A mandate to strengthen the health system

This is an exceptional election. Many Australians have memories only of a federal Liberal Government in power, and a health system based on Medicare and public hospitals, with a greater balance and contribution from the private sector in the past few years. The issue for the Australian Medical Association (AMA) is: what will this federal election outcome deliver for the health of Australians?

We believe that our health system provides for the community to a degree, but at the same time needs rejuvenation. The AMA wants to ensure that the health system is capable of serving the Australian community properly into the next decade and beyond. The system needs to incorporate clinician-driven ideas, fresh thinking, and more strategically targeted and audited funding and resources.

The AMA has put forward its blueprint for reform in the Key health issues for the 2007 federal election document.1 This is not an all-encompassing plan, but highlights the pillars of health that must be reinforced if we are to continue to provide high quality and affordable health services in an equitable way to all Australians — and to ensure that we cover any gaps and improve areas of concern.

A few months ago, health was missing from the political table. Neither of the major parties was raising the bids in the great pre-election health policy debate. However, as Election Day draws nearer, health policy continues to rise on the ladder of vote-changing election priorities. Health policy may well decide this election. The signs are there. And some of these indicate a change in thinking.

The Government played a trump card with its Indigenous health and child abuse intervention in the Northern Territory, but it is still too early to judge the success of this action. The Mersey Hospital takeover in Tasmania has delivered mixed results for the Government. Is it a one-off to win a marginal seat, or is it a test case for things to come? Perhaps the Coalition is betting that all health politics are local, affecting individuals at the coalface.

Meanwhile, the Opposition is running hard with preventive care, its $2 billion National Health and Hospitals Reform Plan, and GP Super Clinics. Questions remain in regard to all these initiatives.

Both sides are determined to win the hearts, minds and health votes of the Australian people. The AMA is interested in what will be delivered in terms of real service for Australians.

While Labor still promotes itself as the party that brought you Medicare, which is popular with voters, the party has been out of power for 11 years. In that time, the Coalition has established impressive credentials in health policy, especially since 2004. The Medicare Safety Net, the private health insurance rebate and lifetime health cover, additional rebates for bulk-billing children and health care card holders, and “for and on behalf of” items for practice nurses and allied health providers have all added value to the health system and enhanced the ability of medical practitioners to deliver quality health care. Labor has now embraced these changes.

While Australia has a good health system by world standards, there is more to do. The AMA does not support “big bang” reform to set the health system up for the next decade. We need to identify and build on the positives. Each year, the system delivers a large number of high-quality health services for a relatively modest overall cost (about 10% of gross domestic product, middle-ranking among OECD countries2).

Australians enjoy good health outcomes. For example, the World Health Organization, in its World health report 2000, ranked Australia second in the world for disability-adjusted life expectancy.3 There is value for money in the system: each year, Australians access some 260 million medical services through Medicare (more again in public hospitals), while one in three Australians accesses in-hospital care. The medical workforce works hard to render 100 million general practitioner consultations each year, performing a gatekeeper role that seeks to achieve appropriate early intervention while avoiding wasteful overuse of investigative, specialist consulting and hospital services.

There is always room for improvement, particularly in meeting the health challenges of an ageing population.

The strengths of the Australian health system include:

• A well trained, highly professional health workforce;

• Good quality health infrastructure;

• Complementary public and private health providers; and

• A productive health research sector.

The weaknesses of the Australian health system largely arise because the nation has not invested enough in the health of the nation. Australia has failed to:

• Adequately meet the overall current demand for health care;

• Train enough health professionals to meet the rising expectations and increasing needs of an ageing population;

• Significantly improve the very poor health status of Aboriginal and Torres Strait Islander peoples;

• Find ways to deliver adequate health care to people living in rural and remote areas; and

• Properly educate and inform the community on health promotion and health prevention.

Now is the time to invest — and invest substantially and strategically — in the future health of our nation and our people. The AMA’s Key health issues document articulates where the investment needs to be made.1

Aboriginal and Torres Strait Islander peoples have the poorest health of any group living in Australia. Indigenous standardised mortality ratios are more than three times the expected rate, and death rates in the 25–54-years age group are five to eight times those seen in non-Indigenous Australians. Indigenous infant mortality rates are three times higher than for non-Indigenous infants. The 17-year gap in life expectancy between Aboriginal and Torres Strait Islander Australians and the rest of the Australian population must be closed. It is not acceptable in 2007 for any Australian to have a 1920s’ life expectancy.

The AMA calls for an additional $460 million per year in targeted resources, particularly for primary care, to be delivered in consultation with Indigenous communities and Indigenous health professionals.

Our public hospitals are dangerously underfunded and under-resourced. Waiting times are long. Emergency departments are overwhelmed and under unsustainable pressure. Doctors are working long hours. Morale is low and at crisis level. Patients want access to good-quality public hospital services in a timely manner. Generally, emergency services fall short of reasonable expectations. Public hospitals should not operate for extended periods at more than 85% bed occupancy. Some public hospitals in Australia are operating at 120% occupancy. Patients are treated in corridors. Patients want to be treated in appropriate settings and to be assured of the safety of the system.

All contenders for the election need to take the public into their confidence and, before the election, explain their solutions to the current woes of the public hospital system. The federal government must increase its current funding effort by 8%–9% per annum over the life of the next Australian Health Care Agreement, and commit to a joint federal–state “fix” and regular public audit of the system.

In response to increasingly serious workforce shortages, the Australian Government has embarked on the most significant expansion of medical student places that Australia has ever seen, and announced further measures to increase nursing intakes. Between 2006 and 2012, the number of graduates from medical schools will double. This presents Australia with a unique opportunity to reduce its heavy reliance on overseas-trained doctors.

