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Health policy: up where we belong: speech to the National Press Club, Canberra.



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Australian Medical Association Limited ABN 37 008 426 793

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SPEECH TO THE NATIONAL PRESS CLUB CANBERRA WEDNESDAY 25 JULY 2007 AMA PRESIDENT, DR ROSANNA CAPOLINGUA

**Check Against Delivery

HEALTH POLICY - UP WHERE WE BELONG

Good afternoon, ladies and gentlemen.

The AMA always has as its primary driver, PATIENT CARE.

When we talk about hospitals, doctors, private health, public health, from babies to the aged, from birth to the grave ... it is always about the care of the patient, and keeping that focus in the forefront of our minds.

That care incorporates the preservation of the doctor-patient relationship so that clinical choices for patients are made based on what is best for them.

When you come to see me you want to know, and be certain, that the advice I give you is in your best interests.

You want to know that it is not perversely persuaded by Government controls or by other incentives.

You want to have confidence that the doctor you see is well trained and highly skilled.

You want to know that you are seeing a doctor, and not some substitute that can act out a task, but not really know the ‘total you’ in a medical sense.

You want to know that you are not at risk if you are in a public emergency department, and that your mother or grandmother won’t die alone on a trolley in a corridor, or feel like she has been abandoned … and suffers quietly without complaint … (as she watches the doctors and nurses struggle to keep up with the care they have to deliver).

You want to know that when there are three of you in an Emergency Department cubicle meant for one patient, that the doctor does not have to work out which one of you is the most competent to have the buzzer, because that patient will have to keep an eye on the others.

You pay private health insurance, and you want to know that when you need to use it, it’s the doctor not the insurer deciding the kind of care you will get, which doctor you will be told to have, which hospital you will have to go to, or the prosthesis you need, or how long you can

stay … regardless of your state of health.

If you live in rural Australia, you want to know that the rural hospital has NOT been shut down by the State Government to contain costs.

And you want to be able to see your local doctor when you and your partner and kids need them.

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You want your rural doctor to love being in the bush.

You want your rural doctor to have good cover if he has to go away for a while, and you want him to want to come back and stay.

You want your GP to look after you.

This is what the AMA is about. Making sure that you are looked after as Australians should be looked after.

That’s all Australians - metropolitan, rural, Indigenous, young and old.

But is the health system doing what it should to provide that care?

Indigenous Health

We have recently been confronted with action in the Northern Territory, which eight weeks ago we would not have believed could occur.

This action was long overdue.

The doctors that have worked in Indigenous communities in the Northern Territory and elsewhere across the country have been committed to dealing with the problems for years - making a difference with what they had in resources and their own hard work and connection

with the people.

This must be recognised.

Now we have a Federal focus and nationwide energy behind them and alongside them.

Child sex abuse cannot be tolerated, and it has been allowed to fester and harm some indigenous communities.

This issue has allowed the doors to be opened and a brave ‘once in a lifetime’ initiative is taking place.

The AMA is backing and supporting this initiative. Our doctors have put their hands up to be part of this challenge.

In fact, three of our doctors are currently up in the Territory as part of the first wave.

We are taking the doctors to the Indigenous people and we want the people to want to come to us for their health checks.

Our doctors expect that in their work, when they find clinical problems that need ongoing management and care, there will be referral to specialists or allied health people … and the Government will deliver those ongoing services as well.

We are in for the long haul, and the doctors and the AMA will not support this Indigenous initiative if it is not ‘real’ and followed through.

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It needs to be not just in the Territory, but also across Australia.

The AMA put out a call to the profession and we have some 800 doctors who have responded.

Even though they are already busy, they will create time and space to be involved.

We have GPs, paediatricians, cardiologists, orthopaedic surgeons, ENT specialists, surgeons, physicians … you name it.

They are all ready and willing for the ongoing care of our Indigenous people.

We need a scheme in place that lasts - a scheme that continues to encourage doctors to want to spend time in rural and remote areas as part of their clinical careers.

