SPEECH TO THE H20 HEALTH SUMMIT
“HEALTHY PEOPLE, SUCCESSFUL ECONOMY”
WINDSOR HOTEL, MELBOURNE
THURSDAY 13 NOVEMBER 2014
AMA PRESIDENT A/PROF BRIAN OWLER
**Check Against Delivery
Ensuring wise investment in health
I acknowledge the traditional owners of the land on which we meet and pay my respects to elders past and present.
I have been asked to talk about wise investment in health. In particular, collaboration in policy development and interventions – ensuring wise investment.
The title is important. It is not spending on health. It is investment, and that is how health expenditure should be viewed.
As for collaboration in policy development and interventions, I think we can all predict what I might say.
Health care expenditure, or investment, in this country has been under the spotlight.
We have been fed a narrative from this Government ever since they were elected in September last year that health care expenditure is unsustainable.
This is in the context of a Budget deficit. Fixing the deficit was a key plank of this Government’s platform for election.
Much of the ‘policy’ making in health and other areas, such as education, are purely fiscal and economic.
There is little discussion about actual policy. There has been little policy development, and collaboration has been absent.
There are problems ahead for health care in Australia.
I have said many times that Australia actually has a very good health system.
The Australian health care system is not only affordable, it is effective. It is one of the most efficient and highly performing health systems in the world.
It is a system that is worthwhile protecting, improving, and investing in for the future.
The life expectancy of Australians has been consistently been amongst the best in the world, and continues to increase. For a boy born in 2012 it is 79.9 years, and for a girl 84.3 years. It ranks 6th for boys and 7th for girls amongst the 34 other OECD countries.
Increased life expectancy is not only a good result for us and for our children; it has implications for health care policies in the future.
There are certain principles in the Australian health care system that have fostered this success.
It is very easy to take the health system we have, and the benefits we enjoy, for granted.
It is even easier to undermine, even destroy, that health system. That is why the AMA will defend the foundations of the health care system and our patients.
So, what are the foundations of the Australian health care system that the AMA supports and defends?
The AMA supports an Australian health care system that ensures universal access for patients to affordable health care.
There should also be equity of that access.
We must preserve the independence of the doctor-patient relationship.
By this, I mean independence to allow medical practitioners to exercise independent clinical decision-making where their rights to independently refer, with no interference in referral patterns, are protected.
The AMA supports the community rating for private health insurance.
These are the foundations of the health care system. These are principles that the AMA believes are worthwhile defending.
Australia’s health care system is far from perfect. That is why we won’t sit still and be complacent.
As doctors, we are stewards of our health system and we strive to make it better. Innovating. Using what is termed creative dissatisfaction to create an even better system.
How do you harness this creative dissatisfaction and our innovation? You engage.
Engagement with clinicians is key. It can’t be token.
As part of the reform process that Australia went through in recent years for its public hospital system, there was engagement and, in many jurisdictions, governance arrangements have changed as a result.
It is important that we give those new arrangements, with local boards and more autonomy, an opportunity to work.
The same can’t be said for primary care and general practice, where there was little engagement and GPs were disenfranchised.
If we want to get wise investment in health, then we need to have a process of collaboration and consultation for general practice.
We can’t have poor policies, purely fiscal policies, developed in isolation to health, thrust upon the community such as we have seen here with the blunt $7 co-payment proposal.
Primary Care
There is an acceptance by all stakeholders that we need to re-orientate our health towards primary care. But, to date, Governments have not delivered to the level required.
The previous Government took some tentative steps with the introduction of the concepts of Medicare Locals and GP Super Clinics. But they got the formula wrong – horribly wrong.
It is ironic that the current Government now wants to introduce a barrier to access to primary care, right at the time when we should be gearing up the primary care sector to deal with the epidemic of non-communicable disease.
General practice is the cornerstone of primary care. It provides high quality, comprehensive, and value for money care.
The most recent National Primary Health Care Strategic Framework, agreed to by all Governments, recognised this and highlighted the importance of the ‘medical home’.
This is something which many Australians already have through their relationship with a usual GP or usual practice.
