Transcript: AMA President Dr Steve Hambleton, National Press Club Q&A

TRANSCRIPT

Media Q&A

National Press Club

AMA President Dr Steve Hambleton

18 July 2012

LAURIE WILSON:???? Thank you very much Dr Hambleton.

Let me ask the first question and actually three parts to this. How do you respond to the suggestion that your call for these changes essentially comes down to you wanting more control - you've said that - over the process? And really that means greater control over the funding, over the purse, more money.

Secondly, what would be involved in converting the existing Medicare Local model, the sort of New Zealand-style primary health care model you're talking about?

And, finally, what was it that made - we know this is about politics as well as money. What was it that made the New Zealand situation politically palatable to make that change?

STEVE HAMBLETON:????????? Well, I think the first issue - really the first two questions really come together. It's really, really important when you're making decisions on health policy, be it in the primary care area or in the hospital area, for those decisions to be modified by knowledge of what's happening at the frontline of care. And I guess that's our consistent message, both in the primary care space, AND the hospital space.

The decentralisation of management gives an opportunity for local clinicians to be on those Local Hospital Networks. Medicare Locals, although we'd argue whether they're local enough, is an opportunity to - for those structures to be advised by doctors working at the frontline.

It's very, very important that in the beginning when the Medicare Locals are formed that they don't disenfranchise GPs.

And that comes to the third point that you made. What happened in New Zealand that made them actually embrace the issue of GPs in a governance role on some of these boards? Because when they did disenfranchise GPs they disconnected from that frontline workforce and they delivered really what we're seeing or what we've seen delivered in our hospital systems in this country, and that's a disconnect between management and the doctors actually working on the frontline.

We don't want to see what happened in hospitals replicated in general practice, and so the way we stop that is to make sure we've got GP leaders with governance skills - and we understand the issue about skills based boards. We've got so many GPs now trained in governance available to sit on those boards to provide both governance issues and connection with the frontline that you'll get that - better decisions being made at that level.

And yes, it is about the funding, it is about taking some of that funding and spending it wisely.

It's about not competing with existing successful services, and we've seen that in the super clinic space where significant funding which could have actually been leveraged off existing doctors who invested in their own communities was spent competing with doctors in those communities.

So, they're the sorts of things that clinical leadership with provide at that investment level when you're controlling those resources.

So, all three of those really come together to say we want a better outcome for the health system. And you do that by being advised by doctors who are actually connected with patients who work at the frontline.

LAURIE WILSON:???? Question from Julian Drape.

QUESTION:??? Dr Hambleton, Julian Drape from Australian Associated Press.

I wanted to ask you a politics based question and also a medical question.

On the politics side of things, Nicola Roxon earlier this year said that she wouldn't work under Kevin Rudd again because his approach to health reform was ludicrous and chaotic.

I was wondering what you as vice president of AMA at that time made of Mr Rudd's approach to health reform and whether you'd be happy to work under him again, or with him, if he became prime minister again?

And on the medical advice front, a lot of Australians are watching the Tour de France at the moment. Is it dangerous to be getting by on five or six hours sleep a night for three weeks?

[Laughter]

STEVE HAMBLETON:????????? Well, the second question is easier than the first question. That's about how much sleep I get every week.

But it's a relevant question because sleep hygiene is so important, and for busy people we tend to forget that. Your concentration levels, in fact, the health benefits of adequate amounts of sleep, the work-life balance are really, really important. It may be okay for some people to actually function on five or six hours, but for the majority of us we should not do that on an ongoing basis.

Coming back to the more interesting question, if we - I said in the speech if we turn back to 2007, there was a lot of talk about health reform. Now, the Health and Hospital Reform Commission produced a large document with lots of ideas, and there was a very strong vision from the Government at that stage, and led by Prime Minister Rudd. That vision the AMA supported.

And when we talked about some of the health reform outcomes being diluted, that's the dilution. It's the dilution of what the original vision was compared to what we've got.

Now, if you remember those days we were talking about the majority funding from the federal health - from the Federal Government. Majority funding is appropriate from the arm of government that's got the most revenue coming in. So, if you want a sustained revenue for a health system you've got to get it from the level of government that's got the money.

Now, of course, the state governments are closer to the action and are in a position to manage and control and deliver health. But that original vision was something that the AMA supported and we certainly still support that, and we'd like to see some of that original vision be delivered.

