A Plan for a Better Health System

stethWhile the removalists re-arranged the furniture that Kevin Rudd saved, those now in charge have the task of furnishing Australia with some workable and affordable policies. Voters consistently rate health high on their lists of important government policy; however, both sides of the political divide somehow managed to shirk the issue in the 2013 election. Instead, “voting for change” and “six-point plans” stole the limelight.

Rudd assumed that his re-emergence unchanged somehow equated to change, much in the Orwellian model of Animal Farm. Tony Abbott also implored us to vote for change. Time will tell if we get what the Coalition has promised or whether political correctness and populism will drag it down to obedience of bureaucrats and the media.

So in that spirit, I put forward a six-point plan for change of our nation’s health system.

Change our approach to indigenous health

Whatever we’re doing now is plainly insufficient. By virtually every measurable health outcome, Aboriginal people are behind the Caucasian population. Despite large sums of money spent, numerous well-intentioned politicians, health bureaucrats, doctors, nurses and other health workers, programs remain disjointed, lack penetration and often fail.

Many health professionals lack cultural awareness of even the most basic nature, let alone clinical experience in indigenous health, so as a result they miss opportunities to intervene and help. Even in 2013, it is not uncommon to have doctors look at me anxiously with comments like, “Do you have any Aboriginal patients?” as though I somehow need security guards at the door and a NASA-designed protective suit to shield off whatever it may be they think such creatures harbour.

There are doctors who somehow think a sore throat in an Aboriginal child is different from one in a white child. Yes, it is true that the severity of illness and range of pathology may at times be skewed for Aboriginal patients; but skewing occurs for other patient subsets too, whether it is race, age, gender or sexual preference. Academia and the media have much to answer for, for the alarmism and fear that have been bred into many of our health professionals and the community at large. The result is a worrying level of disengagement and poorer access to health services for indigenous people.

Given Tony Abbott’s zeal to address indigenous disadvantage, highlighted by his regular visits to remote communities and the enlistment of Noel Pearson and Warren Mundine, it is time to propose something better.

Rather than grant-driven, short-lived projects, we would be doing far better if we were to expand or modify the existing Medicare system in a manner that helps indigenous people achieve better health outcomes. This way we would be working with systems that already work well.

A model worthy of adoption, with minor variations, would be the Department of Veterans Affairs (DVA) model. Holders of DVA cards are able to access all that is on Medicare, plus a suite of allied health, transport, pharmaceutical, optometric and dental services. Furthermore, the DVA allows these services in private practices and private hospitals.

Such a program for indigenous patients could be rolled out virtually straight away, with immediate positive results. Clinicians would be able to adapt to such a model easily, without having to learn new ways of jumping through bureaucratic hoops. Rather than set up a new empire in Canberra to administer such a scheme, there is no reason why Medicare or DVA could not run it. The millions saved in existing, failing schemes—which are big on filling forms and often light on treating patients—can be redirected to this new model, which will only reward clinicians when a service is done.

The concept of the private system taking part in such a scheme may be confronting to some, both clinically and socially. However, private practice in Australia is no stranger to helping the public health system when it is not coping or failing. It would be a win for indigenous patients, who would achieve access to services hitherto impossible and unaffordable. It would also be a win to most clinicians, who would be able to help needy patients that they too have not had access to.

Change our medical schools

In Australia in 2013 there are too many medical schools and too many medical students. There are now twenty medical schools in Australia; twenty years ago there were ten. In 2000, about 1200 students graduated from our medical schools; in 2011, there were over 2500. To this total, we have to add about 300 New Zealand graduates and the numerous foreign doctors registered to practise every year.

Any suggestions that Australia needs more doctors are false. Our ratio of physicians per head of population is in the world’s top ten (we actually rank thirteen but when take out the outliers Monaco, Niue, San Marino and Andorra we are number nine). Our ratio of thirty-nine physicians per 10,000 population is over double what it was thirty years ago.

