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Preference: Government and politics

The gap isn’t closing

The nation is failing in its efforts to close the health and life expectancy gap between Indigenous and non-Indigenous Australians.

The AMA Indigenous Health Report Card 2018, launched in Brisbane on November 22, scrutinises the 10-year-old Closing the Gap Strategy and concludes that it is unravelling.

The strategy must now be rebuilt, not refreshed, said AMA President Dr Tony Bartone.

One of the strategy’s main targets was to close the life expectancy gap by 2031, but Dr Bartone said it was obvious Australia is not on track to meet that goal.

“Ten years on, progress is limited, mixed, and disappointing,” he said.

“If anything, the gap is widening as Aboriginal and Torres Strait Islander health gains are outpaced by improvement in non-Indigenous health outcomes.

“The strategy has all but unravelled, and efforts underway now to refresh the strategy run the risk of simply perpetuating the current implementation failures.

“The strategy needs to be rebuilt from the ground up, not simply refreshed without adequate funding and commitment from all governments to a national approach.”

Political leadership and increased funding are lacking on the issue, Dr Bartone said.

A refocussing of effort and priorities is needed.

“It is time to address the myth that it is some form of special treatment to provide additional health funding to address additional health needs in the Aboriginal and Torres Strait Islander population,” he said.

“Government spends proportionally more on the health of older Australians when compared to young Australians, simply because elderly people’s health needs are proportionally greater.

“The same principle should be applied when assessing what equitable Indigenous health spending is, relative to non-Indigenous health expenditure.”

The Australian Institute of Health and Welfare estimates that the Aboriginal and Torres Strait Islander burden of disease is 2.3 times greater than the non-Indigenous burden, meaning that the Indigenous population has 2.3 times the health needs of the non-Indigenous population.

This means that for every $1 spent on health care for a non-Indigenous person, $2.30 should be spent on care for an Indigenous person.

But this is not the case, Dr Bartone said. For every $1 spent by the Commonwealth on primary health care, including Medicare, for a non-Indigenous person, only 90 cents is spent on an Indigenous person – a 61 per cent shortfall.

For the Pharmaceutical Benefits Scheme, the gap is even greater – 63 cents for every dollar, or a 73 per cent shortfall from the equitable spend.

“Spending less per capita on those with worse health, and particularly on their primary health care services, is dysfunctional national policy,” he said.

“It leads to us spending six times more on hospital care for Indigenous Australians than we do on prevention-oriented care from GPs and other doctors.”

The Report Card outlines six areas where the Closing the Gap Strategy can be rebuilt.

These include: equitable, needs-based expenditure; implementing health and mental health plans; filling primary health care service gaps; environmental health and housing; addressing social determinants; and placing Aboriginal health in Aboriginal hands.

“We need those leaders, those health leaders in those various communities, to come together with the peak bodies, with the Aboriginal controlled community health organisations, and all the other people as stakeholders in this space to come together to work collaboratively and with common purpose,” Dr Bartone said.

“We will not close the gap until we provide equitable levels of health funding. We need our political leaders and commentators to tackle the irresponsible equating of equitable expenditure with ‘special treatment’ that has hindered efforts to secure the level of funding needed to close the health and life expectancy gap.”

National Aboriginal Community Controlled Health Organisation (NACCHO) welcomed the release of the Report Card and joined the AMA in calling for the Closing the Gap Strategy to be rebuilt from the ground up.

NACCHO Chairwoman Donnella Mills called for the immediate adoption of the Report Card’s recommendations.

“We congratulate the AMA on their work to support closing the gap and endorse the recommendations in the Report,” she said.

“The Report highlights research which indicates the mortality gaps between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians are widening, not narrowing.

“Urgent and systematic action is needed to reverse these failures and to have any prospect of meeting the Council of Australian Governments’ goal to Close the Gap in life expectancy by 2031.”

 

The AMA 2018 Indigenous Health Report Card is on the AMA website.

 

My Health Record opt-out extended

The My Health Record opt-out period has been extended until January 31, 2019.

The Government had to backdown and delay the cut-off date for people wanting to delete their digital health records in the new system.

The Senate forced the Government into its embarrassing position by voting in mid-November – just before the opt-out was supposed to end – to extend the period.

