killen : Almost, yes. In the week or two following the announcement, we had reports saying that the people had actually been presenting at the EDs under the impression that the co-payment had already been implemented, and they could not afford to pay it and they were not going to pay it.

Dr Judkins : Looking at it from the opposite end, we certainly have not seen any comforting information to say that it is actually going to reduce presentations to emergency departments, so I think that we can only work on the information that we have. We read all the same material and listen to the same material that you have access to, and everything seems to suggest that if measures like this come into play then we will see a spike and a surge in patients attending their emergency departments.

CHAIR: How do your staff normally deal with patients who come to emergency departments who you think should see a GP? How do you manage that currently?

Dr Judkins : Currently we see them. People come to us for care, and we are not going to refuse anybody care, so we see them. There are a couple of different issues. The biggest problem we still have in emergency departments is the issue about overcrowded and full hospital system beds. Patients who need admission getting into the healthcare system provide us with a lot more anxiety than patients with minor problems who could be dealt with elsewhere, but they certainly do take a cohort of our staff and resources. But most of the time we will see them, because it is often quicker for us just to see them and sort them rather than spending a lot of effort and trying to say, 'Well, it's fine that you've come here now, but it's not an emergency department problem; you could do this, this and this.' We do not necessarily want to deny people access to health care.

CHAIR: You soak up a bit of the emergency overflow at the moment, but if this became an increasing trend then how would it impact on the work that you do and your capacity to care for people who genuinely have an emergency?

Dr Judkins : There are multiple, multiple studies, not only in Australia but overseas, that show that, if patients turn up to an emergency department with a crowded waiting room, with physicians and nursing staff who are under stress, patients have poor outcomes. If you are the fourth, fifth or 20th person in line when you walk into an emergency department and you actually have chest pain which is a cardiac problem, any delay that is put in place for you to see the person who is going to make the decision on your treatment will worsen your outcome. So there is no doubt that turning up to an overcrowded and stressed emergency department increases patient morbidity and decreases the level of care that we can provide.

If the staff are overwhelmed, it is a bit like a needle in a haystack: you see so many patients that trying to pick out the patient who was actually the sick one becomes a lot more challenging. You are getting multiple inputs about multiple patients. To try to care for the person who is actually sick and identify the person who is actually the sick person among the increasing number of patients we are seeing does become more challenging.

CHAIR: You made reference in your opening comment to the National Emergency Access Target. Could you give us an update on where that is and any concerns you have about it.

Dr Judkins : For all the negative publicity and concerns about that, one of the positives for us is that it really focused not just individual jurisdictions but the whole health system of Australia on the fact that we need to reform the way we run our public hospitals. If you look at various jurisdictions around Australia, certainly there have been shining lights in Queensland, and Western Australia had their moment in the sun, but they are now struggling a bit. It did actually focus efforts on saying that emergency departments are for emergency patients and we need to unclog our emergency departments. We are concerned that, with the current lack of national focus on emergency department access and overcrowding, that will start to trend back to the bad old days where we had patients lying in beds for 24 hours. There is no incentive to get patients out of emergency departments who obviously need in-patient beds.

CHAIR: Let's just be clear: people who are not in the sector and who thought that there was a set of targets that were in hospitals may still think they are there. Can you explain what has happened, at what date you were advised and what the changes are based on.

Dr Judkins : We are coming to the end of the term of what we call the national emergency access target. That was the four-hour time line that we would look at trying to get all patients admitted or discharged out of emergency departments. It has taken quite a long time to get ahead of steam but we are starting to see significant gains across lots of different jurisdictions. Unfortunately, that national partnership agreement has been dissolved and that five-year period of health reform finishes this year and there is nothing really to replace it. So every state is now grappling with what their target may be and what the drivers are going to be to get patients out of emergency departments and through the hospital system. There is benefit to having a coordinated approach, because everybody learns from each other and everybody looks at examples. If we dissolve that down to individual jurisdictions or individual health services, we feel that the lack of focus will certainly see a decrease in the emphasis on getting patients through our health system.

CHAIR: The decision to stop that target and cut that funding was a decision of the Abbott government.

Mrs Killen : Yes.

CHAIR: To your knowledge, was it based on any evidence, or is it another ideological decision based on dollars only?

