President highlights AMA influence

AMA President Dr Michael Gannon opened the 2017 National Conference lauding the political influence of the organisation he leads.

He told delegates that the past 12 months had been eventful and had resulted in numerous achievements in health policy.

“The AMA is a key player in Federal politics in Canberra. The range of issues we deal with every day is extensive,” Dr Gannon said.

“Our engagement with the Government, the bureaucracy, and with other health groups is constant and at the highest levels.

“Our policy work is across the health spectrum, and is highly regarded.

“The AMA’s political influence is significant.”

Describing the political environment over the past year as volatile – which included a federal election and two Health Ministers to deal with – Dr Gannon said the AMA had spent the year negotiating openly and positively with all sides of politics.

“Our standing is evidenced by the attendance at this conference of Prime Minister Malcolm Turnbull, Opposition Leader Bill Shorten, Greens Leader Senator Richard Di Natale, Health Minister Greg Hunt, Minister for Aged Care and Minister for Indigenous Health Ken Wyatt AM, and Shadow Health Minister Catherine King,” he said.

“Health policy has been a priority for all of them, as it has been for the AMA.”

While the Medicare rebate freeze was the issue to have dominated medical politics, there are still more policy areas to deal with in the coming year.

The freeze was bad policy that hurt doctors and patients.

“I was pleased just weeks ago on Budget night to welcome the Government’s decision to end the freeze,” Dr Gannon told the conference.

“The freeze will be wound back over three years. We would have preferred an immediate across the board lifting of the freeze, but at least now practices can plan ahead with confidence.

“Lifting the freeze has effectively allowed the Government to rid itself of the legacy of the disastrous 2014 Health Budget.

“We can now move on with our other priorities… We will maintain our role of speaking out on any matter that needs to be addressed in health.”

Dr Gannon said while the Medicare freeze hit general practice hard, it was not the only factor making things tough for hardworking GPs.

General practice is under constant pressure, he said, yet it continues to deliver great outcomes for patients.

GPs are delivering high quality care and are the most cost effective part of the health system.

“One of the most divisive issues that the AMA has had to resolve in the past 12 months is the Government’s ill-considered election deal with Pathology Australia to try and cap rents paid for co-located pathology collection centres,” Dr Gannon said.

“We all know that our pathologist members play a critical role in helping us to make the right decisions about our patients’ care. They are essential to what we do every day.

“It was disappointing to see the Government’s deal pit pathologists against GPs.

“The pathology sector is right to demand that allegations of inappropriate rents are tackled, and the GPs are equally entitled to charge rents that place a proper value on the space being let.

“The recent Budget saw the rents deal dumped in favour of a more robust compliance framework, based on existing laws. This is a more balanced approach.

“The AMA will work with Government and other stakeholders to ensure that allegations of inappropriate rents are tackled effectively.

“We want to ensure that patients continue to access pathology services solely on the basis of quality.”

The AMA is a critical adviser to the Government on its roll-out of the Health Care Home trial.

It shares the Government’s vision for the trial, but will continue to provide robust policy input to ensure it has every chance of success.

The AMA has secured a short delay in the roll-out of the trial.

Other issues the President highlighted as areas the AMA is having significant influenced included: the Practice Incentive Program; My Health Record; Indigenous Health; After-Hours GP Services; the MBS Review; public hospitals; private insurance; and the medical workforce.

Chris Johnson

US health care costs more

The latest data confirms that the United States spends more on health care when compared to other countries, and points to the their higher price for many procedures, diagnostic tests and drugs as being a main cause.

The International Federation of Health Plans (iFHP) used data from 2015 that examined detailing its annual survey of medical prices per unit. The federation annually surveys prices that are actually paid for selected health care goods and services in the different countries.

Health care costs are complicated and why the US spend is so high may not be easy to narrow down to a single cause but the iFHP data does highlight that a higher health spend is not always closely related to a higher supply of health human resources or to a higher supply of physical and technical equipment in health systems.

The report showed that Humira, a drug prescribed for rheumatoid arthritis has prices ranging from $552 in South Africa to an average $2,669 in the United States. OxyContin cost less than $36 in Spain but cost an average $265 in the United States.

Hospital costs vary dramatically within the United States, from between $17,358 to $1,494 but is an average of $5,220, only just behind Switzerland at $4,781. Australia came in at $765 per day.

It is interesting to note that the latest data from the Organisation for Economic Co-operation and Development (OECD) shows that the United States, has the level of spending on pharmaceuticals twice the OECD average, more than 35 per cent higher than in Japan, the next highest spender.

