Health

1233 ABC Newcastle

13 March 2007

We all need to understand from the outset that there's no way forward if everyone has a different idea of what the way forward is.  Stop gap measures probably won't even be effective in the short term and this is one area where we need full cooperation between both State and Federal Governments to achieve long term goals that are identified after a careful, objective analysis of the entire system.  We are in the hopeless situation of Governments preventing people in the system from giving accurate information about and sensible criticism of the system, but that's exactly the base data we need.

What we face:

• Our society is getting sicker.  Most forms of chronic disease are increasing by three to four times the rate of population growth and takes time and effort.  A young child with diabetes are looking at major problems in their adult years, including blindness, amputations, kidney problems.
• Our society is getting older and we need more attention.  Managing health demands in the face of a widening gap between the demand and supply in an environment of massively rising costs, will inevitably mean that doctors and hospitals will increasingly have to triage patients to establish priorities among those patients -- pricing signals.
• Declining workforce.  More than half of all doctors and nurses are over the age of 50 and will be retiring within the next 5-10 years.  Current nursing shortage in Australia is expected to soar to 140000 by 2010.  By 2010, 1500 fewer dental professionals and the Hunter Region is losing trained doctors to Sydney.
• The cost of healthcare has been increasing.  The State Government spends $8 billion a year on health --1.3 billion to Hunter New England Health.
• Low socio-economic circumstances result in the reduction in both physical and mental wellbeing.  Maitland has social problems. Romanow Report to the Canadian Government confirms that healthcare contributes positively to the economy and more productive working lives on an individual basis.
• There needs to be medium to long term planning policies; models of service delivery; standards and quality of care; governance structures, including roles, responsibilities and funding; equity of access for different groups within the population and geographic locations; and other barriers to a better health system.  Recognised by IPART report.
• There has been no national review of healthcare to agree on overall directions for reform from the Australian Heads of Government.  
• The individual components of the system and their reform are not being developed in the context of an integrated framework or strategic plan.
• Federal Government Productivity Commission has stated that there is an expected increase of public spending on health from 8-16 per cent of GDP over the next 20 years is unsustainable.

Commonwealth Responsibilities

• set national policies for health care;
• regulate and part-fund GP services, pharmaceuticals and nursing home care;
• regulate private health insurance that partially funds the purchase of health services in public and private hospitals;
• provide part funding to the states for public hospital care; and
• largely determine the number of places available for training clinicians at universities and tertiary teaching institutions.

State Responsibilities

• provide healthcare directly (for example through public hospitals, community health and aged care services);
• purchase healthcare through arrangements with non-government private sector organisations and visiting medical officers, as well as through agreements with Area Health Services (in NSW);
• fund health services by raising revenues (state based taxes) that are appropriated for direct spending on healthcare.

Funding Problems

• The mix of private and public funding and shared responsibilities across governments presents many challenges and has resulted in tension between the levels of government.  The dual responsibilities for funding, administering and delivering healthcare services hamper the delivery of high quality patient care and efficient use of the limited resources available.
• The Commonwealth Government needs to continue to work with NSW Health to progress innovative and joint service delivery models that lead to better health outcomes.
• There is an incentive to shift costs between the Commonwealth and State Governments.  In hospitals there is a different source of funding for exactly the same medical service, depending on whether a patient elects to be a public or private patient.  This encourages providers to address who pays above what is the best means of delivering a service.  Treated in hospital paid by State treated by GP some or all cost paid by Medicare.
• There have been significant changes in clinical practice and the relative role of public and private sector in providing and funding healthcare however Commonwealth/State funding arrangements remain largely unchanged.  Funding is tied to the context in which services are provided, rather than following the patient.
• There is no incentive for Area Health Services and the Commonwealth to engage in long-term, comprehensive health service planning.  Area Health Services are responsible for planning health services, based on the needs of their region, but they can only plan the services they are funded to provide.
• Many stakeholders involved in the Health System believe that the introduction of a 30% rebate for those with private health insurance, has increased the Commonwealth spending on health, but has resulted in little improvement to the healthcare system.  The increase in private health coverage has led to increased activity in private hospitals but this has been less-complex, discretionary procedures.  If the intent was to relieve pressure on the public health system, it would have been more efficient to have transferred the same gross funding to this system.  There are some suggestions that with additional grants equal to the cost of the rebate (2.3 billion a year), public hospitals could treat almost 60 per cent of all patients now treated in the public system.
• There are time limited Commonwealth funded programs financial risks for States because of increased community expectations.
• Joint funding efforts.  Healthshare is a funds pooling mechanism that includes arrangements for joint planning and delivery of all health services for the entire population of a geographic region based on a Resource Distribution Formula.
• Initiatives to increase access to GP services.  For example, the Commonwealth and NSW established and extended the Maitland After Hours Service in the Hunter Area Health Service.  This is a close partnership between the Hunter Urban Division of GPs, the AHS and the Commonwealth.  It comprises of a GP clinic (co-located with the Maitland Emergency Department); a telephone triage and advice line; a home visiting service; taxi transport to and from the GP clinic, for those requiring urgent GP service but have no means of transport.