Mrs Killen : I think at the time of the announcement the wording in the budget was that there was little evidence to support the fact that the NEA targets had been effective. Our college produced some evidence to suggest that they were in fact gaining momentum and had in fact been successful in some states. So we found that rationalisation somewhat interesting at the time and would argue that there was actually some momentum occurring with regard to NEA targets. In fact, after the announcement, some of the state premiers came out and said that they intend to continue with the targets because they had been successful. There has been silence on that since that time and we have not really heard a lot of information. The feeling amongst the fraternity seems to be that the target is dead in the water, which we think is a shame because there were certainly some gains occurring.

CHAIR: Probably a lot of the consumers of health would be a little disappointed. They are probably still harbouring the impressing that they are going to get in and get out in four hours and that that is a goal. So that is no longer the situation?

Mrs Killen : No. As Dr Judkins intimated, the really good thing about it was that it was a whole-of-system approach. The hospitals had to take responsibility. The entire hospital was responsible for the throughput of patients and the patient journey. We were starting to see some really models of care being introduced in certain areas that were being very effective in moving the patients through. Of course, with the cessation of this target and the end of the partnership, there is no incentive for hospitals anymore. It is a shame, because there has been so much good work done and not an insignificant amount of money put into implementing these targets. Like everything else, the frustration is that you just start to get something working and then they take it away. It is disappointing.

Dr Judkins : And the evidence for these sorts of things does take time to appear. In fact, some good evidence has just come out of Queensland around the improvements they had within their hospital system with the national access targets, which showed that it was improving patient morbidity and patient mortality. So we were starting to get to the point where we were identifying success when the targets were being dissolved. Certainly there are lots of arguments about what the right target is et cetera, but there is certainly evidence to show that if you can focus a whole system on getting patients moving through the system in cutting inefficiencies, cutting waste and focusing on the right thing for the patient, you will see better healthcare outcomes.

Senator McLUCAS: Thanks very much for appearing before us again. I want to go to your point, Mrs Killen, about the anecdotal evidence around increased presentations. You were talking about the two weeks post budget—after the budget last May. I know it is anecdotal—and that is fine—but what did you hear?

Mrs Killen : What I heard were reports from various hospitals. We had contact in the college just to let us know for our interest, I suppose, that there were patients appearing in their emergency departments who were under the impressing that the co-payment had already been implemented and they had chosen to come to the ED because of that; that they would normally go to the GP but, because of the GP co-payment, they were coming to us. When I say 'anecdotal', it was definitely anecdotal. I can quote a number of calls that I got about this, but I do not have any—

Senator McLUCAS: Was it two or five?

Mrs Killen : Probably four or five phone calls about it. If I had done some emailing around and asked, perhaps I could have got more significant evidence but at the time it was just somebody ringing me up and saying, 'You might be interested in this.' I do not have anything other than some phone calls and anecdotal—

Senator McLUCAS: It ties in with evidence we heard this morning from a group of GPs, one of whom reported a decrease in attendance at her surgery in the fortnight post the budget and other GPs said there was not a decrease—these are GP services in areas where you have a 2½ week wait to get into surgery. So it is not as if there were a depletion in numbers; it was just a reduction in the time you had to wait to see a GP. So those people who did not go to the GP turned up at your place.

Mrs Killen : Yes. There are a lot of major concerns around that. Anything that disincentivises someone from attending their GP for us is a major concern not just for the overcrowding issue for our EDs but for the patient themselves who may put off coming. A preventable issue might become something chronic or worse and that leads to much worse outcomes and costs a lot more money in the long term.

Senator McLUCAS: There is no way we could put some more evidence around that anecdotal material, is there?

Mrs Killen : We could do surveys but they would be retrospective and I am not sure how my much validity they would be given.

Senator McLUCAS: It is a long time ago now.

Dr Judkins : Certainly we could look at data like tendencies at emergency departments to see whether there was a trend. Obviously we would have to get a lot of that information from health departments.

Mrs Killen : And there could be some confounding factors because it was winter. People say that that is because there was an outbreak of colds or something.

Senator McLUCAS: What you are telling us does stand to reason. It is probably accurate.

Mrs Killen : Yes.

Senator DI NATALE: Are you aware of the Productivity Commission report which came out yesterday on government services? Did you see any of that?

Dr Judkins : I saw a little bit of it last night. Certainly I seem to recall there was comment about the access to GP services and the extra costs of not seeing GPs.

Senator DI NATALE: There is also some stuff in there about emergency departments. It said that:

Nationally, 23.6 per cent of people who went to a hospital emergency department for their own health in 2012-13 thought at the time that care could have been provided at a general practice.