The US continues to spend much more on health per capita than all other OECD countries but is not in the top group in terms of the number of doctors or nurses per population.

The OECD also reveals in the United States, the gains in life expectancy over the past few decades have also been more modest than in most other OECD countries. While life expectancy in the United States used to be one year above the OECD average in 1970, it is now more than one year below the average. Many factors can explain these lower gains in life expectancy.

Meredith Horne

Weight loss surgery in Australia 2014–15: Australian hospital statistics

Weight loss surgery in Australia 2014–15: Australian hospital statistics is a new report in AIHW’s series of summary reports describing the characteristics of hospitals and hospital services in Australia. In 2014–15, there were about 22,700 hospital separations involving one or more weight loss surgery procedures. Seven in 8 of these separations occurred in private hospitals. Around 18,000 of weight loss surgery separations, or 79%, were for female patients. From 2005–06 to 2014–15, the total number of weight loss surgery separations more than doubled, from about 9,300 to 22,700.

[Editorial] Thyroid cancer screening

Whether screening for a disease is beneficial or not is widely debated. Last week, the US Preventive Services Task Force (USPSTF) recommended against screening for thyroid cancer in adults who show no signs or symptoms of the disease, concurring with its 1996 recommendation.

Primum non nocere: rethinking our policies on out-of-home care in Australia

Are our child protection policies causing more harm to our most vulnerable children?

In Australia, there were 43 399 children in out-of-home care (OOHC) on 30 June 2015 (Box).1 Over the past 18 years, the rate at which Indigenous children have been placed in care has more than tripled and more than doubled for non-Indigenous children.1–3 This is disturbing, and particularly so for Indigenous children where one in 19 are in OOHC.1 A recent review of child maltreatment across various countries, including Australia, concluded that 40 years after contemporary child protection policies were introduced in the 1970s, there has been “no clear evidence for an overall decrease in child maltreatment”.4 Despite the call by this review for more evidence,4 there have been no studies planned to assess the effectiveness of our current OOHC policy in Australia.

OOHC refers to the care of children and young people up to 18 years of age who are unable to live with their families and who are, in turn, placed with alternate caregivers on a short or long term basis. Most children in care are in good physical health and display improvements in psychological functioning over time. Recent statistics show that 93.4% of all children in OOHC in Australia live in home-based care. Eighty-one per cent of children in OOHC are in care for more than 1 year, of whom 41% remain in OOHC for over 5 years.5

Children in care experience significantly poorer mental health outcomes than children who have never been in care, with one study recording up to 60% having a current mental health diagnosis, including attention deficit hyperactivity disorder, depression, and attachment and conduct disorders.6 Children in care are less likely than other children to continue their education beyond the age of compulsion. They are likely to attend a large number of different schools and experience substantial periods of absence from school, and many have to change school as a result of a placement change.6 Several studies have identified that children entering care have usually experienced trauma and neglect and, as a group, are at significantly increased risk of mental health problems.7,8 However, there is no evidence to indicate that OOHC reduces the prevalence of mental health problems in this population.

Community concerns about the risk of a child protection matter leading to the death of a child are out of proportion with the statistics. The homicide rate for children has remained the same at about 0.8 per 100 000 for the past two decades.9 A major concern is that there is evidence that children in OOHC in Australia may experience an increased risk of harm while in care compared with children who have never been in care. A review of child deaths in New South Wales found that there were 41 reviewable deaths due to suspected child abuse and neglect in 2012–2013; 14 of these deaths involved children who were in OOHC in NSW during the time of review.9

A South Australian study identified a significant minority of children in care (24%) with a history of placement disruption.10 This group of children experience an average of 11 placements during their time in care and have experienced five placement breakdowns in the previous 2 years. The study showed a strong coincidence of early trauma and abuse and subsequent placement instability.10 A key to mitigating the impact of the child abuse on vulnerable children is to have a stable long term placement; either reunited with their own family if possible, or in a stable alternative home as soon as practicable.11

International experience

The Australian experience of rapidly rising numbers of children in OOHC over the past two decades has not occurred in the United States or New Zealand. In the US in the 1990s, there were 570 000 children (8.9 per 1000) in OOHC,12 and there was concern that many children in OOHC languished in placements that were not permanent, leading to poor long term outcomes for those children. In response to this, in 1997 the US introduced the Adoption and Safe Families Act, which aims through legislation to compel state child protection authorities to limit the length of time children are allowed to remain in foster care. Almost two decades later in the US, there has been a 30% reduction in the number of children currently in OOHC, to 400 000 in 2014, and a 40% reduction in the rate of OOHC, from 8.9 per 1000 to 5.4 per 1000 between 1990 and 2014.12

