AMA backs call for inquiry into institutionalised racism

The gap between health outcomes for Indigenous and non-Indigenous Australians will not be closed until systemic racism is rooted out of the health system, the Close the Gap Campaign says.

Releasing its 2017 Progress and Priorities Report on National Close the Gap Day on 16 March, the Campaign Steering Committee called for a national inquiry into institutionalised racism in hospitals and other healthcare settings.

“The reality for Aboriginal and Torres Strait Islander peoples is that we have a life expectancy at least 10 years shorter than non-Indigenous Australians. We need urgent action,” Close the Gap Campaign co-chair Jackie Huggins said.

The report found that four interacting factors within Australia’s health system continue to be ‘potentially lethal’ for many Indigenous people:

limited Indigenous-specific primary health care services;
Indigenous peoples’ under-utilisation of many mainstream health services and limited access to government health subsidies;
Increasing price signals in the public health system and low Indigenous private health insurance rates; and
Failure to maintain real expenditure levels over time.

“The persistence of these factors reflects systemic racism; that is, racism that is ‘encoded in the policies and funding regimes, healthcare practices and prejudices that affect Aboriginal and Torres Strait Islander people’s access to good care differentially,” the report said.

“Failure to engage effectively with Aboriginal and Torres Strait Islander people through their elected peak organisations allows such racism to continue.

“The progress of the headline targets in the Closing the Gap strategy will continue to be disappointing until these issues are properly addressed.”

The AMA supported the call for the inquiry, and for knowledge of Indigenous culture to be built into medical school curricula.

AMA President Dr Michael Gannon, AMA Vice President Dr Tony Bartone, and all eight State and Territory AMA Presidents toured the Winnunga Nimmitjah Aboriginal Health Service in Canberra on Close the Gap Day.

Dr Gannon said that while Aboriginal community-controlled health centres like Winnunga Nimmitjah were vital for primary care, it was not realistic to have hospitals dedicated to treating Indigenous patients only.

“It’s so important that patients feel safe in the hospital setting, whether that’s the tertiary hospital setting or in secondary hospitals,” Dr Gannon told reporters.

“If patients don’t feel safe, if they don’t feel secure, if they’re exposed to racism, well that’s simply not good enough.

“So we support that call for the inquiry. It’s so important that primary health care services are very much driven and delivered by Indigenous communities, but we need to do better when, inevitably, like all other Australians, Aborigines and Torres Strait Islanders end up in hospital.”

Keeping medical curricula up to date with community needs was a constant challenge, but more needed to be done to teach medical students about Indigenous culture, he said.

“We talk a lot about the importance of positive experiences at medical student level, at junior doctor level, into specialist training level in rural areas, and the same should apply when it comes to Aboriginal and Torres Strait Islander health,” Dr Gannon said.

“If I reflect on my training as a medical student in Perth, seeing Aboriginal patients was in many ways sadly commonplace.

“But it’s so important that we give medical students across Australia, whether that’s in the rural clinical schools or in the middle of our big cities, exposure to Aboriginal and Torres Strait Islander patients and their wants and needs.”

Dr Gannon said that days like Close the Gap Day were a good opportunity to recognise the advances that have been made, but to realise that there is still so much work to do.

“It’s going to take time, when we look at the metrics, whether they’re in the area of health, whether they’re in the area of employment or education, it is going to take time,” he said.

“But I think that it’s important that at least once a year on National Close the Gap Day, that we reflect on how far we’ve come, and hopefully as every year goes by, we talk about the gap shrinking in whichever target we’re talking about.”

Maria Hawthorne

May Budget could bring on the thaw

The Federal Government has given its strongest indication to date it will unfreeze the Medicare rebate in the May Budget.

Health Minister Greg Hunt announced on March 19 that he was looking at ways of accommodating doctors’ insistence that the freeze be lifted.

“I am very confident, very confident, that we will reach an outcome which is positive for the medical profession, and positive for the sustainability of Medicare, and most significantly, improves patient outcomes,” he told Sky News.

The Minister said he and Prime Minister Malcolm Turnbull were determined to work with the AMA to provide long-term support for Medicare and doctors.

He hinted that the freeze could be lifted in the Budget in return for doctors’ cooperation “for ways of making our system more sustainable”.

“More people are accessing doctors, and more people are accessing doctors without having to pay for it, and we’re now working on that long-term plan very cooperatively with the doctors,” he said.

