Medicare review ‘not a savings exercise’, Ley promises

The AMA has warned the Federal Government its plan to update the Medicare Benefits Schedule to eliminate inefficiencies and reflect advances in medical practise could be undermined by the ongoing Medicare rebate indexation freeze.

Health Minister Sussan Ley has launched a review of the Schedule, to be led by Sydney Medical School Dean Professor Bruce Robinson, to scrutinise and assess the appropriateness of the more than 5500 services listed.

In parallel, the Minister has also appointed immediate-past AMA President Dr Steve Hambleton to head a Primary Health Care Advisory Group to recommend improvements in providing care, particularly for patients with mental health problems and chronic and complex illnesses.

AMA President Associate Professor Brian Owler said doctors supported the MBS review, but it should not be simply a cost-cutting exercise.

“There’s no doubt that the Government is looking for savings, but as I’ve said to both the [Health] Minister and the Prime Minister, we’re not going to participate in a review that simply is about saving money,” A/Professor Owler told ABC radio. “What we’re happy to do is participate as a profession to make sure that we get a schedule that reflects modern medical practice, but it’s not going to be a hit-list of savings. It’s not going to be something that just looks at trying to take money out of the system.”

Ms Ley sought to allay fears the review was solely driven by the need to pare back health spending, insisting that “this is not a savings exercise”.

“I expect that savings and efficiencies may well come from it, but I’m not going to predict that because, while we start this process, we don’t know exactly what our initial scoping of the MBS will determine,” the Minister said, adding that no savings target had been set.

But A/Professor Owler said that while ever the four-year freeze on Medicare rebate indexation remained in place, there was justifiable concern that the overriding objective of the review was to cut spending.

“The AMA and the medical profession will work closely with the Government and the [MBS Review] Taskforce to ensure Medicare reflects best practice clinical care and provides the highest quality and easily accessible services to patients,” he said. “But the ongoing freeze of Medicare rebates threatens to undermine the good intentions of these reviews.”

A/Professor Owler indicated in early March that he was in discussions with Ms Ley about how restructuring aspects of the MBS could improve patient outcomes and achieve efficiencies that would obviate the need for an extended rebate freeze.

He said the freeze would threaten the viability of many GP practices, cut bulk billing rates and push up patient out-of-pocket expenses.

“Freezing Medicare rebates for four years is simply winding back the Government’s contribution to patients’ health care costs. The freeze will also have a knock-on effect that could ultimately lead to higher private insurance premiums and higher out-of-pocket costs for patients,” he said. “If doctors absorb the freeze, their practices will become unviable.”

Ms Ley told ABC radio she regretted the freeze, but added it was necessary for “fiscal responsibility”.

She said the freeze would not be withdrawn in the May Budget, but expressed hope that it could be removed earlier than 1 July 2018, as currently planned.

“I would like it to be removed earlier than that. I’ll be working towards removing it earlier than that, and I very much hope that it will be,” the Minister said. “Yes, it’s here in the up-coming Budget…but I would like to see it go. It freezes what I might call an inefficient Medicare system.”

A/Professor Owler said it was reassuring that the MBS Review and the Primary Health Care Advisory Group were both being led by eminent and highly-regarded clinicians, making it likely their recommendations would be based on frontline medical evidence and experience.

“We’ve got some eminent people that are going to be involved in these reviews. And this has to be clinician-led. It has to be based on evidence,” he said. “And if the review delivers some savings – and there will be some savings I expect that can be found – then we’d be very happy to participate in that, as long as some of those savings are actually re-invested back into health care as well.”

Ms Ley said there were several examples where the MBS system did not support best clinical practice, such as creating incentives for GPs to order x-rays for patients with lower back pain, and to encourage en masse tests for vitamin D and folate deficiencies.

“I believe the biggest modernisation that needs to happen is because the clinical practices and the equipment and the technology are moving faster than the MBS updates,” the Minister said. “So, where you use scopes to look down people’s throats and look at cancers, they weren’t done in the same way years ago. They’re now much different.”

The MBS Review and the Primary Health Care Advisory Group’s work will also be accompanied by a crackdown on Medicare rorting.