The AMA will drive this.

We need the commitment and funding of all political parties and all governments.

We will keep them accountable.

Getting to the kids and the communities will start to make a difference to those stats that the AMA keeps talking about.

Aboriginal and Torres Strait Islanders have the poorest health of any group living in this country.

Death rates in the age group between 25-54 are 5 to 8 times higher than that seen in non-Indigenous Australians.

Indigenous infant mortality rates are three times higher than for non-Indigenous infants.

I remind you; there is a 17-year gap in life expectancy between Aboriginal and Torres Strait Islander Australians and the rest of the Australian population.

They expect to die in their early 60s, while we can make it to 80. I find that remarkable….

We have to provide Indigenous Australians with access to quality medical services that make a difference to them from in utero through life.

We have to address the measurable health outcomes.

Fewer low birth weight babies, the eradication of rheumatic heart disease, the management of diabetes, and the prevention of sexually transmitted infections are all goals we can achieve.

We know that medical interventions that can actually produce improved measurable health outcomes are not used by Indigenous people.

We have to change this, and the Indigenous health initiative is an opportunity for that change.

The gap in life expectancy must be closed within 25 years.

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The AMA believes we also need:

• A minimum additional $460 million a year in targeted resources, particularly for primary care;

• A minimum $20 million a year, plus some initial set up costs, to provide all indigenous pregnant women with Mothers and Babies services

• A target of 2.4 per cent of all health professionals being from Indigenous backgrounds by 2012

We must ensure there is an ongoing commitment to provide the long-term service needs that will be uncovered in the clinical process currently underway in the remote communities.

The AMA would like to see policies that extend this initiative to address other concerns such as:

• overall health services • housing • sanitation • education • and other social and environmental impacts on the wellbeing and life expectancy of

Indigenous Australians

We have felt the shame, now let’s make future generations of Australians proud of us.

So what about the rest of the population? How are they faring with their health care?

Let’s talk about the AMA wanting to make sure you get to see a doctor, and a well-trained one at that, into the future.

Doctors

And I am not talking about speaking to a call centre rather than a doctor ...

Call centres costs more per call than a Medicare rebate for you to be with the real thing.

Call centres have been shown to cause an increase in attendance at Emergency departments …

But that is a debate for another day.

There has been a sudden realisation for many that Australia has come to rely on overseas trained doctors.

Our international medical graduates have been helping to look after Australians for decades.

Many rural communities have had long and strong bonds with their overseas trained doctor GP.

These doctors help to hold the Australian health system together.

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Unfortunately all the concern about terrorist associations and doctors may taint the good standing of our colleagues.

We must ensure that they know that we respect and appreciate them, and that patients will continue to trust them.

Around 30 per cent of our medical workforce is overseas trained and in rural areas - up to 50 per cent in some cases, like regional Queensland.

Around five-and-a-half-thousand overseas trained doctors arrive each year on temporary visas, including the 457 visa.

Another 500 arrive as permanent residents.

Without them, many of our rural, outer metro and even teaching hospitals would be without doctors.

The profession strives to ensure that doctors are people of good standing in the community, and that they have the skills to provide good clinical care to patients.

The focus, as I said, has been on doctors, but they make up only a small proportion of people coming to Australia on 457 visas.

In 2005-06, around 40,000 people arrived in Australia as temporary skilled migrants.

The events that have unfolded around terrorist activities are not just about doctors, but also about immigration and national security.

Our view is that the Government should ensure that it has in place appropriate security checks that are applied consistently and across different professions.

So how did we end up with this need for so many international medical graduates?

Previous governments had a philosophy to hold down doctor numbers and services, by restraining the medical student intake and using provider number restrictions.

We have an increasing population, and an ageing population with greater health needs, more chronic disease.

We also have a greater ability with advances in medical knowledge to practise preventative medicine, and to manage patients for better outcomes.

Therein lies the gap between the need for doctors and our local graduate ability to fulfil that need.

The overseas trained doctors have been here for us.