“The way we’re doing that is laying out the approaches which can help strengthen and stabilise Medicare so as we can reinvest funding into the sector, in return for co-operation from the medical profession.”

“…I’m certain that, not just within my portfolio but across the portfolios, we’ll be able to bring down a budget which meets our commitment to strengthening Medicare, and at the same time, achieve the overarching national task of ensuring that we live within our means.

“On the progress that I’ve seen so far, both at the budgetary level, and the progress within the health portfolio, I think we’re able to do both things.”

AMA President Dr Michael Gannon confirmed he had been having frank and open discussions with the Minister, who has no doubt of the importance of the need to lift the freeze.

“The freeze affects not only patients attending GPs, but other specialists as well,” Dr Gannon said.

“And it’s just one of the elements putting more pressure on the value proposition of private health insurance. It’s a measure that is increasing the pressure on our public hospitals. So it has effects across the entire health system.

“The sooner the freeze is unravelled the better. That’s good news for patients. It’s their rebate. It’s their contribution to the cost of seeing a doctor.

“For a lot of doctors, they will bulk bill patients roughly 85 per cent of GP services. And depending on the specialty, between 30 and 50 per cent of visits to private specialists.

“So it’s important for them. It’s their rebate. But it also affects the rest of the health system.

“The other thing about unravelling the freeze is it gives Minister Hunt and it gives the Turnbull Government clean air to try and navigate their way through a health narrative – some new health policy. It gives them clean air to negotiate other elements of their agenda.

“We know that they’re keen to identify savings. But one of the things they’ve worked out is that those savings are not obvious. One of the things that I’ve said to Minister Hunt on many occasions is that we need to start looking at the spending in the health system more as an investment, not just a cost.

“The Coalition was burnt badly at the last election. That’s because they were seen not to value health the same way the Australian population does.

“They need to find extra dollars. They need to work out ways that they can find this increased spending. Now we’re being responsible on this. We know that there is a whole range of things that the Commonwealth Government spends money on.

“We know it’s difficult. We think it’s good government to aim to bring the Budget back to balance. But they learnt to their own cost at the last election that people care about Medicare. If they don’t unravel the freeze and they don’t produce a positive story in health they will get burnt to toast at the next election.”

Labor campaigned hard and successfully in last year’s election on a health platform suggesting the Coalition was abandoning Medicare.

It became known as “Mediscare”. Since just scraping back into office, the Government has been at pains to forcefully repeat their “absolute commitment” to Medicare.

Chris Johnson

Labor commits to end the freeze

Opposition Leader Bill Shorten addressed the AMA Federal Council in March – the first time he had done so – to discuss health policy and hear firsthand about the issues doctors want addressed.

Shadow Health Minister Catherine King accompanied the Labor leader for a 40-minute question and answer session before the full Council.

The Medicare rebate freeze topped the discussion, with Mr Shorten giving a rock-solid commitment to support it being lifted.

“There’s no doubt in my mind that one big test coming up in the May Budget will be of course what happens to indexation,” Mr Shorten said.

“Labor is firmly of this view that if you’re going to fix the problem of the freeze, you need to do it with all categories – not just GP rebates.

“We understand that these payments are not payments to doctors or to specialists. This is lifting the rebate to patients… increasing the rebate which Australians receive.

“If the Government chooses to relinquish the freeze, we’ll be very supportive of that. Full stop.”

He said the Government know the freeze is no longer sustainable, but he expressed concern that the Coalition might only tinker with a slow thaw.

“Do it once, do it right. Don’t be back here arguing about it again in the future,” Mr Shorten said.

“If we were to form government in a year-and-a-half’s time, we won’t start with the view that everything that’s happened before is a waste of time.

“The more we can move health policy beyond changes of governments, the more we can create certainty in funding and certainty in direction.”

Other issues discussed included private health insurance, mental health, hospital funding, Closing the Gap, the Pharmaceutical Benefits Scheme, the sugar intake of children, preventative health, 457 visas, the medical workforce and professional development.

“I’m asked about the big picture and the appetite for reform,” Mr Shorten said.

“I’m determined at the next election that if people know nothing else about the brand of the party I lead, they know that one of our four issues will be health care.

“Health is not the most important issue, but there is no public issue in Australian life that is any more important.