Ms Ley said that although the “vast majority” of doctors acted appropriately and conscientiously, a “small number do not do the right thing in their use of Medicare. Their activities have a significant impact on Medicare and may adversely affect the quality of care for patients”.

Shadow Health Minister Catherine King said the Opposition cautiously welcomed the MBS review, but remained “deeply suspicious” about the Government’s intentions.

Ms King said Labor began an MBS review while in Government, and changes it made would save $1 billion over the next five years.

But she said it was “crucial [the review] not be used as just another excuse to rip money out of health”, and called for any savings made to be reinvested in the health care system.

Ms Ley said each of the three taskforces was expected to provide recommendations by late this year.

“Basically, there’s wide agreement the Medicare system in its current form is sluggish, bloated and at high risk of long-term chronic problems and continuing to patch it up with bandaids won’t fix it,” Ms Ley said. “Not imposing a savings target allows us to work with doctors and patients to deliver high-quality health policies that focus on delivering the best health outcomes for every dollar spent by taxpayers.”

Adrian Rollins

Specialist unemployment: time to be worried?

Consultants working for free to maintain their recency of practice. New Fellows accepting positions with reduced conditions to get their foot in the door. Others prompted to work part time or as locums. Young Fellows choosing to do more sub-specialty training because they cannot find work in their chosen field.

Apocryphal stories maybe, but there is genuine concern in the profession that some specialists are experiencing underemployment or even unemployment.

“Exit block” from training – where recently graduated Fellows stay in training positions that would otherwise be filled by specialist trainees because the consultant jobs aren’t there − is a knock-on effect from this scenario.

We should be worried about shrinking employment opportunities for new Fellows and exit block for specialist trainees.

Among other things, it would mean that some specialists are struggling to get the workload they need to keep their skills fresh. Nor would trainees be getting access to the positions that provide the clinical cases they require to complete their specialist training. It would ultimately mean that Australia is squandering its considerable investment in the medical workforce over the past decade.

So are we really seeing the early signs of an oversupply of specialists, or is the issue a poorly distributed workforce?

Unfortunately, there is no hard data, but anecdotal reports of underemployment and unemployment in some specialties are emerging.

A specialty that might be affected is anaesthesia, where there is increasing concern that an oversupply of anaesthetists is looming. There is a range of possible reasons for this situation, including the large numbers of anaesthesia trainees employed by public hospitals; fewer opportunities for consultants in the public system; fewer private sector opportunities in major metropolitan areas; difficulties in getting credentialing at private hospitals; and senior specialists delaying their retirement.

I met with the Australian and New Zealand College of Anaesthetists and the Australian Society of Anaesthetists in January to discuss the state of the anaesthesia workforce.

Surveys of new Fellows run by both organisations showed that some had experienced unemployment and underemployment after gaining Fellowship, and were concerned about future career prospects.

I understand that the situation in anaesthesia could be emerging in some other specialties as well.

The outcome of the meeting was a joint submission to the National Medical Training Advisory Network (NMTAN) asking it to include the anaesthetist workforce in its modelling program as a matter of urgency. Pleasingly, it has told us that this is indeed a priority for the network.

The AMA is being proactive in getting an understanding of the scale of specialist unemployment across the specialties. The Medical Workforce Committee is taking the lead, working closely with our doctors in training.

We need to get this right and find out whether an oversupply of specialists is building, or whether the problem is one of distribution.

Both scenarios would have obvious, and very different, implications for developing and coordinating the future medical workforce.

Separate to the joint submission on the anaesthetist workforce, the AMA has asked NMTAN to undertake the data collection needed to determine what’s happening across all specialties, and identify the measures needed to ensure that, subject to community demand for medical services, there will be sufficient jobs for doctors when they finish their training.

I’m hopeful that NMTAN is taking the issue seriously.

In the meantime, we are liaising with the Colleges on how their new Fellows are faring.

While we don’t want to generate unnecessary angst among trainees on their job prospects, it is important that they have a clear idea of future workforce scenarios when they make their career choices.

The AMA a persistent and powerful voice on Indigenous health

By Professor Ian Ring, Professorial Fellow at the Australian Health Services Research Institute, University of Wollongong. Professor Ring has worked with the AMA on Indigenous health issues for more than 20 years.

Nothing exemplifies quite so clearly the AMA’s concern with issues far broader than simply representing the interests of doctors as does its role in Aboriginal health.