LAURIE WILSON:???? Let me follow up the question. So, how would you feel about working with Kevin Rudd again, and what about Tony Abbott?

STEVE HAMBLETON:????????? Well, we certainly had a good relationship with Prime Minister Rudd. It certainly - through Minister Roxon and Minister Rudd there was a lot of engagement with the AMA, and that's exactly what we're offering to the current Government, it's exactly what we're offering to the Opposition.

And so if there was a change - and the AMA certainly would be happy to work with anyone in government - we'd certainly be comfortable with any change that the Labor Party decided to make.

Turning to Mr Abbott, if you actually read the history of the AMA there's some really interesting episodes that Mr Abbott was involved in, and that was the indemnity crisis, it was actually the recognition of the quality of general practice. Some very good things happened in health care in Australia under the - in the health system when Mr Abbott was there.

So, as I say, the AMA is apolitical. We're happy to work with Government, we're happy to work with Opposition. The message is the same: if you want to make a better decision, you need to be informed by doctors working at the frontline. That offer is an open offer for anyone who leads the Labor Party, for anyone who leads the Liberal Party, for both sides.

LAURIE WILSON:???? Andrew Tillett.

QUESTION:??? Andrew Tillett from The West Australian.

Dr Hambleton, there's been a lot of coverage in recent weeks about XANAX and STILNOX, both particularly sort of addictive prescription medicines.

GPs are obviously at the frontline at prescribing these sorts of drugs. I wonder if I could get your thoughts on whether you think that some of your colleagues are sort of over-prescribing these drugs and whether we need to have some sort of tighter regulations, restrictions on their availability for patients, particularly in light of things like claims of doctor shopping and things like that.

STEVE HAMBLETON:????????? Certainly I think that information to help GPs make decisions about their patients is actually going to be really helpful, and this is going to be one of the benefits if we can properly start to share prescribing information.

That one-to-one relationship between a doctor and a patient is so important and yet doctor shopping exists. And it's in those circumstances where if you haven't got access to the past history and you don't know what's been prescribed before, that multiple prescribing can take place.

Now, we've got the system in place for pseudoephedrine. We've actually - we know that there's actually computer solutions that can help us. So, we need to help our GPs at the frontline with information to help them make better decisions.

Those drugs have certainly got abuse potential and so I guess have a large number of other drugs, including the narcotics. But selectively used in the right people they can be appropriate, if they're used properly.

And that one-to-one relationship with the family doctor is so important in actually building that relationship and making sure they're not overused, over-prescribed or misused, in fact.

So, information systems are going to help us there and we need to develop them as soon as we can.

LAURIE WILSON:???? Simon Grose.

QUESTION:??? Simon Grose from Science Media and Inside Canberra.

I've got a question about the PCEHR, particularly the personally controlled bit of it. In your guidelines to practitioners, you deal with the issue - potential issues that arise when a patient refuses to have certain clinical information uploaded into their shared summary. And this advice goes to the - the actual bottom line is to consider refusing being their nominated health care provider.

This seems to me to raise a lot of potentially conflicting liability issues; the responsibility of the practitioner to the patient, of the practitioner to the larger system, to the - and to the potential third party health providers who may work off information on the system.

Am I right there? If so, are you - is the AMA content as to how those liabilities are managed in the way the system is organised? Or are we going to have to go through a few episodes of litigation to find out what the status is?

LAURIE WILSON:???? Before you answer, I should say in terms of that acronym, Simon, you've been talking about, electronic health care records essentially.

QUESTION:??? Personally Controlled Economic[sic] Health Records system; one of this Government's least pronounceable acronyms.

STEVE HAMBLETON:????????? It's personally controlled non-economic health record. What you're talking about is the shared health summary, which is a part of that Personally Controlled Electronic Health Record.

And that does raise some concerns. As I say, the AMA supports the vision, and that is accurate sharing of appropriate information between health individuals to actually improve outcomes.

One of our big concerns, and this is a new thing we're doing with this PCEHR, with a shared health summary, normally I will write a letter about my patient to a specific specialist and it will have a list of past history, it will have allergies, it will have demographics, it will have all the information you'd expect. But the difference is that the shared health summary is actually shared by me potentially to everyone.