“So we have a big appetite to get our health policies right.

“We regard health as mainstream business of Federal Government. You’ve got to be prepared to find priorities in the Federal Budget to fund health…

“We have plenty of appetite for good quality reform.”

AMA President Dr Michael Gannon welcomed the Opposition Leader, saying the whole council was looking forward to learning more about the ALP’s policy position on health.

“You’ll know that the AMA commended the Labor Party on many elements of its policy taken to the last election, but it’s time to move forward,” Dr Gannon said.

“And you know that I’ve commended you personally.”

Ms King answered a number of questions an also expressed her desire to work more with the AMA on the issues of hospital funding and private health insurance.

Chris Johnson

[Editorial] Syria suffers as the world watches

March 1 5, 2017, marks the sixth anniversary of the civil war in Syria, a conflict perhaps unprecedented in its apparently shameless disregard for international law. The world has stood by in horror, watching the death toll rise and the humanitarian and refugee crises spread their indelible stain on the world map and human history. The Syrian conflict has been marked on the one hand by immense suffering and on the other by a stunning lack of adequate condemnation or action from governments, international agencies, or the medical community.

The time is now to act on inequalities

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

An appropriate response from Australia and its new Health Minister to the health problems our country is confronting would start with a goal-based strategic approach to inequality and the injustice and health disadvantage that travels with it.

Many social and political analysts agree that inequality has manifested itself as an immense force in recent elections, including the vote on Brexit and the elevation of Donald Trump. The core temperature in the social volcano reached a critical level as workers’ wages froze while top executives received ever more millions. Now the volcano has erupted. A period of prolonged social unrest and loss of confidence in political structures is predicted.

At the World Economic Forum in Davos, Switzerland last month, inequality received unusual attention. The Forum is traditionally for high-flying business magnates, princes of the financial world and others who have benefited immensely from recent decades of global economic progress. But this year the glitterati, as they checked their ski bindings, nervously added inequality to their agenda. Inequality they ranked as “the most important trend likely to determine development across the world over the next decade”.

Now inequality may seem remote from us, our patients and the health of our communities but it may be closer than we think. Life expectancy and quality of health and life depend on life opportunities being relatively equal. Inequality is a powerful risk factor and as UK (nee Australian) epidemiologist Michael Marmot has shown and spoken forcefully in his 2016 ABC Boyer Lectures, can outweigh even smoking as a damage to health.

Hear the rumble in the mountain and be afraid

Voices urging health professionals to heed the rumbles deep in the mountain include those of Marmot and Flinders University’s Professor Fran Baum. And thank goodness that to an extent we have done so. The Aussie “fair go” has contained the avarice of economic fundamentalists who would turn the torch of unfettered market forces on everything. And so Australia retains Medicare, public education and social welfare programs that mitigate potential catastrophes and life-long loss of opportunity. With the exception of Indigenous health, our social gradients in life expectancy are not savage although far from top drawer compared, say, with Scandinavia.

What to do?

We can analyse the statistics and note the extent of inequality and its effects, but it is quite another to work out what we might do about it.

A recent article in the BMJ by Kate E Pickett and Richard G Wilkinson, epidemiologists at York University, reflected on the agitation on the Davos ski slopes. Inequality, they observed, “during the 20th century in most rich countries fell almost continuously from the 1930s to the 1970s but then increased dramatically from the 1980s”.

So presumably the deeply troubling levels of inequality that are driving current unrest can be undone. As John Kennedy observed, man-made problems are generally amenable to man-made solutions.

Pickett and Wilkinson remind us that the late Tony Atkinson, an economist and activist who spent his lifetime concerned about inequality, identified several actions relating to taxation and minimum wages that he calculated could help. So good minds have been at work.

Marmot has written extensively on what might be done about inequalities. His reports, built on a strong base of evidence, focus on six areas for action:

Give every child the best start in life;
Enable all children, young people and adults to maximise their capabilities and have control over their lives;
Create fair employment and good work for all;
Ensure healthy standard of living for all;
Create and develop healthy and sustainable places and communities; and
Strengthen the role and impact of ill-health prevention.

“Delivering these policy objectives,” he writes, “will require action by central and local government, the [national health authority], and the private sectors and community groups. National policies will not work without effective local delivery systems focused on health equity in all policies.”