Our medical students are restless. They worry about job security. They worry about the quality of their training. They worry that the wrong people are teaching them (many of their teachers are not doctors). They worry about their roles being taken away by other health workers. They worry that the government has sold them down the river.

The quality of training and clinical experience has been diluted as students and junior doctors trip over themselves for access to patients and hands-on training. The academics, who have an interest in having as many schools and students as possible, keep reassuring us that “modern education techniques” can fill the gaps.

I do not agree. Whilst computers, internet, animation, simulators and robots are wonderful teaching tools, at some stage learning clinicians have to learn on real patients, in real situations of stress, life and death. And they need to learn many lessons over many years before they learn the art of medicine. The technology can teach the science, but not the art. But even the science is lacking.

A generation ago, it was unthinkable to graduate from a medical school in Australia without having sutured a few patients, delivered a few babies and taken the odd pap smear. Likewise, one assumed that a graduating medical student could examine an eye, perform a rectal or vaginal examination, and assist in an operating theatre. In 2013, one cannot assume any such competence of a graduating medical student. There are even postgraduate Fellows of the Royal Australian College of General Practitioners who fall into this category.

Politicians have been over-ambitious in hurriedly opening medical schools before knowing where the teachers and clinical placements are going to come from. By opening the doors to so many more students, the entry criteria have slackened to the point at which we can no longer assume that the medical-student collective is the academic elite it once was.

With so many curricula and versions of degrees in play around the country, Australia’s medical profession and Australian patients have a right to know that a minimum standard is being taught to our medical students, not to mention all the international graduates that come to our shores. It is time to consolidate the medical schools and introduce some common exams with minimum pass marks that all doctors hoping to practise in Australia must pass and pass well.

Change red tape

If there is anyone in Australia who can name every single health bureaucracy, let alone its function, that person deserves an Order of Australia! We have too many departments, too many offices, too many forms to fill out, and under Labor they seemed to grow by the day. As Judith Sloan wrote in the Australian on September 10:

It’s been hard keeping up. We have had the Social Inclusion Board, the Workplace Gender Equality Agency, the Australian Workplace and Productivity Agency, the Climate Commission, the Climate Change Authority, the Australian Health Practitioners’ Registration Agency, the Charities and Not-for-Profits Commission, the Australian Curriculum, Assessment and Reporting Authority, the Tertiary Education Quality Standards Agency, the Australian Institute of Teaching and School Leadership, the Australian National Preventive Health Agency, the National eHealth Transition Authority, the COAG Reform Council and the list goes. (I could use up my entire word limit simply by listing all the new agencies.) It really makes you wonder how we ever got along without …

As a doctor, what annoys me most about the list of twelve agencies above is that all twelve have a direct or indirect effect on how medicine is practised or will be practised in this country. Again from the Australian, Julie Novak wrote on September 11:

Large federal bureaucracies have emerged with little or no service-delivery role, charged with enforcing policy standards and administrative procedures in relation to grants funding to large state bureaucracies. This trend has not only led to an excessive size of government, with two bureaucracies intervening across different areas of policy, but to the creation of perverse incentives in which federal and state politicians blame each other for poor policies and unsatisfactory service standards.

This is nowhere more palpable than in the health sector. What Novak and Sloan have omitted is that these bureaucracies are replete with brazenly left-wing apparatchiks with their eyes alert for “Liberal moles”.

The compliance costs—in terms of both time and money—of being a doctor and doing business as a doctor have reached the point at which the good intentions of the regulators are being offset by the hindrance and inefficiencies to our clinical care. In medicine the concept of accreditation has taken root—yet another bureaucracy and more red tape. This year, when an Australian study showed accreditation confers no advantage to patients, the “accreditation industry” refused to abandon its fervour for the process. It seems that those in the academic and administrative fairylands, far removed from the realities of the coalface, practise two types of evidence: the evidence that they impose on others and the evidence they choose to ignore themselves. It now seems that we spend one minute doing something and five minutes writing about it. No patient gets better by having a form filled in.