Despite this, Health Minister Greg Hunt described the vote as win for the Government because Labor had tried to extend the opt-out period by 12 months.

“Labor’s plan to delay and derail the rollout of the My Health Record was blocked today,” Mr Hunt said after the Senate vote.

“We thank the crossbench for not delaying this important policy change as Labor tried so desperately to do.”

But Shadow Health Minister Catherine King said the Government was “dragged kicking and screaming” into accepting the extension.

“For months, Labor has been calling for an extension in order to get this important reform right. For months, the Liberals have been insisting there was no need for an extension,” Ms King said.

“But in the Senate on Wednesday the Government quietly capitulated and accepted a two-and-a-half month extension.

“It’s extraordinary that Labor had to force the Government’s hand by introducing legislation to make this happen.

“Minister Hunt could have implemented an extension with the stroke of a pen weeks ago.”

More than one million Australians have already chosen to opt out of My Health Record system. The extension gives another 17 million Australians the opportunity to do the same.

AMA President Dr Tony Bartone said the time had come now to get on with the process of implementing the online system, which he described as an important and valuable tool in the delivery and communication of health records.

“At the end of the day, it’s called My Health Record because patients will be able to control and ensure who can or can’t see,” Dr Bartone said.

“Now, if a patient doesn’t feel comfortable with the security or privacy provisions that have been enhanced significantly… they can opt-out.

“Now there’ll be a degree of people that will fall into that category, but what we’ve been missing now… we don’t have the critical mass of records created with the critical information and data.

“We still don’t have most hospital data on that My Health Record for the ones that have been created. We’re only now getting the ability to have the pathology and diagnostic imaging results communicated. And the list goes on.”

 

NSW govt ‘addressing’ hospital concerns

Health bureaucrats say doctors’ concerns about the running of Sydney’s new $600 million hospital are being addressed.

The public-private Northern Beaches Hospital has come under scrutiny since its opening three weeks ago after staff issues and supply shortages became public.

Staff working up to 110 hours a week, junior doctors being responsible for up to 60 patients, a lack of supervision and a lack of hand hygiene pumps were among the issues raised by the Australian Salaried Medical Officers’ Federation last week on behalf of its members, AAP understands.

Midwives and doctors have also complained they were given an inadequate orientation before the 488-bed hospital opened.

Hospital management has begun addressing concerns including assigning two doctors to move between wards to improve staff-to-patient ratios in busy areas.

However, Fairfax Media reported on Tuesday anaesthetists were threatening to refuse elective surgery patients unless staff shortages, supply shortages and systematic problems were fixed.

The health department said it met with hospital operator Healthscope and the Australian Medical Association on Tuesday to “ensure all necessary steps are taken to respond to clinicians’ concerns”.

“Patient care is front and centre for NSW Health and we are ensuring that clinicians’ concerns are addressed,” a Northern Sydney Local Health District spokeswoman said in a statement.

“Healthscope has assured NSW Health that they are taking immediate action to address all issues.”

NSW Premier Gladys Berejiklian told reporters on Monday although there had been some “teething problems,” the hospital has already completed more than 600 surgeries.

Meanwhile, supporters of the lobby group Save Mona Vale Hospital will rally outside the NSW parliament on Wednesday after acute services were transferred to the new hospital 12km away.

Chairman Parry Thomas says population growth meant the government would inevitably need to reopen pediatrics, emergency and other acute services at the beachside hospital.

The new hospital has a 50-bed public emergency department, about 243 public beds and 195 private beds.

WILLINGNESS GROWS TO END RHD

BY AMA PRESIDENT DR TONY BARTONE

Rheumatic heart disease (RHD) is a preventable illness affecting about 6,000 Australians, with Indigenous children 55 times more likely to die from the disease than their non-Indigenous peers.

The AMA recognises the role RHD contributes to the widening of the life expectancy gap between Indigenous and non-Indigenous Australians. In 2016, we launched a Report Card on Indigenous Health, A call to action to prevent new cases of RHD in Indigenous Australia by 2031 (target year for ‘closing the gap’ in Indigenous life expectancy).