Conceivably many of us can do a bit about several of these goals. A big challenge demands a big response and an imaginative and creative political push. It’s ages since we had a national health policy that made you stop and think with its depth and challenge. Let’s help make it happen.

Will the bush ever have equitable broadband access?

DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS

As some readers may know, the AMA released a Position Statement in January calling for better access to high speed broadband for regional, rural and remote health care. This Position Statement was developed in response to concerns by rural doctors that were highlighted in the findings of the AMA Rural Health Issues Survey conducted in April 2016.

The survey, which sought the views of rural doctors across Australia to identify key solutions to improving regional, rural and remote health care, found that access to high speed internet services was the number one priority for rural GPs and the second highest priority among all rural doctors.

The AMA Council of Rural Doctors, at its recent videoconference meeting in February, discussed this issue with representatives of the National Broadband Network Company (nbn) directly. We were told that at the time of the survey, the widely criticised Interim Satellite Service was providing internet services to regional and remote Australia. Since then, nbn has launched the first Sky Muster satellite, and will soon bring on board a second satellite that will offer business grade services around the second quarter of this year.

Currently 68,000 Australians are connected to the Sky Muster service, which has undergone a range of fixes and improvements since it first began offering services on 28 April last year, and according to the nbn this has led to far fewer drop-outs than used to occur. This is good news for those relying on satellite internet. The speed of these services will be either 12/1mbps (upload/download) or 25/5mbps, depending upon what plan you choose.

While these speeds are nowhere near the speeds available in the big cities that use fibre technology (up to 100/40mbps), they are sufficient for a range of uses, and should allow doctors, health services and hospitals to upload health summaries to the My Health record, undertake telemedicine via videoconference and exchange high resolution images. These speeds should also enable doctors to do business with Government, comply with Government requirements, participate in online continuing professional development and education activities, and reference online help such as clinical decision-making tools and other support.

Following our strong comments about data allowances, we understand that nbn is working on making eligible health centres, practices and large medical facilities Public Interest Premises. This will potentially afford them a higher data allowance (150GB per month).

Now comes the big HOWEVER. Will the data allowance be sufficient to do all this? There is much concern in the bush about the ‘data drought’. I understand the satellite technology has inherent limitations that restrict the amount of data available. There is a real need for ‘business style’ plans to be made available, recognising the unique nature of the speeds and data allowances that businesses require.

So, while the nbn will clearly deliver improved broadband access for satellite users, it is hard to see how it can keep up with the needs of an increasingly digitally enabled health system. It’s an area that the Government will need to give much greater thought to.

What I would also like to see happen over time is an extension wherever possible of the fibre and fixed wireless services into the satellite footprint and/or the introduction of alternative technologies to lessen the reliance on satellite for those living in rural and remote Australia. Maybe then, in time, we can say there is equitable access to broadband for all Australians.

Time to address the perennial problem of unequal distribution of the medical workforce

AMA VICE PRESIDENT DR TONY BARTONE

One of the questions I’m often asked as I travel across Australia is why can’t we get enough doctors to the bush, especially with all the medical students we are graduating.

The unequal distribution of the medical workforce is one of the perennial problems that has weighed down Australia’s health system. The reasons are many, as are the potential fixes offered.

Last year, we saw some positive signs that the Government has turned its gaze from funding more medical schools to addressing workforce shortages.

In this space, the issue du jour is the distribution of medical school places. As I write, a Government stocktake of the number and location of medical places, as well as the schools, campuses and clinical training sites is well underway.

The main focus is whether the distribution of medical Commonwealth-supported places should be changed. I understand that the recommendations that emerge from the review are likely to be considered by Federal Cabinet in April.

So would redistributing medical school places to universities with rural clinical schools, or to schools in rural areas ultimately get more doctors to the bush?

This question was given a great deal of thought by the AMA Medical Workforce Committee (MWC) at its recent meeting. As with many complex policy matters, there is no simple answer. But given the importance of the structure of medical training to Australia’s future medical workforce, it is critical that we get this issue right.

The MWC believes that unless there are more places for postgraduate training and in the undersupplied specialties, the problem of workforce shortages in rural areas will not go away over the longer term, no matter where the students are.

Should the Government decide to redistribute medical school places, then we believe it should be guided by three important principles.