That interest is broad in scope, genuine and effective, and dates at least from Dr Brendan Nelson’s term as AMA President in the mid-1990s.

Almost every President since has shared Dr Nelson’s deep, personal and organisational concern and involvement in Aboriginal health, and that involvement is the specific reason I, and no doubt others, joined the AMA many years ago.

That involvement has taken a variety of forms – lobbying, promoting public awareness through the media, preparing and disseminating annual Report Cards on a wide variety of relevant topics, and active engagement with Indigenous organisations and leaders.

Promoting public awareness of issues regarding Aboriginal health has been central to the AMA’s role and purpose, and has taken many forms.

For example, Keith Woollard and I travelled to New Zealand during his term as President (1996-98), notionally to learn more about international experience in improving Indigenous health, but with a secondary aim of drawing the attention of the Australian media. Both aims were achieved. There was substantial Australian press coverage and, equally, we learnt a lot about the linkage of health services with community, cultural, social and economic programs.

Lobbying has taken many forms.

During the late 1990s, when the lack of progress in Aboriginal and Torres Strait Islander health was seen as an international disgrace and symptomatic of a national failure to come to grips with the issues concerning Australia’s Indigenous peoples, the AMA arranged to bring together political, public service and health leaders in an effort to bring about a more effective focus on Indigenous health.

It organised meetings with the-then Prime Minister John Howard and several of his ministers, including Senator Amanda Vanstone, Michael Wooldridge, Tony Abbott and John Herron and Commonwealth Department secretaries. It also met with Aboriginal leaders and organisations, notably the National Aboriginal Community Controlled Health Organisation (NACCHO) and the Australian Indigenous Doctors Association (AIDA) and other leaders of the medical profession.

The AMA’s role became more institutionalised during Dr Kerryn Phelp’s term with the formation of the AMA Indigenous Taskforce, whose membership was drawn from NACCHO, AIDA, the Indigenous branch of RACGP, Aboriginal health leaders, AMSA , AMA council members and other AMA members with an active involvement in Aboriginal health.

Since its inception, the Taskforce has produced annual Indigenous Health Report Cards highlighting issues including infant health, inequality, incarceration, low birth weight, workforce requirements and Indigenous primary health care.

Under the leadership of the current President Associate Professor Brian Owler, the AMA is an active participant in the Close the Gap campaign and lobbies effectively on matters of key importance to Indigenous health, such as patient co-payments.

This is in keeping with the AMA’s well-established role as a persistent, sustained and powerful voice on Indigenous health for at least the past two decades.

During that time, much has changed for the better, particularly as a result of the Close the Gap campaign – although recent cutbacks to funding are a significant concern.

For the future, the development of the Implementation Plan for the National Aboriginal and Torres Strait Island Health Plan will be a priority, including ensuring that it is guided by the voice of Aboriginal people and effectively addresses issues of culture and racism, as well as the practical issues of service models, building service capacity and ensuring an adequate workforce and funding.

No early relief for cash-strapped hospitals

Hopes of short-term funding relief for the nation’s cash-strapped public hospitals have been dashed following a decision of the nation’s political leaders to defer discussions on the issue to a special retreat to be held in July.

In a sign that there will be little new spending on public hospitals in next month’s federal Budget, Prime Minister Tony Abbott has convinced his State and Territory counterparts to delay talks on health financing for consideration as part of proposals to reform the Federation.

AMA President Associate Professor Brian Owler said that, although doctors would have preferred the meeting to have reached an agreement on hospital funding, the fact that it would be on the agendas of the COAG leader’s retreat was welcome.

Mr Abbott said the country needed to take a “very holistic look” at the way it funded public hospitals to ensure “we get the best possible value for our dollar, because we’re under pressure”.

“Sure, the states and territories are under pressure for their hospital funding, but we’re under pressure for our tax take,” the Prime Minister said. “No-one is volunteering to pay more tax. So, we need to handle this in a way which acknowledges the need for ever-better health services, but which also appreciates that resources are not unlimited, and that’s what we want to be able to discuss in an honest and candid and collegial way as part of the leaders retreat later on in July.”