Our Report Card made a strong statement on the devastating impact of RHD and the importance of new, collaborative strategies to control the disease. Its recommendations included calling for Australian Governments to commit to a target to prevent RHD. It also recommended that governments work in partnership with the Indigenous community to fund and implement a strategy to end RHD.

The Report Card also provided an opportunity for a group of leading health, community, and research organisations to form a coalition END RHD. The purpose of the coalition is to advocate for urgent, comprehensive action on this preventable disease of inequality, and to support those living with the disease and prevent new cases arising.

The founding members of END RHD are the AMA, Heart Foundation, RHD Australia (based at the Menzies School of Health Research), the END RHD Centre of Research Excellence (based at Telethon Kids Institute), the National Aboriginal Community Controlled Health Organisation (NACCHO), the Aboriginal Medical Services Alliance Northern Territory (AMSANT), the Aboriginal Health Council of Western Australia (AHCWA), the Aboriginal Health Council of South Australia (AHCSA), the Queensland Aboriginal and Islander Health Council (QAIHC), and the Aboriginal Health and Medical Research Council of NSW (AH&MRC).

To eliminate rheumatic heart disease in Australia, the coalition calls on the Federal Government to:

  • guarantee that the Aboriginal and Torres Strait Islander leadership drives the development and implementation of RHD prevention strategies;
  • set targets to end RHD in Australia;
  • fund a roadmap to end RHD by 2031;
  • commit to immediate action in communities at high risk of rheumatic heart disease; and
  • invest in strategic research and technology to prevent and treat acute rheumatic fever and rheumatic heart disease.

In the two years since the Alliance was formed, END RHD has been working with the communities at risk, securing funding and political will to translate research into action and educating Australians to play a role in ending RHD.

I believe the momentum is growing. RHD was discussed at the COAG meetings in August and October 2018. This has been further helped by the recent commitment from Indigenous Health Minister Ken Wyatt, to a Roadmap to end RHD in Australia, which is due to be completed by early 2019.

There is no doubt that funding is a crucial part of the equation to ending RHD. Recent developments include $3.7m being allocated to five Aboriginal medical services for local community-led pilot Acute Rheumatic Fever (ARF) and RHD prevention programs.

A further $950,000 has been granted to the Telethon Kids Institute to work with the Kimberley Aboriginal Medical Services to establish an innovative END RHD community program focussed on environmental health and local workforce development.

On 23rd October 2018 an advocacy event at Parliament House, co-hosted by END RHD and the Snow Foundation, where the Government was asked for non-partisan commitment to eliminate RHD in Australia. Minister Wyatt and Shadow Assistant Minister for Indigenous Health Warren Snowden both made commitments in public to tackle RHD as a non-partisan issue. It is an important step for political leaders to acknowledge the seriousness of the problem.

Now, with community-driven change and funding to enable the change, we can hopefully start to bring about the end for RHD in Australia.

 

MBS Review – Chance for your say

BY ASSOCIATE PROFESSOR ANDREW C MILLER, CHAIR, AMA MEDICAL PRACTICE COMMITTEE

The AMA support for a review of the MBS has always been contingent on it being clinician-led, with a strong focus on supporting quality patient care. This includes having the right mix of practising clinicians on each committee, with genuine input into a process of transparent decision making.

The AMA, of course, would like to see a review process that delivers a schedule that reflects modern medical practice, by identifying outdated items and replacing them with new items that describe the medical services that are provided today. In doing so, it is crucial that any savings from the MBS review be reinvested into the MBS, and that the review is not simply a savings exercise.

The MBS Review is by no means a small feat, undertaking to review 5,700 items, some which have not been reviewed in 30 years. Obviously, the outcomes of this herculean review not only impact on Government operations and budgets, but significantly affect the entire health system—the always difficult balancing act between the public and private health sectors, the vast number and range of medical practitioners, specialties and medical services, and of course the public.

It was noted by the AMA that the Senate estimates transcripts (30 May 2018) indicated about $600 million in Government savings from the MBS reviews over the 2017 and 2018 budgets, with only $36 million reinvested into new items.

With so much at stake the AMA, specialty colleges, associations and societies must all work individually, and together to hold the MBS Review clinical committees, Taskforce and Government to account on their considerations and recommendations. They cannot be based on anecdotal evidence and narrow perspectives, rather than on data, scientific or robust evidence, or extensive and lived perspectives.