Firstly, overall student numbers must remain unchanged (until medical workforce modelling recommends otherwise). Unless you are a university trying to improve your bottom line or a nervous politician in a marginal seat, it is accepted that workforce projections are on the money and we do not need to train more doctors or open new medical schools.

Secondly, any decision to redistribute places has to be based on rock-solid information. What are the infrastructure requirements at the destination university or region; what criteria will be used; will quality supervision and appropriate resources for teaching be assured?

Thirdly, any change to the distribution of places must be linked to improved availability of downstream postgraduate training posts.

On this last point, the AMA has a number of innovative policy proposals worthy of consideration. These include our community residency program and regional training networks model for enabling medical graduates to complete most of their training in rural areas.

We now recruit almost a quarter of medical students with rural backgrounds and almost a quarter of Australian students go through rural clinical schools.

Though the AMA believes these allocations could be expanded, we nonetheless have a promising number of rural graduates. What we need now is a strategic approach to providing the training pathways that will give them the opportunity for rewarding careers in the bush.

In the end, it is about better medical services for local communities.

These ideas are outlined in our recent submission to the review. It is available online at (URL to be advised). I encourage you to take a look.

Aboriginal and Torres Strait Islander People Have the Solutions to Close the Gap

AMA PRESIDENT DR MICHAEL GANNON

We continue to be handed myriad government reports on Indigenous affairs and hear well-meaning words spoken by our political leaders. But, in 2017, we still see governments fail to deliver on their commitments to improve the health and wellbeing of Aboriginal and Torres Strait Islander people.

The 9^th Closing the Gap report, handed down in Parliament House by Prime Minister Malcolm Turnbull on 14 February, reflects the inadequacy of government performance against their own commitment to close the gap in health and life expectancy between Indigenous and non-Indigenous Australians. Whilst there have been some encouraging gains in health and educational outcomes over recent years, the gap in health and life expectancy between Indigenous and non-Indigenous remains wide.

Discouragingly, only one of the Government’s seven Closing the Gap targets is on track to being met.How much longer do Aboriginal and Torres Strait Islander people in Australia have to live in disadvantage? How much longer do they need to be sicker and die younger than their non-Indigenous peers? Australia must and can do better.

Positive progress can be made if governments work directly with Aboriginal and Torres Strait Islander people, and better understand the approaches that work in their own communities. Aboriginal and Torres Strait Islander people have long called for, and continue to call for, structured engagement with governments and involvement in decision-making. The AMA recognises the importance of self-determination and fully supports Aboriginal and Torres Strait Islander people in wanting to take charge of their own lives.

Governments must recognise and value the knowledge and expertise that Aboriginal and Torres Strait Islander people have. They must understand that Indigenous people have the solutions and the expertise to deliver. This was made clear in the lead-up to the release of the Closing the Gap report, when Aboriginal and Torres Strait Islander leaders presented the Prime Minister with the Redfern Statement – a statement that calls on governments to better engage with Aboriginal and Torres Strait Islander Australians, and contains the solutions to improving health and life outcomes for Indigenous people.

The AMA considers that the current Parliament has an unprecedented opportunity to work closely with Indigenous people and meaningfully address the disadvantage that Aboriginal and Torres Strait Islander experience. The AMA urges the Government, opposition and minor parties to take note of the Redfern Statement and ramp up their efforts to achieve health equality for Aboriginal and Torres Strait Islander people and take further steps in building on existing platforms.

The AMA, along with many others working in Indigenous health, has been campaigning for long-term funding and commitments from government to improve the health and wellbeing of Aboriginal and Torres Strait Islander people. We will continue our advocacy to help achieve this goal.

We must find a way to celebrate Indigenous advancement where there is evidence of real improvement. Some gaps remain because of equivalent improvements in the health of non-Indigenous Australians. It is important to avoid a nihilism about Aboriginal and Torres Strait Islander affairs. We must never consign these issues to the ‘too hard’ basket and we risk that if we do not carefully appraise measures that are working and acknowledge them.

But having only one single Closing the Gap target on track is truly disheartening, and frustrating for Aboriginal and Torres Strait Islander people when their solutions are being ignored. It is imperative that the Prime Minister and his Government act urgently so that we can finally begin to see genuine improvements in health and life outcomes for Aboriginal and Torres Strait Islander Australians.