In New Zealand, the number of children in OOHC has also been trending downwards. Between 2008 and 2012, the number reduced from 4522 to 3783.13 Based on NZ population statistics,14 this represented an almost 20% reduction in the proportion of children in OOHC, from 5.1 per 1000 in 2008 to 4.2 per 1000 in 2012. This is likely the result of the policy changes of the Ministry for Vulnerable Children, where there has been a deliberate effort to reduce the number of children entering care by having agreements to have the children placed with kin without formally placing those children under the guardianship of the court. There has been policy encouragement to have those carers seek additional guardianship and custody rights as a consequence of the Care of Children Act 2004.

Reducing the number of children in OOHC in Australia

More than 90% of the children in OOHC in Australia have been placed there after a court order. The substantiated abuse in over 70% of these cases involves neglect and emotional abuse.1 The majority of parents involved in child protection matters are from marginalised groups in society who frequently do not have access to legal representation for non-criminal matters. This means that there is frequently a great power imbalance between well resourced officers of state or territory community services departments, whose applications to the Children’s Court are mostly unchallenged by legal representatives acting on behalf of either the biological parents or the child recommended for placement in OOHC.15 In Australia, OOHC has been assumed to be the safest option for vulnerable children if there is any suggestion of risk of further harm to the child. This assumption needs to be challenged.

In 2015, a Senate committee report on OOHC was commissioned by the Australian government because of concerns about the increasing number of children in OOHC, the grossly disproportionate representation of Indigenous children in care, and the challenge of finding enough suitably trained carers and homes to cater for the increasing numbers of children. The report made 39 specific recommendations about how OOHC could be improved. The focus was on improving the quality of care and training provided to better support foster carers in Australia.16

The report noted the achievements of the US in reducing the number of children in OOHC and the need to consider similar strategies here. However, it maintained the assumption that we should expect an ever-increasing number of children in OOHC in Australia. Even if all the recommendations were to be implemented, they would not reduce Australia’s reliance on the OOHC system for vulnerable children. It is disappointing that the report did not consider the broader societal questions of why we are placing such a large number of children in foster care and whether there are ways to reduce the number of children who experience abuse and neglect and who need OOHC.

There is no one policy innovation that will change the number of children placed in OOHC in Australia. Decreasing our reliance on OOHC will require many different strategies implemented over a sustained period of time. There is little hope of achieving change if we consider OOHC in isolation from other social policies regarding welfare and increasing societal inequality evidenced by the 17.4% of our children being raised in poverty in Australia.17

We need look no further than the public health success stories in Australia of reducing cigarette smoking rates among adults from 38% in 1974 to 15% in 2013,18 and reducing the national road toll from a rate of 30 per 100 000 people in 197019 to 5 per 100 000 people in 2014.20 These successes have been achieved through multiple initiatives over decades leading to incremental and sustained improvement.

Conclusion

There are far too many children in OOHC in Australia. A child being placed in OOHC should be seen as an indicator that our society needs to do better rather than being accepted as an expected consequence of modern society. The resources to support our most vulnerable children should be directed more towards strengthening the family into which they are born as the first option. We need to ask politically charged questions, such as should we be developing policies that encourage disadvantaged families to have fewer children? We need to aggressively invest in young vulnerable mothers when they have their first child in disadvantaged circumstances, and not wait until there have been documented problems with child neglect before the child protection and social services systems react. We must incrementally reduce our reliance on OOHC as a key goal in overcoming the complex problem of child abuse, neglect and increasing inequity in Australia.

Box –
Children in out-of-home care in Australia at 30 June, 1997–20151–3

Year	Total		Indigenous children		Non-Indigenous children		Ratio of Indigenous to non-Indigenous children
Year	No.	Rate per 1000 children	No.	Rate per 1000 children	No.	Rate per 1000 children	Ratio of Indigenous to non-Indigenous children

2015	43 399	8.1	15 455	52.5	27 817	5.5	9.5:1
2005	23 695	5.2	5450	26.5	18 245	3.9	6.8:1
1997	13 965	3.0	2785	16.3	11 180	2.5	6.5:1

The scratch test for determining the inferior hepatic margin

Still a valuable component of the physical exam

Evaluation of liver size by palpation is a basic component of the physical examination. Suspicion of an enlarged liver should prompt the clinician to examine for possible causes (Box 1) and investigate further with appropriate imaging such as ultrasonography. Palpation to detect the inferior liver margin may not be accurate or possible in certain clinical conditions (eg, obesity, abdominal distension, tenderness, or guarding). In such cases the scratch test may be useful. We describe the technique of the test and review the evidence base for its use.