Treasury figures show the Federal Government’s decision to walk away from National Health Reform Agreement funding guarantees and cut the indexation rate of future contributions will rip $57 billion out of the public hospital system in the next 10 years.

The massive funding cuts are due to hit a system already showing signs of strain.

The AMA’s Public Hospital Report Card, released a day before Mr Abbott met with the nation’s premiers and chief ministers, showed that elective surgery waiting times remain stubbornly high (for the fourth year in a row the national median waiting time in 2013-14 was 36 days), admission delays remain unsatisfactory and the proportion of beds per population is shrinking.

A/Professor Owler warned the looming funding cuts would create “a perfect storm” for public hospitals already struggling to cope, and would cause patient waiting times to blow out.

“Public hospitals and their staff will be placed under enormous stress and pressure, and patients will be forced to wait longer for their treatment and care,” he said. “Funding is clearly inadequate to achieve the capacity needed to meet the demands being placed on public hospitals.”

The issue threatened to dominate the Council of Australian Governments meeting on 17 April after NSW Premier Mike Baird led a chorus of complaints from State and Territory leaders about the Commonwealth’s funding cutbacks.

But, following the meeting, Mr Baird said the fact that it would now be considered in the context of broader federal-state relations was “a tremendous step”.

“This is not just an individual state issue, it’s not a Commonwealth government issue – we have to do it together,” Mr Baird said. “It is a huge challenge. It is the number one challenge to our finances – full stop. Commonwealth and state.”

Setting the tone for discussions, Mr Abbott made it clear that, while acknowledging the increased financial pressure on the states, the Commonwealth would not be putting more money on the table.

“I accept that, with public hospitals in particular, there are a lot of cost pressures, I absolutely accept that,” the Prime Minister said. “I’m a former Health Minister, I know all about the health rate of inflation, [that it] tends to exceed the general rate of inflation because all the time we’re coming up new and better treatments which are very expensive.”

In the absence of more money, focus is turning to identifying further savings and efficiencies in the way the health system is managed and care is provided.

Mr Abbott said that although this would include examining funding arrangements, more importantly it must also involve overhauling “the structures” to achieve greater efficiencies.

Mr Baird said that “the only way we can deal with it is come together, and what we need to do…is look at the roles and responsibility; can we do it better, can we do it smarter, take away duplication, and can we make sure that we have got the funding to continue to deliver the health care services we do and, importantly, it has to be patient focussed.”

Adrian Rollins

Patients face longer delays as ‘perfect storm’ set to hit stressed public hospitals

Patients face increasingly lengthy waits for hospital care as the Federal Government squeezes funding despite rising demand, creating a “perfect storm” for the nation’s hospitals, AMA President Associate Professor Brian Owler has warned.

As Prime Minister Tony Abbott prepares to meet with State and Territory leaders tomorrow, the AMA’s annual Public Hospital Report Card, released today, shows that, despite the best efforts of doctors and other health professionals, who are working increasingly efficiently and effectively, hospitals are struggling to meet the needs of an expanding and ageing population.

In a clear sign of a system under stress, the national median waiting time for elective surgery has remained stuck at historically high levels.

For the fourth year in a row, patients waited an average of 36 days for elective surgery in 2013-14, almost 10 days longer than they were a decade earlier.

Meanwhile, less than 80 per cent of category 2 patients were admitted within the clinically recommended time of 90 days last financial year, well short of the national target.

Evidence of the strain on public hospitals is set to add to the pressure on Mr Abbott when he meets the nation’s premiers and chief ministers at the Council of Australian Governments in Canberra tomorrow.

Treasury has admitted that Commonwealth funding cuts unveiled in last May’s Budget and December’s Budget update will strip $57 billion from public hospitals between 2017-18 and 2024-25.

The cuts have outraged the premiers who, led by NSW Premier Mike Baird, intend to press Mr Abbott at the COAG meeting to restore the funds.

A/Professor Owler said the States and Territories were facing “a huge black hole in public hospital funding after a succession of Commonwealth cuts”.

“The hospital funding blame game is back, and bigger than ever. Public hospitals and their staff will be placed under enormous stress and pressure, and patients will be forced to wait longer for their treatment and care,” he said. “Funding is clearly inadequate to achieve the capacity needed to meet the demands being placed on public hospitals.”