Rudd’s so-called “Superclinics” are the crystallised version of this inefficiency. The sooner Abbott stops funding this nonsense, the better. Some Superclinics have been proximal to existing services, where there is clearly no need for them. Other Superclinics have struggled to find staff, becoming white elephants. The grants process associated with Superclinics is political and mired in red tape.

With a bit of luck all twelve agencies listed by Sloan will be gone within this term of Parliament.

Change the AHPRA

This was one of the greatest failures of the Rudd–Gillard–Roxon–Plibersek health era. Sold to us as a process to streamline registration across state borders, the Australian Health Practitioners’ Registration Agency has instead provided us with more interference and raised the cost of registration considerably (for example, it has almost doubled for doctors).

New South Wales has not adopted the AHPRA complaints system, Queensland has rejected AHPRA in parts, and Victoria is holding an inquiry into AHPRA.

A diverse group of health and allied health professionals has been lumped together under the one organisation, even though the needs and roles of the individual groups are so varied. The AHPRA stable so far includes: Aboriginal and Torres Strait Islander health practitioners, Chinese medicine practitioners (with acupuncture and herbal subsets), chiropractors, dentists (plus therapists, prosthetists, hygienists), medical practitioners, medical radiation practitioners, nurses, midwives (separate from nurses), occupational therapists, optometrists, osteo­paths, pharmacists, physiotherapists, podiatrists and psychologists.

Whilst the list seems impressive, those who are not on the list are perhaps the biggest worries of all. For example, where are the naturopaths and homeopaths? It seems those who practise quackery, with the least scientific basis, are those who are escaping regulation! Not being an organisation to spare any expense, AHPRA oversees boards and some state offices for the abovementioned groups, of course.

The registration process, rather than protect the public, is doing the opposite. Practitioners can register online, without supporting documents submitted to AHPRA, meaning only a random audit can catch out someone cheating the system. AHPRA was bound to fail, is failing, and needs to be changed stat.

Judith Sloan said it so well in that same article:

The Australian Health Practitioners’ Registration Agency was always a solution in search of a problem, which has now become a problem itself. The teething problems associated with its establishment were monumental and the agency still only covers a fraction of all health professionals. Registration fees have more than doubled for no noticeable benefit to health professionals or the public.

And searching for problems it does very well! The public are assisted and encouraged to make complaints. The latest figures suggest that doctors in Australia have a 4 per cent chance of being reported to AHPRA. That isn’t a 4 per cent chance over the doctor’s working life—it is a 4 per cent chance every year! And given the way AHPRA operates, the doctors are often presumed guilty until proven innocent. Rights to legal representation are often restricted, details of the complaints are sometimes hidden from the doctors, and complainants cannot be sued for vexatious and defamatory complaints. Kafka could not have invented a scarier organisation.

Change Medicare Locals

Peter Dutton had promised to scrap Medicare Locals, until Tony Abbott stated in a live televised debate that he would not close them. Not closing them does not mean not changing them! As a minimum, Abbott and Dutton need to conduct a full review and restructure.

Many Medicare Locals are still struggling to define themselves. Funding seems to be very much based on grants, projects and timelines, lending itself to “project officers” and “program co-ordinators”. Many of these programs come from on high, making the “Local” in “Medicare Local” a misnomer. Most of the employees are not medical, and many are not even nurses. Well-paid positions, complete with offices, cars, business cards and computers, are being invented and given to people with little understanding of clinical issues. Spin-off organisations, such as state groupings of Medicare Locals, make the situation worse still, for every spin-off means less local autonomy, more talk-fests, more hangers-on, more distraction from clinical work and less money finding its way to patient care.

Each Medicare Local has a website, often re-hashing information already available elsewhere. The websites often advertise existing government programs that need no re-advertising. A classic example is the Closing the Gap project for indigenous patients; this program opens up some extra services and cheaper medicines for indigenous patients. The program was already up and running before Medicare Locals, so why do Medicare Locals need to get involved now?