The scratch test is a type of auscultatory percussion which was described as far back as 1840, and used to ascertain the size and form of various organs, including the heart and liver.2 The principle behind the scratch test is that the sound from a scratch on the skin overlying the relatively solid liver will be transmitted to a stethoscope located at another point over the liver better than a scratch not over the liver (ie, separated from the stethoscope by bowel or air).

Method for performing the scratch test3

The diaphragm of the stethoscope is placed on the xiphisternum (point C in Box 2).
The examiner repeatedly and lightly strokes the skin with a single finger, parallel to the suspected liver edge, starting from the right lower quadrant and moving towards the costal margin along the midclavicular line (point A in Box 2).
The examiner will hear very little transmission of sound to the stethoscope until the scratches reach the liver edge (point B in Box 2), at which point there will be a sudden increase in volume and quality of the sound transmission.
A control manoeuvre is recommended to exclude a false positive finding, which can occur in up to 10% of cases.3
To ensure that the sound transmission is not purely through the skin, we suggest using the same stroking technique to scratch up the midline to the xiphisternum until the point of sound transmission is reached (point D in Box 2).
If the distance from the detected liver edge to the xiphisternum (BC) is more than the control distance (CD), then it can be assumed that the transmission of sound heard at point B was through liver.
If the distance from the detected liver edge to the xiphisternum (BC) is less than or equal to CD, then it can be assumed that the sound conduction was likely due to skin conduction and that the liver edge did not extend beyond the right costal margin.

A video demonstrating the use of the scratch test is available online at mja.com.au.

Is the scratch test still useful in practice?

Very few studies have formally evaluated the scratch test and yet, based on limited evidence, calls have been made to abandon this test.4,5 We believe this call is premature for a number of reasons, as follows.

Small numbers of participants in previous studies, leading to low precision.
Conflating the reference standard of the inferior hepatic margin with the overall hepatic span — the lower hepatic margin does not correlate with the overall liver span given the variation in the superior border of the liver.
Interobserver variation in choosing landmarks (eg, midclavicular line).4
Elementary statistical analyses restricted to correlation coefficients — the question with a physical examination manoeuvre is not absolute accuracy, but whether it is useful enough to yield some information. In our evaluation of the scratch test,3 we noted only a moderate correlation (Spearman correlation coefficient, 0.37) but that 37% of ratings fell within 2 cm and 53% within 3 cm of the ultrasound-located edge. This level of accuracy is still potentially clinically useful.
Lack of definition as to whether the start of the sound transmission was taken as the liver edge or the point of maximal sound transmission. In our study,3 we noted, anecdotally, a difference of about 2.5 cm between these two points, which could be an added source of error. We also noted that by using the point of initial sound transmission, the accuracy rate could increase to 43% of ratings falling within 2 cm and 76% falling within 3 cm of the ultrasound-located value.
Lack of any control site for auscultation to guard against skin transmission of sound.
The scratch test was sometimes performed by the same examiner who performed other manoeuvres, such as palpation, and so was not interpreted independently.
Lack of any training or standardisation of examiners.

Further, a Bland–Altman plot indicates that raters tend to overestimate small spans and underestimate large spans,3 so physicians should be aware of this bias. With some practice and an awareness of this bias, we believe the scratch test can still be a valuable part of the physical exam.

Box 1 –
Causes of an enlarged liver1

Hepatocellular carcinoma
Liver metastases
Fatty infiltration (alcoholic and non-alcoholic)
Haematological disease
- Myeloproliferative neoplasms
- Lymphoma
- Leukaemia
Infiltration
- Amyloidosis
- Haemochromatosis
Acute hepatitis
Biliary obstruction
Right heart failure or pulmonary hypertension (usually pulsatile)

Box 2 –
Landmarks on the abdomen in relation to the measurements used for the scratch test*

* The costal margin is marked with a solid line.