And so patients, quite rightly, need to engage with their family doctor or their curator of that record to say well, what information am I comfortable sharing everywhere?

And, clearly, there are issues that we've all got in our own lives that we'd say, well, yeah look, share all that but I don't know whether I want to share this bit; which is so important for a health professional to be engaged in that process and spend some time and say, well look, no you don't need that and I'm quite happy to put my name against this shared summary to give it veracity.

So, when my colleague opens the shared health summary and sees Steve Hambleton wrote it, he can say, well, I know he had a conversation with the patient and I know the information here is the information that's appropriate for me to know. I also know it's probably not everything but it's the relevant stuff.

Now, if there's relevant stuff that a patient doesn't want to share, we've got to have a conversation and we've got to say, well look, your health outcomes could be adversely affected if we don't share this piece of information. And if you don't want me to share it, I'm sorry, I don't want to be the curator because my reputation goes with that document.

And it does cause potential liability risk because if I've shared something and said, this is appropriate for the next person to pick up, and it's missing key information, then the court may well look and say, well, why didn't you convince the patient, why didn't you actually withdraw from that arrangement.

So, if we share the right information and we have a discussion with our patients about what's appropriate - and it's going to be different. If I'm sending you - sending a lady to an obstetrician, there's information in there that's really personal that might need to go. If I'm sharing that same lady's information, so the physio, the OT, even the emergency physician is going to have a fair summary, it's going to be different.

So, I think that it's very important for practitioners to realise that they will actually be exposing themselves to increased liability because their reputation goes with the quality of the work they produce.

LAURIE WILSON:???? Can I just ask you, we've been talking about the benefits of e-health now for more than a decade, I guess, and it's been a slow transition but there are clearly - there's clearly headway being made. But, more broadly, in terms of e-health, are you satisfied with the pace of that transition now or not?

STEVE HAMBLETON:????????? Well, I think we're still on the - I think we're still at the beginning. I honestly think that NEHTA has does some very good things. It's easy to poke fun at NEHTA for what it hasn't done. But what it has done is actually given us a classification system that we've finally settled on, that we can all use.

And that means I can actually analyse my practice and I can compare it with another practice, and I can actually see whether I - in fact, when I was in New Zealand, they were telling me about how many diabetics they had in their practice and how well they treat them. And I said, well, I'm a good doctor, I've got all these diabetics and I treat them really well. And they said, prove it. And I said, well, I can't actually analyse my software at the moment but one day I'm going to be able to do that.

So, I say we're on the threshold of being able to do so many better things with our software in our practices. I mean, you simply couldn't look through paper charts and do this sort of stuff.

But if we've got a classification system I can analyse it, I can see what their HbA1c, their blood sugar level, is. I can see how often they've had the test. I can even compare myself against someone else.

The other thing NEHTA has done is it's given us protocols for secure communication so we can actually send stuff electronically. And if a patient of mine, for example, very soon wants to go from Brisbane to Perth, I can actually pick up their record and I can dump it on someone else's computer. Today you can't do that but we're going to be able to do that very soon.

So, this PCEHR is only part of the e-health change that we're seeing. We support that but the background is actually improving as well. That will allow our GPs to analyse what they're doing, prove they're doing a good job. And when they can do that, the AMA is going to go after extra funding for them.

LAURIE WILSON:???? I should mention for our viewing audience that NEHTA is not a comparative adjective, it stands for National E-Health Transition Authority.

Mark Metherell?

QUESTION:??? Dr Hambleton, Mark Metherell from The Age and The Sydney Morning Herald.

Can I ask have you spoken to Kevin Rudd in recent months about health reform at all? Do you think there would be a better chance of health reform being rebooted if he were to regain the leadership? And also one of his great phrases was to end the blame game, which you say is alive and well. Can you give us one or two examples of where the blame game is still at play?

STEVE HAMBLETON:????????? Well certainly. And, well, I guess the AMA's main focus at the moment is to communicate with the health minister. So, our role is to talk to Tania Plibersek. If the Labor Party wanted to change the health minister, we'd be happy to talk to a new one. Whether that would change if they changed their leadership, I guess is for someone else to judge.

No, I haven't spoken to him in the recent past either.

There was another question, Mark, I'm sorry?

QUESTION:??? Blame game.