Projects often have no evidence base and are simply feel-good in nature. Attending community sports events, agricultural field days, and other social gatherings appear to be among the Medicare Local specialties. Other organisations were performing such roles in the past, often voluntarily, without the layers of bureaucracy Medicare Locals bring to the mix. They’re often the sorts of things a community nurse, a Rotary club or ladies’ hospital auxiliary did for free in the past. And in the end, the odd patient identified with a problem is sent to a GP or emergency department anyway. Medicare Local won’t fix the problem.

Want to promote something a little unorthodox? Let’s say infant massage, a coffee-shop chat group, an imaginative childhood obesity focus group? Medicare Local is here to help, and spend, and spend some more. They’ll discuss the matter through a few layers of management, a couple of committees and then rope in a few other interested parties to run a project. Someone in the Medicare Local office might know someone who will then be paid to visit all private practices in the area to promote the project; or there might be a budget set aside to advertise the position. A web page will be posted with the mandatory sprinkle of Facebook and Twitter too. To keep up with the times, the Medicare Local workers may want to post a few selfies with the local women’s rugby league team, as they promote drinking the right type of energy drink. As we sit at our computers and scroll through the images, we can all feel Australia getting healthier by the minute, can’t we!

If all the money hasn’t run out by this time, and the staff has not moved on to something else, projects—or at least parts of them—will happen. Naturally, everyone will need to do a survey for someone else in the Medicare Local to analyse. A year later, we all may have forgotten about the projects anyway.

I have yet to meet a doctor not on a Medicare Local payroll who does not have serious reservations. I even know a number on the payroll who do. Lack of medical input and leadership, uncertain future direction, lack of efficiency, lack of accountability and the nature of funding of Medicare Locals are the main concerns of doctors.

Some doctors go as far as suggesting Medicare Locals are the instrument for government to accelerate doctor-substitution and usher in fund-holding models to further ration an already rationed public health sector. Judging by the examples above, who could argue?

Change e-health

E-health has much to be said for it. Access to information, speed, mobility and portability have achieved levels not even science fiction writers could have imagined a generation ago. However NEHTA (the National eHealth Transition Authority) was put together in haste and execution was lacking. The government refused to heed the warnings from overseas that such projects can turn into very expensive mistakes.

Dr Mukesh Haikerwal, ex-AMA President and Chair of the World Medical Association, was the clinical leader of NEHTA. In August 2013, he and other senior clinicians resigned en masse from the organisation. This will now leave non-clinicians in charge of what should be a clinical project.

Practices and patients have not adopted the Patient Controlled Electronic Health Record (PCEHR) and other e-health initiatives as had been hoped. This is despite monetary incentives, advertising and cajoling from government. Part of this failure is due to poor communication from the government. Part of it is suspicion about privacy and intellectual property issues. While it may appear logical for patients to control their own health records, the information in the records is often complex and therefore inappropriate for untrained people to be editing and distributing. Doctors also have the dilemma of sharing their pensées with patients and everyone else with access to the PCEHR. It may reach the stage where doctors need to keep two sets of notes—one for the electronic record, and one for themselves. Yet again it would be a case of a government project wasting time when it was intended to save time.

Medical practices are already overwhelmed with forms, programs, passwords and codes. Adding another layer from government has been a burden, not a help.

We need to step back and take e-health more calmly. Many doctors still have not come to terms with touch-typing, electronic prescribing and medical record-keeping, especially specialist practices (general practices in Australia have an impressive level of computerisation already).

Let’s walk before we run. I often wonder whether a compulsory touch-typing course in schools or universities would do more for efficiency in medicine (and to this we can add many other professions) than many of the fancy programs our politicians usher in.

What is outlined above is only the tip of the iceberg for health, but this six-point plan would be a great start. Let’s hope Palmer’s Titanic does not crash into the iceberg. Jaymes Diaz should be able to master the six points by the 2016 election. And Fiona Scott’s sex appeal will get her acquainted with the six points in a flash. Over to you, Tony!

Dr Aniello Iannuzzi is a family physician who practises in rural New South Wales.


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