In other words, one in four people ended up in an emergency department when they thought they could just as easily have gone to a GP.

Dr Judkins : Yes. It is already an issue. From our point of view there are a number of different issues that affect emergency departments. The GP type of patient, again, is something we do not necessarily like to overstate because we have bigger fish to fry as far as access is concerned, just getting patients out of EDs who need to get into the hospital system. Certainly, there are already comments that one in four patients are turning up. If that increases—as I said, we do not need anything to encourage patients to come to us to access care because we do not provide good GP type of care for patients. We see them once and send them on their way. We are not there for continuity of care. We are not there to treat chronic conditions. We are therefore for accidents and emergencies.

Senator DI NATALE: Fair enough. Hence the name, I suppose. Can I ask you about the Choosing Wisely initiative you are involved with. That is run by the NPS or auspiced through than National Prescribing Service—is that right?

Dr Judkins : Yes, that is right.

Senator DI NATALE: And I do not know whether it has been officially launched yet.

Dr Judkins : The launch is on 26 April or something like that.

Senator DI NATALE: I have a few questions about how that is going. I agree absolutely with the analysis that we do a lot of things in medicine. There are other areas we should be targeting that would improve the system—better value for money, a lot of low-value items. You are involved in this along with the other medical colleges?

Dr Judkins : We are involved with the colleges of physicians, radiologists, general practice and—I cannot remember the other college off the top of my head, but there is a core—

Senator DI NATALE: Are the AMA involved as well?

Dr Judkins : The AMA are not necessarily involved because they are not at college. It is really trying to get the learned colleges in to try to use evidence to say what is best practice. They wanted to really start off with a core group of engaged colleges and then try to expand out to involve all specialists.

Senator DI NATALE: What is the process?

Dr Judkins : The process has been that each college goes to its members and identifies procedures, processes, tests, medications and treatments that actually do not have any evidence.

Senator DI NATALE: How do they do it? Do they just write to their members?

Dr Judkins : It is evidence based. We look at the studies. I will give you an example. A bit of low-hanging fruit would be doing back X-rays for back pain. There is no evidence to suggest that that is a useful investigation, yet thousands of X-rays are performed all across Australia for back pain and they do not change management. So there are a lot of things that we do throughout the whole health system that are not evidence based. They are based on what we used to do. They are not based on any evidence at all, and they are based on patient expectation. Patients want something done.

Mrs Killen : There is consultation across the college around what our members feel are the top priorities. We are looking at the moment for maybe the top five.

Senator DI NATALE: So how have you done that? You put a call out to all your members saying, 'We are engaged in this process. Tell us your top five'? Or are you engaging people to do a literature review?

Mrs Killen : We are just in the early stages.

Dr Judkins : We have basically done a literature review and we have a committee. We have basically cut it down to 10 investigations or procedures and then we are putting that out to our members. If we asked them, we could come up with a list of 100. We want to get the big-ticket items that everybody knows and then start to work on those and really try and get that culture change throughout—

Senator DI NATALE: That is my next question. There are different ways of doing this. One is that you remove the item number, or whatever it might be if it is in private practice. I suppose that is a blunt way of doing it. The other way is to try and engage the profession. How do you see that translating into, 'We are no longer doing X-rays for back pain'? That is the step I do not quite get yet.

Mrs Killen : We have discussed this quite extensively and of course this is not a quick fix. This is not something that is going to save money in the next two or three years. This is a long-term cultural change involving education of the medical profession and the consumer. I think consumers come to emergency departments and expect to get a raft of tests and, if they do not, they feel they have not received the proper service. We need to educate the community and change the expectation of the consumer around the risks of radiation, overprescribing and inappropriate interventions, rather than have people coming in saying, 'I want a CAT scan,' 'I want an MRI,' 'I want a chest X-ray,' 'I want drugs' and, 'Why didn't you give me antibiotics?' It is a long-term process of education and cultural change—and that is part of the problem, because it is not a quick fix. It is not just taking out the MBS number and saying, 'That is no longer covered.'

Dr Judkins : The difference here is that this is a national campaign that says it is okay not to do these things, whereas when it is a one-on-one doctor-patient relationship and the patient says, 'I want this test done,' it is very hard to deny it, to say to a patient that you do not want to do it. There is an expectation from the community that these things need to be done, but I think having that overarching authority to say, 'This is okay because we don't support this investigation anymore,' will actually see that culture change. Most doctors, at least the people in my college, want to practise the best evidence based medicine, but occasionally you do need the support of the college and other organisations to say, 'That's fine,' and, 'If you don't do it, that's okay.'