The OECD reports that Australia’s general practitioners are doing a terrific job managing diabetes in the community.
The hospital admission rates per 100,000 population for uncontrolled diabetes in Australia are the best of the OECD countries at 6.9 – well under Canada at 15.8, and the UK at 22.8. Sweden and Germany are at 53.8 and 55.5 respectively.
GPs are increasingly working with other health professions as part of a shift to team-based care, including practice nurses and other allied health professionals.
Changes to Medicare have supported this trend.
The management of chronic and complex disease is a key part of general practice, comprising more than a third of all problems managed.
The chronic problems most often managed by GPs are hypertension, depression and anxiety, diabetes, cholesterol-related disorders (brain and heart attacks), chronic arthritis, oesophageal disease, and asthma.
Many older patients suffer from two or more such chronic illnesses simultaneously, and this significantly complicates diagnosis and management.
This is also true for Aboriginal people and Torres Strait Islanders.
Australia has moved to implement more structured arrangements through Medicare to tackle chronic and complex disease, but more needs to be done.
The AMA has been advocating for the adoption of a broad program, like the Department of Veterans Affairs (DVA) Coordinated Veterans Care (CVC) program. It provides additional funding support to GPs to provide comprehensive planned and coordinated care to eligible veterans with the support of a practice nurse or community nurse.
This program is designed to reduce avoidable hospital admissions and deliver overall savings to the health system. It is the type of program that the AMA thinks private health insurers could look at adapting for their members, where they are at high risk of hospitalisation.
The AMA has been in a dialogue with major private health insurers about the role of general practice in PHI arrangements.
Most private health insurers have introduced a number of programs that provide their members with access to services such as telephone coaching, exercise physiologists, dieticians, and physiotherapists to better manage their chronic conditions.
While these programs can potentially be of benefit to patients, they generally work in isolation to the usual GP who understands the patients care needs. This is a significant problem.
The AMA believes it is time for a discussion about how GPs could play a more prominent and central role in private health insurance arrangements.
By supporting a greater role for GPs through private health insurance arrangements, there is the potential for the coordination of patient care to be improved, for care to be provided in the most appropriate clinical settings, and unnecessary hospital admissions to be avoided.
The AMA has identified areas where this approach could be explored. They include wellness programs, maintenance of electronic health care records, hospital in the home, palliative care, minor procedures and GP directed hospital avoidance programs.
The AMA believes that any move to expand the role of private health insurers should be carefully planned and negotiated with the profession. This would ensure that the outcome is in the best interests of patients.
It would also ensure that it does not compromise the clinical independence of the profession, or interfere with the doctor-patient relationship.
We need to look at how we can roll out pro-active approaches such as the DVA CVC programs with the private health insurers.
The need to invest in a healthier future with better disease management, and prevention of avoidable costly hospital admissions, is obvious.
Indigenous health
In talking about wise investment in health to achieve outcomes, health issues for Indigenous Australians must be a key priority.
The AMA is committed to improving the health of Indigenous Australians. We are committed to Closing the Gap. Indigenous health has been a cause for many AMA Presidents. I share that interest.
The life expectancy of Indigenous Australians is 10.6 years less for men and 9.5 years for women.
We must continue to invest in Indigenous health and in the social determinants of health. It is an area where health investment must be wise.
While the gap in life expectancy remains unacceptable, there have been gains in Indigenous health.
Life expectancy has increased by 1.6 years and 0.6 years for men and women respectively over the past 5 years.
The child death rate fell by 30 per cent between 2001 and 2012. It remains too high and the improvements in life expectancy too slow, but it shows that there have also been gains.
The rate of heart attacks fell between 2007 and 2011 by 10 per cent for Indigenous Australians. That is good. But for non-indigenous Australians it fell by 20 per cent.
The Prime Minister has been committed to improving the health of Indigenous Australians. However, the focus has been on improving employment and education. Getting children into school. Tackling truancy rates. Getting people a job. The focus on specific health programs has been sadly lacking.
The Assistant Minister for Health, Senator Fiona Nash, has been working on a health plan for Indigenous Health, and currently an implementation plan is being developed.