Council of Private Specialist Practice created to respond to challenges

ASSOCIATE PROFESSOR JULIAN RAIT

The Council of Private Specialist Practice (CPSP) is the most recent of the Federal AMA’s Councils – created in 2016 to recognise and respond to the key challenges that face private practitioners within the Australian health system. Our Terms of Reference provide for us to identify issues relating to private specialist medical practice and make recommendations to Federal Council, as well as develop and draft policy or position papers on key topics.

Private practices are an essential component of a sustainable Australian health system. The private system alleviates much of the demand on the public system – providing nearly 70 per cent of all elective surgical admissions.

And as with all other advanced economies, Australia requires both a strong private and public health system to meet the challenges that lie ahead – including an ageing population, rising health care costs and increasingly complex care.

The structure and format of private specialist practice is also changing – with solo and group practices competing with corporate entities.

Two big “funders” of private health, the Commonwealth Government via the MBS, and the Private Health Insurers, continue to grapple with how best to fund the system in an era of escalating cost pressures. In response, they are seeking to drive down their costs, especially by curbing the growth in their outlays. This creates significant pressure on the private medical practitioner who is trying to deliver a high quality and economically viable service. Consequently, patients are incurring escalating out-of-pocket costs, prompting many to question the value of their private health insurance.

Private health is an area currently under extensive review, and subject to increasing scrutiny. We’ve seen the previous Health Minister announce the Private Health Ministerial Advisory Committee (PHMAC), and under this committee, a further number of working groups.

CPSP has been engaged, and supportive of the AMA’s work in relation to PHMAC’s deliberations– which clearly indicate that our Federal Government is considering various options in an attempt to make private health insurance a more attractive proposition for Australians. This includes considering clear categories of health insurance, reviewing of hospital contracting arrangements (and especially second tier funding provisions), while making polices easier to understand and removing impediments to policy portability for customers.

The reality is that a great deal of discussion will arise from the usual hot button media issues – with constraints on out-of-pocket costs and online rating sites being hailed as the ‘answer’ to make private health insurance “more attractive”. Meanwhile, health insurers continue to record extraordinary profits and breathtaking returns on equity. For example, news outlets are reporting NIB recently received approval to lift its premiums by 4.48 per cent after announcing a 65 per cent increase in net profit (compared to the prior year) and scoring a return on equity of 32 per cent – with the latter result being double that of the Commonwealth Bank.

The CPSP has, and will continue to, be firm advocates for the profession on these issues. A little known fact among the broader population is that medical fees only account for 16 per cent of private health insurance benefits with 85.6 per cent of medical services having no gap, and 92.3 per cent of services having nil or a known gap charge[1]. So you might agree that the gap fees of medical practitioners are not the leading cause of the PHI affordability challenge.

However, despite these modest figures, there is a perception that out-of-pocket costs are not being actively managed by the profession – a view apparently held by governments, consumers and mass media. The profession can no longer ignore the issue around significant or unexpected out-of-pocket costs without it being seen as a failure of the profession to self-regulate appropriately, and become the scapegoat for all the affordability problems of the system. Insurers and consumer groups have commenced research on the quantum and frequency patients experience these costs.

Moving beyond private health insurance reforms, we’ve also seen the Federal Government embark on changes to the medical indemnity insurance subsidy schemes. Many doctors would be aware that last year the Government included a funding cut of $36 million to one of these long-standing subsidies that underpin medical indemnity insurance in the Mid-Year Economic and Fiscal Outlook (MYEFO). Furthermore, they have announced a review into all the Government’s indemnity support schemes – signalling that strong consideration is being given to future cuts to these important Government subsidies for the profession.

To that end, CPSP will be closely monitoring any proposed changes and the AMA will be participating in the forthcoming review.

The AMA has already written to the Government, reminding them of the truly disruptive crisis that brought about the current support schemes, and warning that any changes made without effective consultation with the profession, and their indemnity insurers, could lead to significant unintended consequences. CPSP has also discussed the importance of universal coverage arrangements (whereby no registered doctor can be denied insurance) – agreeing that any changes here need to be carefully considered.

Finally, there continues to be a number of reviews underway which may have impacts upon private practice. The Senate Community Affairs Committee has an inquiry into Prosthesis List Framework, the Australian Competition and Consumer Commission is calling for submissions on their annual report to the Senate on Private Health Insurance, and of course the MBS Review Taskforce continues. CPSP will be navigating all these reviews, ensuring that the private practitioner’s voice continues to be well placed to advise the AMA on the implications of any changes.