In that vein, I thought it timely to provide a sample of some of the AMA work in this space.

MBS Review clinical committee reports – consultation timeframes

Within the last two months, the Department of Health has requested feedback from AMA on 25 MBS Review clinical committee reports. The reports included around 2,000 MBS items and more than 2,000 pages. The number of items reviewed in these reports are almost 40 per cent of the total number of items in the entire Medicare schedule.

The MBS Review Taskforce has provided the AMA, colleges, associations and societies with only a few months to respond, whilst the Taskforce has deliberated on the review over the last three years. Furthermore, the reports are not publicly available – rather they are sent in a targeted fashion to certain stakeholders. The AMA has pushed back on this and called for them to be posted publicly online.

Obviously, this expediated consultation timeframe presents risks for having the ability to interrogate the clinical appropriateness of proposed changes for the profession, and increases potential for unintended consequences to go unremarked. The AMA has raised these issues with the Minister’s office and the Department to call for timeframes to be pushed out, as is reasonably practical, to ensure the profession are appropriately and adequately consulted on the recommendations.

Surgical assistants

In September, the AMA worked extensively behind the scenes with the Medical Surgical Assistants Society of Australia (MSASA), the Royal Australasian College Of Surgeons (RACS), individual surgical assistants (AMA members and non-members) and AMA Council members to tease out the key issues and lodge a submission strongly opposing the MBS Review Taskforce’s proposed changes to remuneration arrangements for surgical assistants. The AMA was also responsible for ensuring other groups were aware of the submission process.

 

A number of AMA communications and medical media was generated around the proposed changes and AMA’s response. This included AMA ‘Rounds’ and GP Network News, and in the medical press and social media.

The following key issues formed the basis of the AMA submission:

  • that surgical assistants are independent practitioners and they should remain so;
  • negative impact on surgical training;
  • risk of de-skilling GPs in rural and remote areas;
  • proposed derived fee – baseless assumptions;
  • Private Health Insurance and Out of Pockets Reforms already underway;
  • there are alternative mechanisms to address Taskforce’s concerns; and
  • no data provided on the problem.

 

MBS Review Clinical Committee reports – Gynaecology, Breast Imaging, Nuclear Medicine

The AMA has also lodged a submission to the Department of Health on the MBS Reviews on gynaecology, breast imaging and nuclear medicine.

The main issues raised in the submission related to the gynaecology review and the following were discussed:

  • Inadequate profession engagement;
  • Time based item descriptors – perverse incentive and unintended consequences;
  • Additional auditing provisions – onerous and unnecessary;
  • Item restructure – simplification and streamlining are required; and
  • Recommendation 19, Item Number 35750 – disagree with recommendations.

In this submission, the AMA also provided broad observations on the MBS Review including concerns regarding operation of committees, as well as inadequate communication and consultation and the removal of the reports from the public website.

MBS Review Clinical Committee reports – Anaesthesia and maximum 3 item rule for surgical items

The AMA recently wrote to the Chair of the MBS Review Taskforce (Prof Bruce Robinson) supporting the Australian Society of Anaesthetists (ASA) opposition to the majority of the MBS Review anaesthesia clinical committee (ACC) recommendations. In the same letter the AMA also raised concerns regarding the maximum three item rule for Group T8 surgical items.

The AMA urged the MBS Taskforce and Government to work with the ASA to come to mutually agreeable changes to the anaesthesia items in the MBS that align with contemporary clinical evidence and practice and improve health outcomes for patients.

The AMA also communicated to Prof Robinson that it is deeply concerned that whilst on the one hand the PRC deferred its decision regarding the three-item rule, due to consultation feedback, but on the other hand this recommendation is taken forward and applied in a specialty clinical committee report (eg urology) without reference to any previous profession feedback on the recommendation.

The AMA sought Prof Robinson’s assurances that the three-item rule is open for further discussions and that the MBS Taskforce will coordinate with the affected Colleges, Associations, and Societies to come to mutually agreeable changes; that is consistent, as much as is reasonable, across the specialties; that align with contemporary clinical evidence and practice and improve health outcomes for patients.