Changes in medical education to help physicians meet future health care needs

Generalist training may be a solution for responding to future population health needs

Health care needs are changing due to the rapidly ageing population and the increasing number of patients with long term conditions and comorbidities.1 This has occurred at a time of continuing maldistribution of the medical workforce in Australia and increased specialisation and subspecialisation within the medical profession and the medical education system. As the next generation of doctors will need to serve an older population and those with more than one condition, a more useful focus would be “much less on narrow disease silos and … more on the breadth of possible permutations of co-morbidity”.1 Long periods of training and increasing subspecialism may also lead to difficulty in changing the scope of practice in times of surplus or reluctance to move to geographic areas with medical workforce shortages.2 For example, despite increasing numbers of medical graduates in Australia, there are existing shortages in generalist specialties, such as general practice, general medicine and psychiatry, and many rural communities still have reduced access to medical care compared with urban populations.2 Do current models and degree of specialisation encountered in medical training optimally prepare physicians to serve the needs of all patients?

Generalism, and the role of the generalist, has been proposed as one solution to reforming the nature and education of the health workforce. Generalism has been defined as “a philosophy of care that is distinguished by a commitment to the breadth of practice within each discipline and collaboration with the larger health care team in order to respond to patient and community needs,” and generalists have been defined as “a specific set of physicians and surgeons with core abilities characterized by a broad-based practice. Generalists diagnose and manage clinical problems that are diverse, undifferentiated, and often complex. Generalists also have an essential role in coordinating patient care and advocating for patients”.3

According to Reeves and colleagues,4 generalism includes continuity of care, principles of person-centred decision making, practice of interpretative medicine, and first contact care for a wide range of problems, such as undifferentiated and complex presentations. While specialists, who mostly provide condition-focused care, may use some features of generalist care, it is the whole-person focus that defines generalist expertise.4 In the Australian health care system, general practitioners and other generalist specialists provide continuity of care in community and hospital settings; they coordinate whole-person care and manage complex and chronic conditions. With the growing burden of multimorbidity, such generalists are likely to be of great value in urban and rural health care settings.

Generalism has been considered the opposite of fragmentation.5 In most medical education settings, the persistence of an organ- or disease-centred approach and clinical rotation structure encourages fragmentation, which tends to foster concepts and skills for continued subspecialisation and hinders the development of generalism in practice. Moreover, it may not equip graduates with the diversity of skills and experiences they will need to tackle multimorbidity or serve in locations and settings of most need.2 The Australian society contributes to the funding of medical education and there is an expectation that doctors will practice medicine and provide services that meet the needs of patients. A subspecialist may be efficient in managing a single clinical problem in a major urban area, but this may not be viable or cost-effective in regional and outer metropolitan settings.6

It is clear that generalists, specialists and subspecialists are needed in the medical system; however, if we aspire to develop more generalist physicians, learners must be exposed to role models who themselves are generalists.7 Albritton and colleagues7 offer several strategies to achieve this: reward and include generalist role models and mentors in all levels of medical education; incorporate generalists into patient care teams in tertiary care teaching settings; implement collaborative teaching programs involving generalists; ensure that accreditation requirements exist for generalist learning environments, with generalism as a fundamental requirement in all specialist training; and provide a thriving academic base for generalists within the academic environment of health education institutions.

Distributing learning out of the tertiary care centre into the community — and valuing the expertise available from generalists based there — is exemplified by the model of medical education adopted by Graduate Medicine (GM) at the University of Wollongong.8 In 2007, the university launched a new graduate-entry school with a shift in emphasis from teaching and learning in specialism to generalism.9 The GM aspired to deal with the shortage of generalist physicians (general practice and other specialties) in regional and rural communities. In addition, the Northern Ontario School of Medicine (NOSM), aiming to meet rural workforce needs in northern Canada, has also foregrounded learning in generalism.10

Extended immersion in the real world environment of generalism is a distinctive feature of the GM and NOSM educational programs.8,10 All senior students in these 4-year graduate-entry medical courses complete a community-based longitudinal integrated clerkship (LIC) in rural or non-capital city urban settings. While other medical schools have implemented LICs for a portion of their students, the year-long generalist clinical experience for the entire student cohort is a unique element for the Australian medical education. The term primary care captures most of the generalist learning environments in the LIC experience, namely general practice (at least 2 days per week) and hospital emergency practice (one shift per week and after hours). This gives students access to undifferentiated patients and the opportunity to accrue a panel of patients who consult them throughout the year under preceptor supervision. Students also learn and contribute to patient care in hospital wards, outpatient clinics, surgical theatres and delivery suites, and in many instances, following patients they have previously encountered in local primary care. In the hospital, students are supervised by generalists or specialists.