Health Issues 'Aired' by the Citizens of Maitland

• There is a lack of after-hours social work service for the entire Lower Hunter.  Emergencies do not only occur during business hours.  Often these emergencies involve children who are at risk of harm.  The nursing and medical staff are giving the loudest voice to the need for additional social work services since their roles are being hindered by having to try to handle issues other than the medical emergency.
• Health system heirarchies remain top heavy and consultants to health departments suck up huge amounts of resources.
• In 2003-2004 there was no increase in psychiatric hospital beds at Maitland Hospital.  Overnight admissions increased significantly.
• A shortage and/or inappropriate location of residential and community aged care services is putting pressure on public hospitals, as they must accommodate older patients who are ready for discharge but are waiting in hospital for placement in aged care  services.  This is a high priority area where a more permanent policy response is required.  Transitional care improves health outcomes for patients.
• People leaving hospital unsure who will provide follow up care.  Sometimes their GP doesn't even know that they have been in hospital.
• A simple charging regime based on a principle that the less urgently care is needed, the more the patient is charged if they pursued that care would reduce emergency workloads.
• Duplication of services (the same medical tests being ordered internally and externally).  Good planning and communication --duplication and associated cost to patient and the health service could be avoided.
• Focus on inputs and outputs rather than service quality, value for money and health outcomes.  Funding based on more doctors to see more patients or less Medicare funding. 
• There needs to be more focus on health promotion.  Greatest cost benefit ratios are found initially in spending on primary healthcare.
• Looming crisis in medical training unless infrastructure put in place for training.  To convert a medical student to a doctor according to the AMA requires an intensive intership provided by the States.  For that doctor to be fully trained requires several years of clinical training in hospitals with beds that are open, actively treating patients etc.
• Lack of resources for aged care and the mentally ill are a national scandal.
• Problems with policies, communication and clinical care.
• If the system is being pushed by the complexity of disease, by the increasing age of our population and indeed by distances that the staff have to work in in NSW, it's not surprising there are systems issues.
• Paperwork and computer work have impacted on time available at the coal face.  Record keeping, administrative requests and payroll management.
• No childcare facilities associated with health sites outside of Newcastle.
• Renumeration levels for doctors, nurses and allied health professionals to retain them in the health sector.
• Government sets the corporate climate.  Patients seen as numbers, beds, waiting lists.
• Where are the assessments of the future training needs given our ageing population.
• Problems between the interface between the Mental Health Services and other Health services and where the overlap occurs.  The fact that services are separately managed means that 'silo' thinking can occur within each office.  Specialist services often put tighter restrictions around what they do in order to better measure their outcomes.  This occurs whether or not there are other services that are equipped or qualified to manage the patients.
• We have short term simplistic thinking, short term periods in which their effectiveness is measured.  We need a long term plan.
• Hospitals are not only staffed by doctors and nurses.  There are also allied health professionals (physiotherapists, occupational therapy and social work, in order to achieve the throughput of patients and achieve the target 'bed stays'.  Very often announcements are made that additional beds will be opened with additional nurses employed, but no additions to the allied health services.  This only means that increasing numbers of patients are discharged with little or no allied health input, which has a significant impact on health incomes and contributes to the need for readmission.
• Maggie Program is focusing on improving patient journeys to maximise the safety and satisfaction of patients and staff.  Workers are unable to devote appropriate time to their development because they are still providing client care.