AMA MBS Review Webpage

Finally, the AMA ‘s own MBS Review webpage is now live and provides AMA members (and the public) with a one-stop bulletin board on AMA’s engagement and advocacy with the MBS Reviews. I encourage you to visit the website for further information and future updates on AMA’s advocacy work on MBS Reviews. There you will also find all of the AMA’s submissions to date to the MBS Reviews, and advice on what we are currently working on. Furthermore, it provides the contact details so that those members who are interested in helping the AMA formulate its response to reviews can have their voices heard.

Only by members being engaged can the AMA hope to have a positive influence the direction, and outcomes, of the MBS Reviews. 

 

Divestment – medical students say no to fossil fuels

BY ALEX FARRELL, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

In August, the Australian Medical Students’ Association (AMSA) put our money where our mouth is, and announced our intention to divest from fossil fuels. It was a significant moment, as Australian medical students joined the growing movement in the medical sector, including the American Medical Association, the British Medical Association and the Canadian Medical Associations. 

Climate change is the biggest global health threat of this century. That was the conclusion of the Lancet Climate Change Commission, and a message that must be taken up with urgency by the medical profession. The impacts on health are clear; the increase in severe weather including drought and heat-waves, worsening air pollution and worsening of infectious and respiratory diseases. 

Australian medical students have always been passionate about taking tangible steps to reduce their impact on the environment, and the AMSA project Code Green has previously run campaigns such as #MoveMindfully and worked to improve the sustainability of AMSA events.

However, this was our biggest step yet, driven by Code Green, and one I am exceptionally proud of our organisation for taking. For those who are unfamiliar, divesting from fossil fuels is moving investments to a bank or portfolio that doesn’t directly or indirectly fund the fossil fuel industry. It is an advocacy tool that redirects money away from problematic industries and towards ethical alternatives. It is also a statement – a public statement of where we stand as medical students on the fossil fuel industry and its impact on human health.

The announcement was made in an address to medical students from across the country at the 2018 AMSA Global Health Conference in Melbourne, and was supported unanimously by student representatives from all the Australian medical schools. It is a signal that young doctors are conscious consumers who will make decisions about their choices to shop and invest with social and environmental impacts in mind. 

As future doctors of Australia, we want to invest in a healthy future. We know that there is more to medicine than just curing illness once our patients are already sick. We need to take into account the upstream factors that are making them sick, and the way our society and our environment affects our health.

Australia’s healthcare system is responsible for more than seven per cent of the nation’s total carbon footprint. Earlier this year, AMSA held a forum with a sustainability expert Dr David Pencheon, who founded the Sustainable Development Unit in the UK’s National Health Service. This unit successfully led the NHS to cut its carbon emissions by 11 per cent between 2007 and 2015. Whilst addressing the RACP Congress, Dr Pencheon said: “Doctors have nothing to lose, but the future.” As the ones who will see the impact of climate change play out in the lives and health of our patients, the current situation is no longer a status-quo we can accept. Many changes are necessary and possible, but for now, let’s keep it simple.

Divesting doesn’t require an overhaul of our health system. It doesn’t need a change in Government policy. It is simply a change of bank. Something that everyone, from the smallest student group, to the largest medical representative organisations and colleges, to clinics and hospitals, has the capacity to do. 

Internationally, medical associations are leading the way on divesting from fossil fuels. We have already seen doctors use divestment as a tool for public health in Australia, like the work of Dr Bronwyn King from ‘Tobacco Free Portfolios’. 

It is time that we join together to focus that energy and drive on climate change, following the example of Doctors for the Environment. Together, the investments that the medical industry make have a large impact. Let’s use that impact to join other global leaders to stand together for health, and against fossil fuels.  

Reflections on a rural medicine conference

BY DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS

Rural Medicine Australia is the biggest Australian conference focusing on rural medical issues. There aren’t many of you rural doctors, too few of you as a matter of fact, but still we meet every October. This meeting is getting bigger and bigger, in fact there were over 750 delegates at RMA18 in Darwin this year – that’s big.

Representatives from both State and Federal politics attend this conference. I heard that this year Federal Department of Health representative quietly went to multiple sessions to listen and absorb what us rural doctors were troubled by and advocating for. Shadow Health Minister Catherine King came to us in person to address the crowd, Rural Health Minister Bridget McKenzie relayed a taped message.