In recent years, we have at last an increase in medical student intake from 1200 domestic graduates in 2000 to 3000 in 2012.

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Good news.

But I know that you want these young doctors to be highly trained and qualified for the future.

The AMA will ensure that State and Federal Governments invest in good training.

This will need money for infrastructure and support across public and private sectors.

The Governments must fund the places for these young doctors.

The public hospitals are central to this.

Public Hospitals

Public hospital services are delivered by State governments.

All State Governments are Labor at this time.

The funding in the Australian Health Care Agreement comes from the Federal, currently Coalition, Government.

You don’t reckon that health is an election issue?

The Health Care Agreement will be on the table. We saw hints of that yesterday.

We are told that Australia is enjoying an unprecedented period of prosperity.

The economy is in good shape, unemployment is at record lows, and people are being encouraged and assisted to buy houses, have more babies, and spend up big.

So you’d think we’d have a health system that reflects the so-called ‘booming’ economy.

But public funded health has been left behind.

The AMA is putting its hands up for Australians.

While State and Federal Governments are in surplus, I want money invested in the public hospitals for today and to establish some foundation for the future.

I want to see real money go to real infrastructure - refurbishments, equipment, expansion, more beds and new hospitals.

I want rural hospitals open.

I want real money going into attracting doctors and nurses and keeping them in the public sector.

I want real investment to train doctors for Australia, in Australia.

I want real money in supporting service delivery so that it makes a difference to patients.

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We cannot accept over-run emergency departments, with delays for urgent patients.

We cannot accept wait lists for priority patients when the wait will adversely affect their health outcome.

Doctors and medical staff work hard but their morale is low when they know that patients are compromised.

Public hospitals should not operate at more than 85 per cent bed occupancy … but some of them are at 120 per cent (remember the patients in the corridors?).

Too much has been spent on plans and reviews and not enough on the provision of beds and services - and the States are clearly at fault here.

However, the Commonwealth and State and Territory Governments are all responsible to work together to fix things.

The negotiation of the next Australian Health Care Agreement will commence in earnest immediately after the Federal election.

Tony Abbott resisted moves to get started yesterday.

The AMA wants a commitment to annual increases in funding that are consistent with health index increases.

The Commonwealth indexation has been approximately five per cent per annum over the life of the current Agreement. That’s clearly not enough.

Five per cent indexation is barely sufficient to cover increases in wages and equipment costs, let alone activity and complexity increases.

Let’s see the commitment of both sides before the election … and let’s see the accountability for the money being spent.

If these are the good times, let’s invest heavily in our public hospitals so they can survive the bad times.

In all the wealth, let us not let government responsibility for health drop off the platform.

To its credit, the Federal Government injected much-needed funding and new policies at the 2004 election, which improved the situation significantly at the time.

But three years later, the effect of those initiatives is eroded and the same problems exist, and new ones arise.

Likewise, the aged care sector is in desperate need of new funding and ideas to cope with growing demand.

A major challenge is how to make medical care more accessible for older Australians - either in a Home or in their own home.

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Aged Care

The care of older Australians is an election issue.

Demand for aged care services is growing rapidly.

In the past 30 years—between 1975 and 2005—the number of people aged 65 and over increased from 1.5 million to 2.7 million.

In the next 30 years, the number of people aged 65 and over is projected to increase by 3.5 million to 6.2 million.

That’s an increase from 13.1 per cent to 23 per cent of the population - almost a quarter of Australians will be aged 65 and over. That’s a lot of grey voters.

Future generations of older people are likely to have more complex needs and demand a higher quality and level of service than is currently available.

They will expect more choice and better value for money. I know I will.

Older Australians must have access to a range of quality aged care and health services - home care, acute, residential and community care - to meet their changing needs.

They must be able to access them in the most appropriate setting for their circumstances.

The AMA expects there will be an increasing user preference for care in the community, where possible and for as long as possible.

There will also be an increasing need to provide quality dementia care in all settings.