Generalism is valued as the professional philosophy of practice for these long term placements. Students learn from generalist solutions to the complex problem of person-centred care for people presenting with multimorbidity. Longitudinal participation also enables involvement in continuity of patient care. One GM preceptor lamented the lost educational opportunity he experienced with his own short term placements, remarking that “you never saw anyone for more than [a] week … and you never knew what happened to them”.8

The preceptor’s commitment to long term supervision and the patient’s engagement are fundamental for a quality student generalist experience; the preceptor legitimises student participation in the wider health care team, and patients trust the student as they trust their doctor.11 The broad experience of learning from, and working with, a range of patients and public and private health professionals is the foundation from which students can differentiate in post-graduate training.

Expansion of primary care-based medical education doesn’t mean “[throwing] the baby out with the bathwater”.12 Teaching hospitals remain a key learning environment for medical education. Primary Health Networks and Local Health Districts are focusing on smooth transitions for patients between the hospital and community. Longitudinal and integrated involvement in patient care allows medical students to learn from all stages of the patient journey through care.

Learning and working with generalists is likely to be beneficial across the continuum of medical education. In rural settings, specialists tend to be generalists by necessity, but generalists may be incorporated into patient care teams in tertiary care teaching settings. Although the GM is still too young to have gathered significant long term data about graduates’ career outcomes, data collected at the graduation of four recent cohorts revealed a generalist specialist career preference by 36.8% of graduates (Federation of Rural Australian Medical Educators [unpublished survey data 2010–2013]). Moreover, GM graduates are choosing internships in rural settings (43%) or non-metropolitan areas (61%),13 contributing to the health care of populations there. Likewise, 61% of NOSM medical graduates have chosen family practice (predominantly rural) training.10 These are promising signs from curricula offering students greater opportunities for generalist training.

In Australia, the Commonwealth has invested considerable funds in rural undergraduate medical education to manage the maldistribution of the medical workforce, which is a major driver for more generalist training. The funding increase to the Practice Incentive Program Teaching Payment to further support medical students’ exposure to community generalist settings has been greatly welcomed. A recent review of intern training in Australia has recommended expanding intern training settings; moving to a longitudinal integrated, transition-to-practice model; and giving interns clinical experience in the full patient journey. New initiatives are needed to replace the discontinued Prevocational General Practice Placements Program and give pre-vocational students greater exposure to generalist learning environments. The Murray to the Mountains Intern Program, in Victoria, is one example of applying continuity and generalist supervision to pre-vocational training.14

In a similar manner, the Rural Generalist Medicine program is a post-graduate initiative focused on training generalists with special skills to meet the health needs of rural and remote communities (http://acrrm.org.au/the-college-at-work/rural-generalist-medicine). Government funding will soon be available to build local resources to support regional- rather than urban-based specialist trainees. However, all post-graduate training programs need to examine whether they are building the skills and experience that future doctors will need to deal with the challenge of multimorbidity. Ahern and colleagues15 recently recommended a national integrated governance structure across all phases of medical training to support an integrated and consistent approach to medical training and workforce planning. This approach to accreditation will likely be influential in ensuring that all medical training programs foster sufficient flexibility and exposure to generalism to meet the health needs of all populations.

Government had to reassure Australians about Medicare

After almost losing last year’s federal election over cuts to Medicare, the Government has used this Budget to display its commitment to the national health scheme.

It is setting up a Medicare Guarantee Fund and from July this year money from the Medicare Levy as well as from personal tax receipts, will be poured into the fund to cover the costs of Medicare and the Pharmaceutical Benefits Scheme.

(A 0.5 percentage point Medicare Levy rise in 2019 will help fund the National Disability Insurance Scheme.)

Labor hammered the Coalition during the 2016 election with its so-called Mediscare campaign, requiring a clear message on Budget night from the Government.

“Tonight, we put to rest any doubts about Medicare and the Pharmaceutical Benefits Scheme,” Treasurer Scott Morrison said in his Budget address.

“We are lifting the freeze on the indexation of the Medicare Benefits Schedule. We are also reversing the removal of the bulk billing incentive for diagnostic imaging and pathology services and the increase in the PBS co-payment and related changes.

“The cost of reversing these measures is $2.2 billion over the next four years

“Tonight, I also announce we will legislate to guarantee Medicare and the PBS with a Medicare Guarantee Bill.

“This new law will set up a Medicare Guarantee Fund to pay for all expenses on the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme.

“Proceeds from the Medicare Levy will be paid into the fund. An additional contribution from income tax revenue will also be paid into the Medicare Guarantee Fund to make up the difference.