The Keynote addresses were each inspiring:

  • Dr Jillann Farmer, the Medical Director of the United Nations’ Medical Services Division, and a former rural Australian GP who stated she was an expert of nothing, but her generalism was her strength.
  • Orange Sky Laundry, networking and peer support disguised by a free laundry service.
  • Donna Ah Chee, the CEO or the Central Australian Aboriginal Congress of NT, an inspiring powerful Aboriginal woman.
  • The Rural Health Commissioner, Emeritus Professor Paul Worley, discussing something other than the National Rural Generalist Pathway, talked about the backbone behind all rural doctors – our families.
  • Glenn Singleman, an extreme sport enthusiast and a rural doctor, taught us that whether it’s base jumping or remote resuscitations, it is all about perception and fear

There were plenty of skill enhancing sessions, such as ENT emergencies, ophthalmological emergencies, Rural emergency workshops, and, most memorably, trauma management done outside in the stinking humidity – a real life Australian simulation.

However, many of the workshops and break-out groups were focused on the business end of life in rural Australia. For students there were lessons for preparing for exams from those who have sat them and help with career planning. There were rural women workshops focusing on the subtleties of bullying. And then there were discussion on how to survive, with stories from as far as Japan and from each State and Territory and across the medical specialties.

Rural doctors also know how to party. Every night of the conference there were events happening. Even after the conference finished I noticed there were harbour cruises, surfing in the wave pool and visits to the RFDS museum.

I have been to many conferences over the years, but this one is unique. The networking among rural doctors is so much more important for rural doctors because it becomes our safety net when we go back to the isolated areas where we live and work. We learn names and see faces – new and old – and we begin to learn who we can turn to. We also learn who we need to provide support to and foster a career in this challenging but rewarding part of medicine.

We leave the conference inspired – with good memories and a to-do list of projects for the year that follows.

RMA19 will be at the Gold Coast in October next year. Mark it on your calendar and I will see you there.

Keeping cool in the global warming debate

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY

I have a dear friend and colleague who injects good humour into intense discussions by observing, “So many storms; so few teacups!” 

When our Editor asked me to write about climate change I took fright: teacups were scarce but storms abounded.

Our addiction to Growth

Climate change and global warming are terms that strike fear. They have apocalyptic features that make us worry about future generations.

Miles Little, an eminent Sydney surgeon and ethicist, has thought and written extensively on the topic.  In a recent email he wrote:

We live with what we condone. Western liberal societies condone almost any practices that produce “growth”, and many of those practices have consequences that destroy or degrade the environment in the interests of material and short-term benefit. The destructive forces of climate change and pollution are enhanced by the laissez faire attitude our political leadership takes to the negative consequences of land resumption, land clearance and the polluting effects of industry and mining. We seem to be caught in a series of vicious vortices, in which we can no longer even acknowledge our present or future losses.

The latest from the IPCC

An October report from the Intergovernmental Panel on Climate Change (IPCC) (http://report.ipcc.ch/sr15/pdf/sr15_headline_statements.pdf) claims that we are already 1°C above pre-industrial levels. Without further reduction in greenhouse gas emissions over the next 12 years, warming will increase beyond 1.5°C.

In brief, the estimates of damage due to an increase of 1.5°C are somewhat lower than for an increase of 2°C but not all that much. It’s rather like asking how much less damage would occur if you dropped one nuclear device rather than two.

Discussions about climate change carry heavy baggage. There is the science, the imputed causes, the doomsday anxiety and prophetic proclamations about the end of the world, the confusion that occurs when advocates mix science and politics (explosive) like a salad.

Blaming a single cause

We tend to seek a single entity – coal, for example – that we can blame. Unlike tobacco and lung cancer, there is no one cause of climate change. The underlying systems are super-complex, not one-germ-one-disease type arrangements. Little argues that we need a different style of thinking to handle the complexities of climate change. The risk in overlooking the complexity and multiple determinants of climate is accompanied by a second risk, that of minimising in our minds the immensity and complexity of social and economic changes required to reduce our dependence on fossil fuel. 