A/Professor Olwer warned that “a perfect storm” was building ahead of new, lower indexation arrangements for Commonwealth public hospital funding due to come into effect from 2017-18 that will reduce funding from its already inadequate levels, further hampering performance and undermining patient care.

“State and Territory Governments, many of which are already under enormous economic pressures, will be left with much greater responsibility for funding public hospital services,” he warned. “Performance against benchmarks will worsen and patients will suffer. Waiting lists will blow out.”

The AMA said the situation in the nation’s public hospitals was already even worse than the data in the Report Card suggested.

It said official figures disguised the true length of delays that elective surgery patients faced because they only started to count waiting time from when the patient saw their specialist, rather than from the time of referral by their GP.

“This means that the publicly available elective surgery waiting list data actually understate the real time people wait for surgery,” the Report said. “Some people wait longer for assessment by a specialist than they do for surgery.”

Much of this is due to an inadequate number of beds and the staff to serve them.

The AMA’s analysis has found that hospitals have proportionately far fewer beds than they did 20 years ago, contributing to lengthy waits in emergency departments and for elective surgery.

The number of beds per 1000 people fell to just 2.57 per cent in 2012-13, down from 2.62 the previous year, and shows no sign of improving.

Among those most likely to need hospital care, the picture is just as bleak. The number of beds for every 1000 Australians aged 65 years and older has reached a record low of 17.5, a massive 56 per cent decline since the early 1990s.

“Public hospital capacity is not keeping pace with population growth, and is not increasing to meet the growing demand for services,” the report said.

A/Professor Brian Owler said the results showed that, even before the latest massive Federal Government funding cuts bite, public hospital performance was already being hit by inadequate resources.

In last year’s Budget, the Government announced measures that will rip $20 billion out of hospital funding in coming years, including the renunciation of spending guarantees and cut in funding indexation to the inflation rate plus population growth. These cuts were compounded late last year by a further $941 million reduction in spending over the next four years.

A/Professor Owler warned the funding cutbacks would entrench sub-par hospital performance.

“If it proceeds with its savings measures, the Commonwealth will lock in hospital funding and capacity at the inadequate levels demonstrated by current performance,” the AMA President said. “Without sufficient funding to increase capacity, public hospitals will never meet the targets set by governments, and patients will wait longer for treatment.”

The Government has argued budget cuts are necessary because health spending is growing unsustainably.

But A/Professor Owler said total health expenditure actual shrunk in 2012-13, and Commonwealth support was now “well short of [what is needed] to position public hospitals to meet increasing demand”.

The AMA Public Hospital Report Card 2015 can be viewed at the AMA website: ama.com.au

Adrian Rollins

AMA Guide to 10 minimum standards for medical forms

1. The form is available in an electronic format that is compatible with existing electronic general practice medical records software.

2. Forms are distributed through medical software vendors. Access to forms does not require web surfing during consultations, nor form-filling online.

3. The form has a clear notation that states that medical practitioners may charge a reasonable fee for their services and whether the services are eligible for rebate by Medicare or other insurers.

4. Demographic and medical data can be selected to automatically populate the electronic form with adequate space being provided for comments.

5. Only information essential for the purpose is requested and must not unnecessarily intrude upon patient privacy.

6. Forms do not require the doctor to supply information when a patient can reasonably provide this in their own right.

7. A copy is saved in the patient electronic medical file for future reference.

8. Data file storage size is kept to a minimum.

9. Prior to their release, forms are field tested under the auspices of a recognised medical representative organisation such as the AMA and the RACGP, in association with the MSIA (Medical Software Industry Association).

10. Consideration should be given to future compliance with encrypted electronics transmission capability, in line with new technologies being introduced into general practice.

Form guide to cutting red tape

The AMA has declared war on unnecessary bureaucratic red tape, issuing guidelines for the design of medical forms and reports that gather critical information in a way that minimises the burden on doctors.

In the course of their daily practise, medical practitioners are required to fill out multiple forms for Government departments including Centrelink, the Department of Veterans’ Affairs and State and Territory WorkCover authorities, with research showing GPs spent an average of 4.6 hours a week on red tape in 2011 – valuable time that the AMA said could otherwise be spent with patients.