The coming weeks will also see the release of the AMA’s Private Health Insurance Report Card – a good chance to shine a light on the key issues facing private health, so please continue to be attentive to our initiatives.

[1] Australian Prudential Regulation Authority (APRA). Private Health Insurance Quarterly Statistics. December 2016 (Released 14 February 2017).

Public hospitals – funding needed, not competition

ASSOCIATE PROFESSOR SUSAN NEUHAUS, CHAIR, AMA HEALTH FINANCING AND ECONOMICS COMMITTEE

Under its terms of reference, public hospital funding is a key focus for Health Financing and Economics’ work. How funding arrangements affect the operation of public hospitals and their broader implications for the health system has always been an important consideration for HFE, and for Federal Council and the AMA overall.

The AMA Public Hospital Report Card is one of the most important and visible products for AMA advocacy in relation to public hospitals.

The 2017 Report Card was released by the AMA President on 17 February 2017. The launch and the Report Card received extensive media coverage.

The Report Card shows that, against key measures relating to bed numbers, and to emergency department and elective surgery waiting times and treatment times, the performance of our public hospitals is virtually stagnant, or even declining.

Inadequate and uncertain Commonwealth funding is choking public hospitals and their capacity to provide essential services.

The Commonwealth announced additional funding for public hospitals at the Council of Australian Governments (COAG) meeting in in April 2016. The additional funding of $2.9 billion over three years is welcome, but inadequate.

As the Report Card and the AMA President made very clear, public hospitals require sufficient and certain funding to deliver essential services.

“Sufficient and certain” funding is also the key point in the AMA’s submission to the Productivity Commission’s inquiry into Reforms to Human Services, in relation to public hospitals. The Commission is expected to report in October 2017.

As part of this inquiry, the Productivity Commission published an Issues Paper seeking views on how outcomes could be improved through greater competition, contestability and informed user choice.

While the AMA believes there is clearly potential to improve outcomes of public hospital services, its submission highlighted that there are significant characteristics of Australia’s public hospitals that must be taken into account.

Health care is not simply a “product” in the same sense as some other goods and services. Public hospitals are not the same as a business entity that has full or even substantial autonomy over their customers and other inputs, processes, outputs, quality attributes, and outcomes.

Public hospitals work on a waiting list basis, usually defined by acuity of need, to manage demand for public hospital services. Private hospital services typically use price signals. There is limited scope to apply mechanisms for patient choice (such as choice of treating doctor) to access arrangements in public hospitals that are governed by waiting lists.

Public hospitals also operate within a highly developed framework of industrial entitlements for medical practitioners and other staff that are tightly integrated with State/Territory employment awards. These measures are intended to encourage recruitment and retention of medical practitioners to the public sector, offering stable employment conditions, continuity of service and portability of entitlements. They support teaching, training and research in the public sector as well as service delivery.

The freedom to choose between public and private hospital care, and the degree of choice available to patients in public hospitals as distinct from private patients, is an integral part of maintaining Australia’s balanced health care system. The broad distinction between public and private health care is generally understood by the community as a basic feature of the health system and part of Medicare arrangements, even though detailed understanding of how this operates, including what they are actually covered for in specific situations, is often lacking for many people.

Introducing private choice and competition elements into public hospital care will tend to blur the distinction between public and private health care, and reduce the perceived value of choice as a key part of the incentive framework for people choosing private health care.

The Commission’s Issues Paper proposes that increased competition will address equitable access for groups including in remote areas, benchmarking and matching of best practice, and greater accountability for performance. These are all worthwhile and important objectives in their own right. As such, they are already the focus of a range of initiatives.

Public hospitals are already subject to policies and requirements that address the same ends of improved efficiency, effectiveness and patient outcomes, including:

Hospital pricing, now supported by a comprehensive, rigorous framework of activity based funding and the National Efficient Price;
Safety and quality, supported by continuously developing standards, guidelines and reporting, including current initiatives to incorporate into pricing mechanisms;
Improved data collection and feedback on performance including support for peer-based comparison.

The single biggest factor that will increase the returns from such initiatives is the provision of sufficient and certain funding. Increased competition, contestability and user choice will not address this need.

The AMA Public Hospital Report Card 2017 is at ama-public-hospital-report-card-2017