Banning nuclear weapons looks pretty tame fare in comparison with halting and reducing man-made global warming. Take a look at any major construction project and note how utterly dependent the project is on fossil fuel. In passing, note that the production of one tonne of ready-mix produces one tonne of CO2. 

An unhealthy debate

The debate about climate change has not been healthy. Climate change sceptics are labelled – pejoratively – climate change deniers and suffer opprobrium otherwise reserved for Holocaust deniers. This leads to predictable reaction – political pushback and paralysing polarisation.  

We need to go back to basics. Science, as philosopher Karl Popper and biological scientist Peter Medawar wrote years ago, proceeds by creative guess work, by conjecture that becomes the hypothesis which is then tested. Scepticism and humility are keys to the success of scientific progress. 

In science, formulating the hypothesis is followed by efforts to knock it down. Even if the hypothesis survives it is only ever a provisional statement. The door of science is always left ajar for new information that may lead in new directions. Uncertainty is ineradicable. This is often forgotten in the fast and furious debate over climate.

What we can do

First, as with all social factors that determine the health of our communities and set the agenda for our patients’ health problems, we can do things individually in managing our patients.  This will be critical with near-inevitable global warming.

As clinicians we use often incomplete information to achieve practical diagnosis and treatment. We can discuss with our patients the prognosis for climate change, always ending with the rather unsatisfying statement that we can’t be sure. But we can start thinking now about measures to assist vulnerable people – in the design of future nursing homes for example – to cope with higher temperatures.

Second, as a profession we can provide health-related comment for public debate and policy based on our limited understanding of the science of climate change but with more certainty about its current and future impact on human health. We can also comment on how we might cope with higher temperatures that will affect the health of vulnerable people.

Under pressure from the apparent urgency of the problem, our view of science may be distorted so it turns into a political process, where consensus rules – 10,000 scientists cannot be wrong (oh, but the history of science shows that they can) – and uncertainty is excluded. This arrogates to science a degree of certainty that it does not claim for itself and makes a mess of the debate.

When we engage as a profession in public discourse about climate change, we may support alternative sources of energy most notably hydro, wind and solar on the basis of prudence.  In so doing we assume nothing. The business case for the development of these technologies must be sound, allowing the market to operate in favour of less dependence on fossil fuels. We might support a price placed on carbon, as has been done in other countries. Revenue so generated could then subsidise renewable energy production. 

The need for civic action

The medical profession – as a profession – has an important part to play, nationally and internationally. In a recent editorial The BMJ (BMJ 2018;363:k4410 doi: 10.1136/bmj.k4410) examines the IPCC report and concludes:

Although Government action is crucial, so is civic action. In particular, doctors and other health professionals have a strong record of steering society to make difficult, unpopular, and at times expensive choices for the sake of public health and safety. This has historically included improved sanitation, housing, water treatment, and air quality and, in the 1980s, reducing the risks of nuclear war.

Such an approach accepts the science – with its uncertainties and no claim on ultimate truth – and commits to do what is within our ability and remit to do but without going beyond that ability as happens when we engage in strident polemic that demands certain actions from Government (‘Government must…’). This does not solve the problem. Instead it tears its own fabric and reduce the likelihood of political change necessary for success.

Government, health funds, private hospitals or usurper groups – who is the true opponent?

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA

As all doctors know, we have discussions with various groups in order to protect the interest of doctors and our patients. We should not be ashamed of the component of self-interest in this – let’s own that whole heartedly and do it well. When doctors are well-trained, have good working conditions, are rewarded for their efforts, and valued and compensated for working long hours or becoming expert in a field, the quality of health care that results is good. There is of course a large component of public health and patient advocacy that the AMA does as well. So, where does our biggest threat come from? 

Look for example at the perplexing suggestion for surgical assistant fees to be bundled with the surgeon and/or reduced. This is unequivocally a dumb idea and one we hope we can dissuade Government from enacting and are working hard to do so. This is indeed a threat, but one I think we can push back and/or divert with ongoing representation. Like a great deal of advocacy, it takes finesse, contacts, access, understanding and persistence. I do think we achieve real improvement.

I’ve said many times before that the threats we face from usurper groups aspiring to back-door role substitution result, in part, from our failure to assist in a true solution of the geographic maldistribution of doctors in this country. We will continue to endure blunt, often misguided Government tools or ideas attempting to solve this problem. This is one area where the AMA and Colleges need to get together – but the threat from usurper groups can be quelled if we do this quickly and effectively.