By 2013, around 3400 intern places per year will be required (current numbers are less than half that, at 1622). Similar increases in vocational training places will also be needed. This is a huge challenge for governments, hospitals and medical colleges. A critical issue will be the expansion of training places without compromising the high standards that have underpinned the high quality of the Australian medical workforce. In particular, if doctors are not given enough experience in dealing with a wide range of medical conditions, then the quality of their training will suffer, and the high quality of patient care will be compromised.

Workforce substitution (using lesser trained professionals) is not the solution. When Australians are sick or injured, they want to see a doctor.

The federal government must provide additional funding and work with the AMA to establish a system for GP training, prevocational training in general practice, specialist training, and training in expanded clinical and rural settings. The states and territories should be locked into cooperating with these arrangements through the Australian Health Care Agreements.

Demand for aged care services is growing rapidly. We are seeing accelerated growth in numbers in the older age group (those aged 65 years and over) and even faster growth in the very old (those aged 85 and over). The AMA expects there will be an increasing preference by users for care in the community, where possible (and for as long as possible), and an increasing need to provide quality dementia care in all settings. A shortage of adequately skilled staff, disincentives for GPs to provide services in both residential and community aged care settings, and difficulty accessing medical specialists continue to affect the quality of care provided to older people.

The federal government must lift funding across the board for aged care, and provide additional incentives for GPs to provide services in residential aged care facilities. This will involve better consulting rooms and equipment in these facilities, with access to computers for patient records and prescribing.

The Australian health system has had an emphasis on curative services. To meet patient hopes and expectations, Australia must become more effective in health promotion and prevention. The responsibility for this falls widely on governments to invest in public health education and reinforcement of lifestyle improvements. Then individuals, GPs and allied health professionals can support and sustain healthy lifestyles and preventive medical interventions to have an impact into the future.

Individual choices are very important in this area. But so too are the social and environmental factors that affect how people live and work, such as education, income, housing and employment. The key health promotion and prevention challenges include smoking; alcohol and drug misuse; immunisation; obesity; nutrition and exercise; and lifestyle diseases such as diabetes. Government has a leadership role in each of these areas. The AMA calls on the federal government to give GPs greater incentives to spend more time with their patients on health promotion and prevention.

Rural and remote Australia is undergoing great change. Some rural communities are growing rapidly through “sea change” population movements, putting considerable pressure on health and community services. Other communities are struggling to survive a prolonged, drought-accentuated decline.

Rural and remote areas deserve, but have not enjoyed, a “fair go” when it comes to access to health care. The lack of access to quality facilities, services and doctors is a key barrier to improving the health and wellbeing of rural communities. Health care in rural areas depends on a strong primary health care workforce and a viable public hospital system. Country patients miss out if they do not have both. Further, without access to quality public hospital facilities, doctors cannot maintain their procedural skill levels, and the opportunity to train new doctors in rural areas is greatly diminished, leaving many communities with no doctors or too few doctors.

The AMA wants the government to link rural health to its recent generous drought-relief programs. Whenever funding is allocated to keep people on the land and working in regional communities, to produce food and resources for the nation and for export, a similar priority should be given to providing the medical workforce and equipment needed to keep the rural population healthy and able to work and support their families.

The Rural Medical Infrastructure Fund, Patient Assisted Travel Scheme, Medical Specialist Outreach Assistance Program, Rural Retention Program and telemedicine programs need a substantial boost in funding and resources. The federal government must take a leadership role in providing rural and regional Australia with properly resourced doctors in adequate numbers to serve local communities.

One of the hardest messages to get into the heads of politicians of all persuasions is that the health system cannot succeed without a well trained, independent medical workforce.

Patients want to see doctors, and have a right to do so. Too much effort is being put into second-best or third-best options when attempting to solve medical workforce problems. The reality is that doctors cannot be replaced or substituted with lesser trained people. We need better utilisation of the health workforce through a carefully managed team approach, in which the doctor is always the coordinator of care and the clinical leader.

Despite patient and community suspicion and concern about doctor substitution, some governments persist with proposals that will ultimately lead to poorer quality patient care. The Council of Australian Governments (COAG) has been pushing one of these perilous barrows for some time, in the form of its plan for a single national system of registration and accreditation for all nine health professions. The federal government has realised the risks in compromising the quality of the health workforce in this plan and is on the brink of rejecting the states-led initiative, but the election has taken the momentum out of this action. The COAG plan must be scrapped postelection, whoever wins.

There has been mutual recognition of registration of medical practitioners between the jurisdictions for many years. The AMA supported previous attempts by the jurisdictions to harmonise standards to allow portability of registration across borders with a minimum of red tape. The last attempt to achieve portability for medical registration in 2003–2004 failed because not all the states and territories would agree on harmonising legislation.

The new COAG model threatens the safety and quality of medical care in Australia, opening the door to government control — for political expediency — of the accreditation of all medical courses and undergraduate and specialist training. These roles should remain independent of government, and the Australian Medical Council must be retained. The quality of Australian doctors is a pillar of our health system.

The AMA wants a government that is prepared to invest in health while times are wealthy, to tide us across the times ahead — with changing population demographics, increasing expectations, increasing ability to investigate and treat deformity and disease, and a sheer increase in population and chronic disease.

This requires dollars, clinicians in the driver’s seat, and accountability at the community level. The AMA has some runs on the board, but the quest is eternal. Our responsibility to our patients and the doctors who serve them does not just peak pre-election; it is a constant work that extends beyond election cycles.