“The Bill will provide transparency about what it really costs to run Medicare and the PBS and a clear guarantee on how we pay for it.”

But Shadow Health Minister Catherine King said the Budget was an insult directly from Prime Minister Malcolm Turnbull to every Australian who relies on Medicare.

She said instead of a staggered lifting of the rebate freeze, it should have been removed across the board immediately.

“When it comes to health, the Liberals haven’t learned a thing. The Turnbull Medicare freeze remains in place across the health system for years to come,” Ms King said.

“The failure to drop the freeze immediately will impact on many of Australia’s most vulnerable patients – such as those needing critical oncology treatment, obstetric services, and paediatric treatment.

“Australians will have to wait more than 12 months for relief and will be left waiting more than two years for the freeze on specialist procedures and allied health to be lifted.”

Greens leader Richard Di Natale described the Budget as a missed opportunity for health.

“The Medicare Guarantee Fund is a glorified bank account and ending the Medicare freeze just undoes a bad decision,” Senator Di Natale said.

“We should be investing more in prevention and redirecting the Private Health Insurance rebate into the public health system.”

Health Minister Greg Hunt said all Australians can be assured Medicare was not only here to stay, but will be strengthened into the future.

“This Budget includes a $2.4 billion additional investment in Medicare over the next four years,” he said.

“Partnerships have been struck with the nation’s GPs, specialists, pharmacists and the medicines sector. These are key to the Turnbull Government’s initiatives that will support the long-term future of Australia’s health system.

“As part of our compacts with Australia’s GPs and specialists, the 2017-18 Budget restores indexation of the Medicare rebate at a cost of $1 billion, starting with GP bulk-billing incentives from 1 July 2017.

“With GP bulk-billing at a record high 85.4 per cent, more Australians are visiting the doctor without having to reach into their pockets. This Budget will help ensure that continues with our indexation commitment to GPs alone worth $543.1 million over 4 years and around $2.2 billion over ten years.

“Indexation of standard GP and specialist consultations will resume on 1 July 2018, and specialist procedures and allied health from 1 July 2019.”

Chris Johnson

Budget 2017-18 from a public health perspective

Analyses of federal budgets are typically couched in clichés. Government’s talk about jobs and growth, initiatives, priorities and investments; while oppositions and minor parties respond with the language of not enough, missed opportunities, disappointments and failures.

In regard to public health and health prevention, the 2017-18 Coalition Budget is all of these things.

There are many welcome and positive public health initiatives in the Budget. The Government has listened to the AMA and is investing $5.5 million into an immunisation awareness campaign. There is a further $14 million to expand the National Immunisation Plan to provide catch-up vaccinations to 10-19 year-olds who missed out on childhood vaccinations. These are measures the AMA has been advocating directly with the Government for.

New mental health funding is also welcome. There is $9 million for a telehealth initiative to improve access to psychologists for people living in rural and remote areas, and an extra $15 million for mental health research initiatives. The big ticket item is $80 million of additional funding to maintain community psychosocial services for people with mental illness who do not qualify for the NDIS. This is a very good measure and shows that Health Minister Greg Hunt has taken on-board concerns the AMA and others raised about people falling through the cracks that exist between the NDIS and State and Territory community services.

However, this funding is contingent on the States and Territories matching the Commonwealth’s commitment. The Government said it will allocate the entire $80 million, even if some States or Territories do not sign up to the matched funding offer. In other words, the money will only go to those jurisdictions who offer a matched dollar-for-dollar commitment. What we don’t know is how these funds will be allocated and what happens if a State or Territory does not sign up or provide new money for psychosocial services. Will the people in those jurisdictions be left with no psychosocial supports? I suspect that the Australian Health Ministers’ Advisory Council (AHMAC), the advisory and support body to the COAG Health Council, may be the entity that negotiates this funding measure.

The mental health sector has been encouraged by this Budget and Minister Hunt’s dedication to mental health reform. Preventative health didn’t get the same attention as mental health in this budget. The Prime Minister told the National Press Club in February: “In 2017, a new focus on preventive health will give people the right tools and information to live active and healthy lives.”

There was, therefore, an expectation that this Budget would deliver in key areas of preventative health, most importantly in tackling obesity. The AMA has been calling for a range of initiatives and measures that are urgently needed to address the rise in obesity, and in this respect the cliché of ‘missed opportunity’ is applicable.