She is working with Indigenous leaders and health experts on that plan. That is good news.
The idea that sorting out the social determinants of health, such as education and employment, will improve health is true. However, what we need to emphasise, as I said this morning, is that without improving health, education and employment will not follow. That is why investment in health must continue.
The problems are large and health spending must be strategic. We have seen that targeting early intervention is indeed a wise investment in health.
The application of high quality comprehensive primary health care can deliver gains.
Last year, the AMA’s Aboriginal and Torres Strait Islander Health Report Card focused on the importance of targeting the early years – getting the right start to life.
Recently I was hearing about the gains made by focusing on antenatal care in the Pitinjarra lands of NW South Australia.
There have been major gains achieved by the Nganampa Health Council in antenatal care where 75 per cent of all pregnant women are seen in the first trimester.
The proportion of children under 3 years of age with significant growth failure has fallen from 25 per cent in the 1990s to less than 3 per cent today.
Immunisation rates approach 100 per cent.
This has not been easy, but it shows you can attain significant outcomes, even in remote communities.
The AMA’s Indigenous Health Taskforce, which draws experts in Indigenous Health together, highlights the AMA’s commitment to working, in partnership with Indigenous Australians, to improve the health of Indigenous Australians. Not to just highlight the problems, but to work on solutions and to highlight the successes as well.
Working with Indigenous experts is important if we are going to make wise investments.
Ebola
For all of the challenges of the Australian health care system, it remains a first rate system where the majority of our citizens are still able to access exceptional care.
The same cannot be said for many parts of the world and, for this reason, any discussion around investment in health also needs to consider not only national investment, but global investment.
As a first world nation, with a seat on the UN Security Council, and a good global citizen, Australia’s contribution to global health is important. In fact, it is a good investment.
It is well established that lifting the health and living standards of poorer nations, bringing people out of poverty, is good for their economies.
It benefits the global economy as those nations develop, trade, and contribute economically.
Australia is a key nation in this region and certainly supports nations in the Pacific such as Papua New Guinea and the Solomon Islands.
Improving the health of these nations is not just a moral obligation, it should be seen as a good investment for this nation.
West Africa does seem a long way away from here in Melbourne.
The Ebola disease outbreak, the Ebola crisis, is an excellent example of why Australia, or any nation, cannot have an isolationist view.
The AMA has been critical of the Government over its response to the Ebola crisis in West Africa.
We are pleased that the Government is contributing a total of $42 million in funding, including the $24 million in funding recently announced to train and resource health care volunteers to work in West Africa, to bring this crisis under control.
This is indeed a wise investment. But could there be more investment? Yes, there could.
Apart from the clear moral and ethical obligation, there is a degree of self-interest.
As we have seen around the world, for example in the United States, is the fear that Ebola could come to our own shores.
The discussion, even today, is focused on immigration and protection of ourselves.
Having protocols and resources in place here, and sensible immigration policy, is important. But what is really important, even acting in self-interest, is to treat the problem at its source.
Contributing to the global effort, including with logistic and human resources, is not only the right thing to do, it is indeed a wise investment in health.
Australian health care spending in West Africa has clear security and economic implications for the rest of the world.
If the World Health Organisation predictions of 10,000 infections per week are correct, and if the predictions of 1.4 million infections by January are correct, then the spread of the disease, the impacts on the travel, trade and the economies of Africa, and the rest of the world, would be significant.
The IMF recognises this and took the step of even encouraging West African nations to borrow funds to tackle this problem.
Now Ebola might be the headline, and deservedly so. But what it highlights is the importance of investing in the health systems of developing nations.
Fostering immunisation programs in countries such as Cambodia and Laos, as Australia already does, is a wise investment in health indeed.
The AMA agrees that we have to ensure that we get the best value for the money that we spend.
The approach should be strategic and our policies should reflect how we invest wisely for health care, not just the bottom line and how we get someone else to pay.
The medical profession is only too willing to engage in the formulation of good health policy, not only for the people of this nation, but for those in our region and, indeed, around the world.
13 November 2014
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