Senator CAMERON: Dr Judkins, what can an X-ray of the back show in someone who presents to an emergency facility with severe back pain? Can it identify issues?

Dr Judkins : I suppose it can identify issues but, depending on the mechanism, it is rare. At the moment I have a bad back and I know that I have a bad back, but I am not going to go and get an X-ray because it is not going to change the management. I am pretty sure that I know what it is going to show. It might show a little bit of arthritis. It might show nothing—

Senator CAMERON: I think you are in a different position from most other people.

Dr Judkins : but the point is the evidence shows that doing a plain X-ray on a patient with your common, run-of-the-mill pain—'I've had a bit of an ache for a few weeks and it's not getting any better'—is not going to show anything. There are red flags, of course, so there are guidelines to say there are a group of patients you should X-ray. We have what we call red flags, so if you have a fever, if you have a funny feeling in your toes, et cetera et cetera, then it is time to start doing investigations. But routine screening of everybody who has back pain is not really going to change back pain management.

It comes down to the question of doing the most good for the whole population. We cannot afford to do a back X-ray on everybody. It might pick up one abnormality in 1,000 patients, but doing X-rays for everybody is not really benefiting society overall.

Senator CAMERON: Are you concerned about some of the submissions we have had that basically say primary health care is the biggest cost saver for government in terms of getting early intervention? I think you would agree with that.

Dr Judkins : Yes, absolutely.

Senator CAMERON: But are you concerned that that could result in cost cutting in the hospital and emergency sector if it is seen that the hospitals are too expensive?

Dr Judkins : If the end result was that the primary care community was providing such good service that we did not need people to turn up to hospital, I would be quite happy. I think that would be a great result.

Senator CAMERON: You would go to primary care.

Dr Judkins : I think it would be a great result. If we had enough resources in the community that people could get good preventative care and good care of their chronic problems and we could decrease the need for people to go to hospitals, that is a good outcome for everybody. If I did not have to do my job, if my job was not necessary, the world would be a great place.

Senator CAMERON: That is right. Has your college had any further discussions or any discussions with ministers on these proposals?

Dr Judkins : No.

Senator CAMERON: Have you sought to have discussions?

Dr Judkins : Yes, we have. We have sought to have a number of different conversations on a number of different topics, but we have not been able to engage.

Senator CAMERON: Do you know exactly how many times you have sought to engage?

Mrs Killen : No. We write occasionally, but to date we have not met with the minister.

Senator CAMERON: Have you had any response?

Mrs Killen : Yes, we get acknowledgement of our letters.

Senator CAMERON: You get a standard acknowledgement of your letter.

Mrs Killen : Yes.

Dr Judkins : We seem to get more engagement at the state health minister level. We have reasonably good relationships at that level, but certainly we do struggle at the national level to get the level of engagement that we would want.

Senator CAMERON: What types of issues would you like to be raising with the minister?

Dr Judkins : Things like the national access targets and the ongoing issues around how we make a public hospital system that is effective, efficient and safe. I think that is something we would like to continue our engagement on. We would certainly like our concerns heard around the issues of the GP co-payments. As I said, we are not health economists. We do not know the ins and outs of the budgetary issues, but we do know that all the evidence shows that, if something like this is implemented, it will make our life harder and make it more difficult for our patients who need emergency care.

Senator CAMERON: You are not building the car; you drive it.

Dr Judkins : That is right.

Senator CAMERON: You are dealing with the practical outcomes. Maybe someone from the minister's office is listening in. They may want to talk to you, hopefully.

Dr Judkins : We hope so.

CHAIR: Thank you very much. We would be keen to continue to receive any information from you and hopefully you will be able to advise us that you have been consulted. That would be a bit of a change. I have one final question. We have had a call for a six-month moratorium on any further policy change in the health sector, but we have also had an indication to the Royal Australian College of GPs that there may only be two more weeks of consultation. Would you support a moratorium for six months with regard to health policy change?

Mrs Killen : I think that would give us all a bit of breathing space.

Dr Judkins : Yes. We are pretty busy over the next two weeks, so having six months to organise something would be most beneficial.

CHAIR: Thank you very much.