There is a $10 million initiative to establish a Prime Minister’s Walk for Life Challenge and a further $5 million for a GPs Healthy Heart partnership with the RACGP to support GPs to encourage patients to lead a healthy lifestyle. These are small but good measures. The AMA has been calling for a national obesity prevention strategy that recognises obesity as a complex problem that can only be addressed through a broad range of measures. The measures announced in the Budget are a start, but fall well short of the funding for community-based initiatives and restrictions on the marketing of junk food and sugary drinks to children that we say are needed to address obesity.

There was no National Alcohol Strategy or any measures that help Australians manage the misuse and abuse of alcohol, and the alcohol-fuelled violence that emergency department staff know all too well.

There were no measures or initiatives that address climate change and health.

The Government has indicated that there will be a ‘third wave’ of preventative health measures, possibly in the next budget. We hope so, because investment in preventative and public health initiatives is smart, cost-efficient and a benefit to future generations.

Simon Tatz
Director, Public Health

More health measures in the Budget

The following is extracted from the Government’s Budget overview document

Budget 2017-18 Guaranteeing the essentials for Australians

A healthy Australia

Providing affordable medicines and investing in mental health and public hospitals. Continuing to provide access to new medicines. Australians will continue to have affordable access to new medicines, with the Government meeting its commitment to list cost-effective medicines on the PBS. In this Budget, $1.2 billion will be provided for new and amended listings on the PBS, including more than $510 million for Sacubitril with valsartan (Entresto®).

Since 2013, the Government has listed more than 1400 new or amended medicines on the PBS averaging 32 new and amended listings a month. These new listings include breakthrough medicines to treat breast cancer, Hepatitis C, cystic fibrosis and severe asthma. Investing in mental health More than $115 million will be invested in mental health, including $80 million for psychosocial services, $9.1 million in funding for rural telehealth psychological services, $15.0 million for priority mental health research and $11.1 million to address suicide hotspots. The Government is providing further mental health support for veterans and their families, by investing $9.8 million to fund pilot programs to improve mental health services and support suicide prevention efforts for veterans.

The Government will also provide $33.5 million to ensure anyone who has served a single day in the fulltime Australian Defence Force can seek treatment for mental health conditions and $8.5 million to expand access to counselling services for veterans’ families. Funding public hospitals Record levels of financial assistance will be provided to State Governments to deliver the public hospital services Australians need. Commonwealth payments to the States for public hospitals continue to grow strongly, from $13.8 billion in 2013-14 to an estimated $22.7 billion in 2020-21. On current Budget forecasts, an additional $7.7 billion will be provided to the States and Territories from 2016-17 to 2020-21 giving effect to the Heads of Agreement on public hospital funding signed by COAG on 1 April 2016. Medical Research In this Budget the Government has committed new funding for medical research, $65.9 million will be provided from the Medical Research Future Fund to support preventative health research, clinical trials and breakthrough research investments. In addition, $5.8 million will be provided for research into childhood cancer.

Full and sustainable funding for the National Disability Insurance Scheme

The Commonwealth will fully fund its contribution to the National Disability Insurance Scheme, giving Australians with permanent and significant disability, and their families and carers, certainty that this vital service will be there for them into the future. To help fund the scheme, the Government is asking Australians to contribute, with the Medicare levy to be increased by half a percentage point from 2 to 2.5 per cent of taxable income. This means that one-fifth of the revenue raised by the Medicare levy, along with any underspends within the NDIS, will be directed to the NDIS Savings Fund. The Government’s decision to increase the Medicare levy from 1 July 2019 reflects the fact that Australians have a role to play, in accordance with their capacity, to ensure this important program is secure for current and future generations. The NDIS is on track to be fully rolled out from 2020. States and Territories will be expected to maintain their commitment and contribution to the NDIS and continue to support mainstream services for people with disability. More than $200 million will be provided to establish an independent NDIS Quality and Safeguards Commission to oversee the delivery of quality and safe services for all participants of the NDIS. The Commission will support NDIS participants to exercise choice and control, ensure appropriate safeguards are in place, and establish expectations for providers and their staff to deliver quality supports. The Commission will perform three core functions: regulation and registration of providers; complaints handling; and reviewing and reporting on restrictive practices.

The Government will also invest $33 million over three years to help existing service providers in the disability and aged care sectors grow their workforce. This package will deliver jobs for Australians in rural, regional and outer suburban areas that require strong workforce growth as a result of the NDIS roll out. The scheme’s cost sustainability is being examined in the Productivity Commission’s review of NDIS costs. Due to be released in September 2017, it will examine factors affecting costs and will help inform the final design of the full scheme.