Private hospitals are at least partially and vicariously responsible for us when working in their institutions and we usually work well together. Indeed, our interests of high-quality health care, stable businesses and good working conditions coincide. Occasionally there will be a hospital that fails to act when it should, or acts too precipitously when it shouldn’t, but these instances are rare.  One of the profession’s defences against this is strong, empowered medical leadership in all institutions. More on this another time.

So that leaves the health funds. Insurers are facing more difficult market conditions and desperately want to preserve their nearly $2 billion profit. Selling less valuable insurance products that leave patients bereft and create hardship for doctors/private hospitals is part of their game, along with an unrelenting desire to pay as little as possible at every opportunity and make this decision someone else’s fault. For example – “The doctor is using the wrong prosthesis” or “the hospital has charged too much” or “we want to reduce unnecessary care”. Whatever that means?

I was taking part in a panel discussion recently at the Ramsey Health Managers national conference. Among the panel members was Mr Marc Miller, Chief Strategy Officer, Medibank. Setting aside that he volunteered he had opted out of the My Health Record, he made some other very interesting comments. We were asked about the imminent Gold, Silver, Bronze and Basic categorisation change to private health insurance (PHI). Rather than accepting that having many thousands of policies is not appropriate and there is undeniable need to make private health insurance more transparent, affordable and useable (i.e. less exclusions), he lamented about the time allowed for Medibank to prepare for the changes and indicated they were probably not going to make a huge amount of difference. 

I agree that the categorisation of policies is a passably reasonable idea that will likely miss the mark. It is, nonetheless, curious to me that there is not greater fund recognition of the current problems with PHI products and a want to reverse current membership decline. One cannot make up for the increasingly inappropriate burden of exclusions by offering a Westfield gift voucher for $100.  The portion of total PHI funds paid to doctors is small – we are not the problem, but there is a predictable and relentless desire to unfairly blame doctors for the poor affordability of PHI. The health funds clearly need to forget the vouchers, and supporting non-evidence based care and substitutes for quality medicine; and offer a limited range of understandable, credible products with minimal to no exclusions that people can actually depend on at any stage of the life cycle.

The real clanger Mr Miller dropped was the suggestion that the system would be improved if all doctors were contracted, including at private hospitals. We should never forget many of the funds want to control everyone and everything, including the choices doctors can make in treating their patients – not necessarily in the best interests of patient outcome, but in minimising their costs (remember they already make close to $2 billion). Managed care and/or any inappropriate control of treatment decision-making or options by health funds must be aggressively avoided. Measures that frustrate the referral process under the guise of fee transparency are equally fraught for the same reason. The independent doctor-patient relationship is sacrosanct, and in this, private hospitals are our firm ally. The public health departments are also allies because Government realises the total funding pool for health care requires PHI and the public system could never efficiently manage significantly increased workloads, e.g. beyond current overstretched built capacity.

Ponder also that Medibank is responsible for nearly half of all complaints to the PHI ombudsman. Their payments to patients are far from the highest and frequently inferior to the not-for-profit insurers. Refer to the AMA Private Health Insurance Report Card:

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In general, my patients tell me they have greater issues claiming with the for-profit funds. It also appears that hospitals have greater difficulty negotiating contracts with for-profit funds – recall the terrible limitations Medibank attempted to write into hospital contracts a couple of years ago that started their public relations decline. We should also all be wary of the BUPA-led charge to restrict gap payments to contracted hospitals only.  Funds now have to use a large portion of premium income to advertise products with more and more exclusions that represent declining value for money.    

For-profit health funds, including Medibank, want doctor fee transparency and control of our behaviour – but seem unwilling to create transparency and value for money in regard to their own product. They could embrace the spirit of Gold, Silver, Bronze and Basic categorisation to improve the transparency and value of health insurance products to improve membership – but seem to rail against the change or side-step it. Rather than tightening their grip on healthcare decision-making and restricting costs to preserve profit, they should invest in good quality health care with independent doctor decision-making which we know produces good outcomes – which is what people will pay for. The true antagonist is revealing itself.