The AMA said that although much of the data provided was vital in helping determine patient entitlements, and could have serious consequences for the effective provision of medical services, often forms also asked for details that were repetitive, extraneous or unnecessarily intrusive in nature, and could be dropped or amended without affecting the quality of information provided.

“We understand that organisations depend heavily upon the accurate completion of medical forms to determine patient entitlements,” AMA Vice President Dr Stephen Parnis said. “Unfortunately, many fail to appreciate the real time implications for doctors having to complete these forms. The key is to focus on obtaining necessary information that is easily accessible, and which does not require doctors and medical practices spending excessive time filling in forms.”

“Doctors prefer spending time on patient care, not bureaucracy,” Dr Parnis said.

The AMA has set out 10 standards that it is asking Government departments and other organisations to take into account when designing medical forms.

These include ensuring that doctors are asked to supply only essential information, that patient privacy is protected as much as possible, and that the forms be available in an electronic format compatible with, and available through, existing medical practice software.

In addition, the AMA said forms must carry clear notification that doctors can charge a reasonable fee for their services.

The Association said that in designing forms, government departments and other organisations often failed to take into account the implications for doctors, and suggested that forms be field tested under the supervision of a representative of the AMA or other medical organisation prior to their release.

“The AMA believes that medical forms can be designed in a way that captures the necessary information in a more simple and concise way,” Dr Parnis said. “Our Guide can help organisations design forms that do not impose unnecessary red tape and compliance costs on busy doctors.”

Adrian Rollins

Plan to boost GP mental health role fails to win Govt support

Health Minister Sussan Ley has ruled out a recommendation of a Government-commissioned review of the mental health system to boost the role of GPs and Primary Health Networks in providing mental health care by redirecting $1 billion of Commonwealth funding from public hospitals to primary health providers and community-based mental health services.

A leaked copy of the long-awaited National Mental Health Commission review of mental health care, obtained by the ABC’s 7.30 Report, has urged a shift in funding priorities away from ‘downstream’ services like acute care and the Disability Support Pension income support to prevention and early intervention care provided by GPs and other primary health providers.

“It is clear the mental health system has fundamental structural shortcomings,” the review said. “The overall impact of a poorly planned and badly integrated system is a massive drain on peoples’ wellbeing and participation in the community.”

The Commission has argued that changing to a “stepped care approach” with a major focus on prevention and early intervention would reduce the severity and duration of mental health issues, ultimately slowing demand for expensive acute hospital care and lowering the incidence of long-term disability.

“The Commission believes one of the most fundamental elements of the stepped care approach lies in prioritising delivery of care through general practice and the primary health care sector,” the report said, citing modelling from consultancy KPMG suggesting this would “slow the rate of increase in Disability Support Pension and Carer Payment costs and the costs of acute care and crisis management”.

The Commission report said international evidence showed that strong primary health care made for healthier people and less costly health care than a focus on specialist and acute care, and suggested the creation of Primary Health Networks was an opportunity to “better target mental health resources”.

Commission Chair Professor Alan Fels told ABC’s AM program that, “we believe that over the next couple of years the Commonwealth should get ready to somewhat rebalance its spending away from it all going into hospitals when it would be better spent on services that keep people out of hospitals”.

The Commission found that mental health problems are inflicting enormous costs on the country despite massive Commonwealth spending.

It said that, despite the expenditure of $9.6 billion on mental health care in 2012-13, around 3.6 million Australians experience mental ill-health every year – including 9000 who die prematurely – and the problem costs the country up to $40 billion a year.

“Our ‘mental health system’ is instead a collection of often uncoordinated services introduced on an often ad hoc basis, with no clarity of roles and responsibilities or strategic approach,” the Commission’s report said. “We need system reform to rebalance expenditure away from services which indicate system failure and invest in evidence-based services like prevention and early intervention.”

Professor Fels said the Commission was not arguing for money to be taken out of mental health care, but that the focus of effort be redirected, suggesting the reallocation of “a minimum” of $1 billion of Commonwealth funding from acute hospitals to community-based mental health services from 2017-18.

“There’s a great deal of Commonwealth spending on people, for example, going into the disability support payment scheme because they’re not well and haven’t been treated well. So, we believe there should be better prevention mechanisms, and system needs to be rebalanced in that direction.”