So, like the public hospitals, we are struggling to cope now - and do you think we are laying the foundations for this future demand?

The last great aged care package from the Federal Government was delivered by my fellow West Australian, the then Aged Care Minister, Julie Bishop, in 2004.

The Government provided a 6.4 per cent boost to aged care funding in the 2004-05 budget.

In the latest Budget, the Government acknowledged a much needed increase in capital expenditure.

We are playing catch-up with a long way to go.

Another significant and visionary aged care contribution is due.

We need a well-crafted aged care policy that delivers:

• More skilled staff, improving nurse to patient ratios • Incentives for GPs to provide services in both the residential and community aged care settings • Better access to medical specialists

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• And better transport options to take older people to heath care services

There must be a significant investment in capital funding to ensure that sufficient infrastructure is in place to meet future demands for residential aged care and community care.

There must be incentives for GPs, practice nurses, geriatricians and psycho geriatricians to provide services in both the residential and community aged care setting.

There must be improvement in the MBS to underpin this.

A minimum of $100 million extra should be allocated each year over the next five years for the provision of increased GP and GP-supervised services in residential and community aged care.

The Government needs to fund programs that will put computers in aged care facilities for the use of attending doctors for patient records and prescribing.

The lack of wage parity between the public sector and the aged care sector must be addressed.

We need private health insurance products and private hospitals to cater for the complex needs of older Australians.

Older Australians support private health insurance but it does not support them enough in turn.

The private sector needs products and services that are also directed for the sub acute needs of older Australians through the provision of specialist geriatric medicine services, rehabilitation and palliative care.

There you go - an aged care policy for the taking.

Judging by the recent polls, rural, regional and outer metropolitan Australia will be hard-fought battlegrounds at election time.

There are quite a few marginal seats out there, and health services are hurting in country Australia.

Rural Health

There are votes to be won and lost in rural health.

The closure and downgrading of rural hospitals is seriously affecting the future delivery of health care in country electorates.

These decisions are often driven by economic rationalism, without sufficient regard to the significant consequences for local communities or the sustainability of the rural medical workforce.

There are many indicators that show rural people generally suffer worse health care outcomes than people in major cities.

The lack of access to facilities and services is a key barrier.

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The state of facilities and equipment in rural hospitals lags significantly behind their metropolitan counterparts.

In the worst cases, facilities and equipment are in a state of disrepair.

Health care in rural areas is dependent on a strong primary health care workforce and a viable rural public hospital system.

You need both.

Without access to decent public hospital facilities, doctors can’t maintain their procedural skill levels, specialists may not visit, and the opportunity to train new doctors in rural areas is diminished.

Without the latest technology, rural patients cannot benefit from improved surgical techniques or improved methods of care.

They may face longer recovery periods or may not have the same quality of outcome as they would have if they lived in the city.

It’s time to rebuild our run down country hospitals.

This means that the next round of Australian Health Care Agreements must provide funding for rural hospitals over and above the usual indexation.

The State governments cannot renege from their responsibility.

The Federal Government, too, can do more. In the May Budget, only four per cent of new money was directed at programs such as the rural retention program.

We know we need to get doctors to rural communities, and we need to make the opportunity to experience rural and remote medicine in Australia an attractive and valuable part of a doctor’s clinical experience.

Meanwhile, rural communities are doing it for themselves.

There was the recent example of the NSW town of Temora offering five-hundred-thousand-dollars to lure a doctor to their community.

Instead of incentive and attraction, the Government has instigated conscription.

Remember our increased number of med students?

Five hundred of those are unfunded bonded medical school places each year.

Students taking up the positions are bonded to work for six years in workforce shortage areas.

They get no HECS relief and are so keen to do medicine that they will allow themselves to be conscripted.

This is unlike any other profession … certainly not like teaching.

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Med students who take up these positions are offered no incentives and must repay their HECS charges in full.

Unfunded bonding does not address the underlying causes of medical workforce shortages.

Overseas studies have demonstrated that bonding medical students has led to serious morale and job satisfaction issues.