STEVE HAMBLETON:????????? Oh yes, the blame game. Look, we've settled on health refinancing. And how long did it take after that settled refinance for a state to say, we've run out of money, you haven't given us enough, we need another package to save us.

Tasmania didn't take long to actually say that we haven't got sufficient funds and we see that repeated in a number of locations. The state governments are complaining they still haven't got enough money, but we're going to have increased transparency so we're going to see where they spend it.

But we certainly know that there's pressure in the hospital sector, that's what our members are telling us. You know waiting times in emergency departments are still long; waiting times for elective surgery are still long. States are still complaining it's not our problem; we haven't got enough money, it's their problem.

And there's cost shifting that goes along with all that as well. And every - there's armies of people still in the states trying to move costs to the other side of government. So, the blame game is alive and well.

LAURIE WILSON:???? Tony Melville.

QUESTION:??? Tony Melville, director of the NPC; that's the National Press Club [indistinct].

My - I've got a double barrel question. I've got family and friends who are dentists, and so I get a lot of whinging about the Chronic Disease program and the various audits associated with that. It's the red tape around it's arcane. Dentists have been trapped in - have been - fallen into various problems and been accused of over-treatment. A lot of them say it's unnecessary. I wonder if you have some sympathy them.

And a related question to that, just the Medicare relationship between doctors and dentists. There's - a friend gave me an example last night of a footballer who comes in with all their top teeth knocked out and if it's been - he's been referred from Medicare, they then have to send him a letter and a treatment plan and that treatment plan has to go back in. He can't treat the teeth and that could lead to all sorts of problems.

Just wonder about that red tape around that sort of thing.

STEVE HAMBLETON:????????? Look, thank you for that question. That's really, really relevant. It's one of the great wishes that we have that both sides listen to and that is to decrease the red tape.

I've certainly got a lot of sympathy for the dentists who actually, in good faith, have done the work, looked after patients and tried to get a better outcome for them.

There's certainly no doubt that good dental health is - well, you need good dental health for good general health. Bad dental health is going to lead to significant problems in the rest of the body.

I've got no sympathy, I suppose, for those dentists who made the claims and didn't do the work. I think there's a big difference between those two.

In terms of how do we do it better, I think we certainly do need to look at decreasing red tape, making it easier, making it easier to get appropriate people through. We certainly support the program. We're able to actually access those funds for individuals, but we're both on the same side in terms of getting rid of red tape.

We're both on the same side, the dentists and ourselves, on the side of supporting dentists who've fallen foul of some comma, tick or a dotting the I. If you've done the work and you've done the clinical bit and you've tripped up on a bit of red tape - full of sympathy for that.

LAURIE WILSON:???? Ken Randall.

QUESTION:??? Dr Hambleton, going back to e-health and appreciating all the things you've said about it today, it still seems to many of us on the outside of the profession that there's a huge degree of scepticism among GPs about the whole concept.

Do you think that's true and, if it is, will information and negotiation through people like me to be enough to get it up?

STEVE HAMBLETON:????????? Well look, I think you've actually raised another point which is very, very important to understand. There's been wave sites around the country where there's been a lot of investment, a lot of information and a lot of practice at using the product but the great majority of my members are really not informed about what the implications are, how it will work for them.

In fact, it's 100 per cent true to say that the majority - well, all GPs do not have the upgrade to the existing software that can even talk to the PCEHR. So we can't upload a health summary today. We can't do that until we get the software. It's not expected until October.

So, there is a great deal of scepticism about what the mechanics of this process are going to look like. I'd say it's probably the opposite for do we think - if we said to GPs, do we actually think that sharing accurately an up-to-date medication list and a summary health record is a good thing. I think you'd almost get 100 per cent of people putting their hand up.

Today, the GPs produce what amounts to a health summary on paper. They hand it to the patient and say you take that to the specialist. Now if we can get that real time transmitted between doctors who need it, we're going to have a good outcome, but the mechanics are driving us all mad, and in terms of the timing of that process - it's the education process, learning what to do next - we all need to get that out.

So, I think we can do it. The problem for some practices and including my own is we need a totally new software package. Some practices will need that which means all of the information that they've got now will have to be transferred. If anyone has had anything to do with IT people, they'll tell you it's easy and it won't be.

So, we've got a fair bit of work to do but, as I say, we support the vision. I think it can be delivered. All of us support the end point. It's just how we get there that's the tough part.