But Ms Ley has poured cold water on the idea, saying the Commonwealth will not make such a change without the full support and co-operation of the states and territories.

“My strong view is we need to be partners with the states if we are to address serious mental health issues in this country long-term,” the Minister told the West Australian. “Our preference, therefore, is to work with the states to deliver better co-ordination of existing roles and funding arrangements, rather than reduce the part they play.”

The Commission’s report was delivered to the Government on 30 November, but it is yet to make a formal response, causing frustration in the mental health sector.

Adrian Rollins

Ley wants ‘bipartisan national approach’ to mental health

The Federal Government wants to set up an all-government working group dedicated to overhauling the nation’s dysfunctional mental health system following a searing critique from the National Mental Health Commission.

Health Minister Sussan Ley said the Commission’s “disturbing” analysis showed clear failures in the system, and argued the need for a co-ordinated national approach to improve the care of the mentally ill.

“The National Mental Health Commission’s Review…paints a complex, fragmented, and in parts, disturbing picture of Australia’s mental health system,” Ms Ley said. “I acknowledge there are clear failures within both the mental health sector and governments, and we must all share the burden of responsibility and work together to rectify the situation.”

The Minister said the scale of the problem meant it required more than a band-aid approach, and that consultation and collaboration between governments was essential.

“I intend to seek bipartisan agreement to revive a national approach to mental health at tomorrow’s COAG meeting of Health Ministers,” she said.

In its four-volume report, released by the Government today, the Commission questioned the effectiveness of almost $10 billion spent each year on mental health services, and urged an increased focus on prevention and early intervention.

Controversially, the Commission recommended the Commonwealth reallocate “a minimum” of $1 billion from acute hospital funding to community-based mental health services from 2017-18.

But AMA President Associate Professor Brian Owler has rejected the suggestion, warning that public hospitals were already under-resourced.

Earlier today A/Professor Owler released the AMA’s annual Public Hospital Report Card showing the nation’s hospitals are struggling to meet performance benchmarks under pressure from a remorseless increase in demand from patients and a squeeze on funding.

The Report found there had been improvements in patient waiting times for treatment, by the AMA President warned these gains were threatened by the Federal Government’s move to take almost $3 billion from public hospital finding by 2017, and to cut the indexation rate of its subsequent contributions.

A/Professor Owler said the changes were creating a “perfect storm” for the nation’s public hospitals, and would inevitably lead to longer waiting times for patients.

State and Territory leaders are expected to confront Prime Minister Tony Abbott over reduced hospital funding at tomorrow’s heads of government meeting amid estimated the Commonwealth changes will short-change them by $57 billion.

Bt Ms Ley moved to allay at least some of their concerns by rejecting the Commission’s suggestion to reallocate a further $1 billion from hospitals.

“The Government does not intend to pursue the proposed $1 billion shift of funding from state acute care to community organisations, as we want to work collaboratively in partnership with other levels of Government,” the Minister said. “While many recommendations offer positive ideas, others are not conducive to a unified national approach.”

Adrian Rollins

Countdown for health to the post-2015 UN Sustainable Development Goals

The UN member states face difficult decisions for health in crafting the proposed, expansive post-2015 sustainable development agenda

In December 2015, the achievements of the United Nations Millennium Development Goals (MDGs) on development in low- and middle-income countries will be assessed. Already we are aware of the progress since they were proposed as part of the UN Millennium Declaration in 2001. The world has reduced extreme poverty by half; over 3.3 million deaths from malaria and tuberculosis have been averted; over 2.3 billion people have gained access to safe drinking water; child mortality has more than halved; and access to HIV antiretroviral drugs has substantially increased.1 Beyond 2015, the residual tasks of the MDGs will be integrated into a new agenda that has arisen from the recommendations of Rio+20, the United Nations Conference on Sustainable Development in June 2012, asking all nations to commit to Sustainable Development Goals (SDGs).

As part of Go4Health, an international consortium advising the European Commission on health-related objectives in the evolving negotiations on post-2015 SDGs,2 we have tracked the debate with increasing concern. In June 2013, after a year’s global consultation and the release of the report by the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda,3 we interviewed key personnel from UN multilateral organisations and related global health agencies. Their reactions to the consultation and report were complex: relief that so much of the health agenda had been maintained, but concern over potential challenges.