Many students, up to 38 per cent, choose to buy out their bond.

Long-term retention rates are poor - about only half that of doctors who practised in these areas voluntarily.

Unfunded bonding is NOT the answer and may even be unconstitutional.

The AMA has proposed an alternative scholarship based scheme.

This involves selection into medical school not conditional on accepting a contract.

We propose that a scholarship should be paid to the student and that there should be an exemption from HECS fees in return for a service period.

Sounds sensible, does it not?

This will deliver to communities a willing medical workforce that is treated equitably.

Rural health is another election issue.

As we do every election, the AMA will release a more detailed health issues document as the real campaign gets underway.

I could continue today with a list of important issues, such as:

• Health concerns around global warming • Obesity • Child and youth health • Drugs

• and binge drinking

Our health system must also be as equally committed to keeping people well, as it is to curing and caring for those who are ill.

So what else? National registration …

National Registration

We have ongoing concerns for the proposed COAG scheme for the national registration and accreditation of doctors.

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We have been told the details are to come soon … and we all know that the devil most definitely is in the detail…

You will be hearing more on this issue over the coming months.

And ah, yes, another topic I must share with you - Medicare Easyclaim.

Medicare Easyclaim

For those of you who don’t know, this is the system that says you don’t have to queue at Medicare offices to get your Medicare rebate, or fill out those forms and pop them in the post and wait for a cheque.

Sounds good.

It will all happen at the doctor’s surgery instead.

The fact of the matter is that Easyclaim is not going to be that easy.

The idea is that the patient will be able to get their Medicare rebate at the point of service when they pay the practice account.

This will happen through the EFTPOS system.

Patients will have to wait while the doctors’ receptionists need to spend more time processing each patient.

I can see mums with one sick kid on the hip and a toddler running away, trying to pull out three cards - credit card, Medicare card and debit card - at the front counter to have the account processed.

Even if it takes only one extra minute per patient, this could be an extra three hours work per day in a busy four-doctor practice.

So far, some practices have got it down to four minutes a patient! That makes 12 hours a day!

There will be additional keying in, and processing failures of up to 20 per cent as now occurs, and the system will take a long, long time and more staff and more EFTPOS terminals to reach efficiency.

Remember the Medicare queue?

I do not want my patients to suffer that in my surgery.

While the objectives of Easyclaim for patients are worthy, the bottom line is that it will save the Government huge dollars in the scaling back of Medicare offices and the processing of claims.

The costs, however, to doctors and their practices, are real.

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We will become the agents of Medicare and we will assume its burden ... in dollars and human burden for patients.

In spite of our concerns, the Federal Government is planning to go ahead with a multi-million dollar advertising blitz to launch Easyclaim in the next few months.

The reality is that every medical practice would need to make a huge time and resource commitment to make Easyclaim work for their patients.

As it stands, though, the system is not attractive for doctors. It will cost money and it will cost valuable patient and practice time.

Meanwhile, we are in deep discussion with Human Services Minister, Senator Chris Ellison, and the Heath Minister, Tony Abbott, over our many concerns.

My message to the Government is simple: without the support of doctors, Easyclaim faces a very hard road. The burden that the Government puts on doctors may well be transferred onto patients.

I am glad to say that the Government is reconsidering the situation.

Conclusion

I will conclude by saying that health policy is the ‘sleeper’ for this election.

Health affects every Australian - we all intersect with health care and it is of key importance and a core responsibility of government.

People are worried about climate change. People are worried about water for the future. People are worried about interest rates. People are worried about education.

But their health and the health of their family and loved ones is with them every minute of every day. Now is the time, and we have the wealth, to invest for the future of the health system and to accommodate the health needs of future Australians.

The AMA will keep ‘patient care’ as its focus, making sure that your needs are appropriately met without compromise. The AMA will be working to ensure that voters know what the health issues are.

We will provide the information to allow people to take health into account when making their choice of the next Government of Australia.

We will put doctors and health policy back up where we belong.

Thank you.