LAURIE WILSON:???? Peter Phillips.

QUESTION:??? Dr Hambleton, Peter Phillips, one of the directors of the National Press Club.

On the occasion of your address, the 50th anniversary of the AMA, a 12-page transcript, six and a half lines in which, on page three, you actually say some quite nice things about the present government, but further down, page three, you do say, to wrap it up in a more comprehensive form:

[Reads from document] From our perspective the dream of health reform that began in 2007 has not been realised.

Is it the unavoidable and certain destiny of the AMA that you'll always bag and blue with the government of the day?

STEVE HAMBLETON:????????? It follows on from I guess the question earlier about has the dream been delivered? I think we can always do better. I think governments can always do better, and I think when governments are making decisions the further they are away from those that deliver services on the frontline, the more imperfect their decisions will be.

I think the AMA's always going to have a role to actually break - to assist governments to make better decisions. So, we are generally critical.

We certainly recognise good work when good work is done and, as you say, we've picked out a few good things that this Government has done. It actually said that there are a couple of good things the previous government, the Liberal Government, did before the Labor Party came in.

But always we're there to say we can refine those decisions, we can actually improve them, we can connect you up with somebody on the frontline about - so you can make a better decision.

It's up to politicians to make those priority decisions but they need to make the best decision. They need to be properly informed and that's what the AMA's role is, to make sure they're properly informed. If we don't like what we see, we'll say so; if we do like it, we'll say that as well.

We recognise that we've got to work with governments and work with oppositions because our interests are in getting a better health outcome, a better health system that works more efficiently for everyone.

LAURIE WILSON:???? The final question today from Maurice Reilly.

QUESTION:??? Dr Hambleton, I want to deal with the grubby money issue. The health system always seems to struggle for money, and governments of both persuasions make priorities. I just wonder whether we should be educating the Australian people better about the cost of the whole health system and perhaps, does the AMA have views about how it should be funded?

Should we, for example, be advocating for an increase in the Medicare levy to fund what ultimately needs - all needs money and it chews a lot of money up and I wonder whether you have views about what Government should really be doing in that area.

STEVE HAMBLETON:????????? Look, I think that's a very relevant question. We are facing challenging times. We've seen an intergenerational report that talks about the ageing population; we know our obesity rate - 60 per cent of adults, 25 per cent of children; the relationship with chronic disease; the increased expense that's going to cause.

And if we don't do something soon, we're not going to be able to afford health. We've actually seen state governments tell us if they - if health cost keeps growing it's going to overwhelm the entire state budget. It's a bit what - like what Tasmania said recently.

There is a national debate that needs to be had about the cost of health care and the future costs of health care, and where investments need to be made. And we need to be part of that; all of us need to be part of that.

In terms of the Medicare levy, it does mislead people to think that they're actually paying the total cost of health care, because it doesn't cover it. So, it would probably be better to scrap it rather than increase it because it just should form part of the revenue base of the Government.

But we have to have the conversation about the fact that the funding is limited and is not unlimited, and that priorities do need to be made. Where do we spend the health funds? You know, we already have it to some degree in pharmaceuticals where the Pharmaceutical Benefits Advisory Committee won't recommend something to Government unless it's cost effective.

And so we need to spend appropriately, and we need to have that debate so people understand if we spend it here, we can't spend it there. We also then need to prioritise the spending. We need to think about - in fact, it's Family Doctor Week - the investment in primary care to look at prevention, early management and good management of chronic disease will save expensive health costs down the track.

So, we need to - we need to actually have that public debate about health costs. What do we spend? Where do we spend it? We simply can't afford, in any country, to fund everything for everyone. So how do we have that debate? We have to have it sensitively, we have to have it realistically, and we're prepared to be part of it.

LAURIE WILSON:???? Let's finish on that note.

[Applause]

Steve Hambleton, thank you very much for sharing your thoughts today with us, and also for choosing the National Press Club to launch your half-century history - we appreciate that.

Also thanks to the National Gallery of Australia for joining us in hosting this event. Thank you very much.

?

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18 July 2012

CONTACT:???????? John Flannery?????????????????????? 02 6270 5477 / 0419 494 761

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Source: http://ama.com.au/media/transcript-ama-president-dr-steve-hambleton-national-press-club-qa

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