One such concern was that the use of health rights language, particularly regarding sexual and reproductive health, would reactivate political conflicts about contraception and abortion and extend to highly charged debate on sexual orientation and gender identity.4 In recent intergovernmental negotiations, language that called for protection of human rights “without discrimination” was opposed because of perceived covert links to sexual orientation and gender identity. Our interviewees shared the apprehension that in the debates about economic and environmental matters implicit in the post-2015 negotiations, sexual and reproductive health and rights may become vulnerable in critical trade-offs.5

In our more recent interviews in May 2014, there was also considerable anxiety among health agency personnel about the risk of fragmentation as the intergovernmental Open Working Group assumed post-consultation responsibility for developing the document on which the final SDG negotiations will be based. This document was submitted to the September 2014 UN General Assembly.6

The Open Working Group’s vision has strengths in its ambitious scope, the centrality of women and its recognition of the potential of technology, but the 17 goals and 169 associated targets are unwieldy and inconsistently framed. At this stage, they lack a cohesive focus that will engage global commitment to transform health and development.7

The health SDG, “Goal 3: Ensure healthy lives and promote well-being for all at all ages”, now comprises 13 associated targets. The goal builds on the MDGs to further reduce maternal mortality and end preventable child deaths and the epidemics of AIDS, tuberculosis and malaria, but now also tackles additional infectious diseases — hepatitis, water-borne diseases and neglected tropical diseases. It includes non-communicable diseases, road traffic trauma, alcohol and substance misuse, tobacco control, and the health effects of pollution. These targets are framed by key health systems targets: achieving universal health coverage, building capacity for risk management, strengthening the workforce, and ensuring access to sexual and reproductive health services.4 All these are worthy concerns that need to be addressed.

However, the task of the SDGs is to galvanise and focus global attention on sustainable development and to ensure the consensus necessary to resource its implementation. Despite UN insistence that the SDGs have been set, in their current formulation, these goals cannot do that. If the weakness of the MDGs was the lack of consultation, under the Open Working Group, the health SDG, in particular, is problematic, reflecting the complex politics of the process and including priorities for every advocate, but diluting the cumulative impact.

Difficult decisions must be faced. If health is to remain central, it must be integral to the whole sustainable development agenda. Renewed focus should again be placed on why the global community is seeking a new set of development goals, and the values and vision for sustainable development that underline them. The UN Secretary-General’s response to the SDGs in his synthesis report on the post-2015 sustainable development agenda has clustered the 17 goals into six “essential elements” — a much more manageable configuration.8 But the duplications and inconsistencies still need remedying, with the aspirational targets being redefined for achievement by 2030.

The health goal and targets need to be reworked into a compelling narrative of how health is integral to sustainable development.9 Let us work with the health goal as it is — healthy lives and wellbeing are reasonable aspirations, and recognising age differences allows both focus and a whole-of-life trajectory. However, the 13 health targets need to be reduced and restructured so that they make sense at both global and local levels and are clustered on the basis of their commonalities. We suggest the following three targets:

“Ensure a policy environment that enables health and wellbeing.” This target could reasonably embrace the initiatives in research and development of medicines and technologies, the negative effects of pollution and trauma, global health risk surveillance and response, alcohol and substance misuse, and tobacco control.
“Achieve universal health coverage.” This target would ensure universal access to services including sexual and reproductive health care, while guaranteeing protection against health-related financial risk, with services underwritten by the necessary finance and human-resource strategies.
“Protect every age group from the major threats to healthy lives and wellbeing.” This target includes both the residual MDG agenda, and the expanded recognition of non-communicable diseases, but allows for other emerging priorities.

Within these three targets, the original 13 targets and other nationally significant problems could be redesignated as health indicators, aggregated to track progress across health as a whole. This restructuring would reframe health within sustainable development, establish coherent links between the systems and policy frameworks that enable interventions, and cluster disease target silos into integrated, comprehensive health services delivery.

The remaining critical matter will be the means of implementation; UN member states must commit to funding change in a global partnership for sustainable development. Forging consensus on the SDGs will be crucial, but even more so will be driving agreement on how to mobilise the domestic and global resources needed to achieve them.