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Everything is on the table! Bring it on Ms Roxon...
LL
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Can I take it from the lack of views and comments that no-one is particularly interested in what could be the greatest quantum leap forward in podiatry/primary care professional practice that this country has ever seen?
Referral to specialists? PBS drugs? Medicare rebates? Decreased medical dominance?
Perhaps it isn't that exciting...maybe I should find some toenails to paint.:rolleyes:
LL -
Is the profession/association getting involved in these talks or putting forward a submission to the federal government??? -
The politics of this siutation is that the AMA, Divisions and RACGP will go crazy at the thought of a dilutation of medical dominance over other profession. The government will seek a middle ground.
The reference committee is to report by mid 2009. This is the same time the NHHRC is providing its report. So there will be many professions, like ours, arguing for the same reforms to occur.
If there are 10 professions arguing against one (powerful) profession - the government will seek a balance. Remember the nurses make up more than 50% of the entire health workforce and are heavily unionised. Podiatry is not, but its about time we were.
If YOU want to see reform, write to your Association, the APodC, your federal MP and blow the podiatry trumpet. This opportunity is a once in a generation opportunity to advance non-medical professions in Australia out of socio-political obscurity.
I know I would love at least to just be able to write a bloody prescription for Keflex for an ingrown toenail, have it covered under PBSS, and refer someone with knee OA to an orthopod without subjecting myself and the patient to an economically pointless GP consultation.
LL -
LL
I agree - this is huge. However, I wonder if the debate will be dictated by the association wielding the biggest stick (ie influence).
The AMA's influence is huge in Canberra, but I would like to think the APodC and state associations will be in there fighting.
I will be writing to to the APodC/state association.
Who knows, maybe a few pea-shooters will distract the big bully enough for a knockout blow to be landed and sway the debate. -
I am very interested in this new direction & whether we're sceptical or not we should become involved and at least try - the other professions will and if we don't we'll miss out (again). Cynicism is not always productive in achieving our goals.
Lucky - just wondering if you could give some of us who are not so confident in political activity some ideas of what to include in our "letters" to the various groups you mentioned. Are there certain points we should cover in particular? It might encourage a few more podiatrists to write if they have some sort of outline and it would give us some sort of consistent message to present.
Look forward to hearing your ideas
Cheers
RStone -
Take another step back - not only could a move in this direction be good for the allied health professional, but also for the users of the health care system.
Is the stage being set for a rise in self management of chronic conditions?
Nicola presented the management of incontinence as an example. Soon we could be presenting patients with a range of health care options to suit their particular circumstances. Not just surgery. How often are patients forced into surgical interventions because they are the cheapest (for the patient) at point of use?
PA posters have mentioned the foreseeable reluctance of the medical profession in letting go of the central role in patient management. I don't see this happening. It shouldn't happen. What is a GP if not the primary health care co-ordinator? (Or am I wrong? Could we really trust consumers to manage their own health?) We should talk about the shift towards self-management. Not taking power away from one profession and distributing it to others. To pull this off we are going to have to take a good long look at our information systems. Crikey. Can we have another rise in alcohol tax please? And another review while we are at it.
The confusing thing for me here, is hearing a politician make sense. It makes me nervous.
Kate -
SARRAH has released a statement endorsing the review, available at http://www.sarrah.org.au/site/index.cfm?PageMode=indiv&module=MEDIA&page_id=110903&leca=2 and quoted below...
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There is an article in yesterday's Weekend Australian "Wider role for allied health staff backed" in Weekend Health pp16-15 that may be worth a look.
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Yes, I read this too. Dissapointingly, there was no mention of the APodC:
LL -
RStone wrote:
For instance, whenever I have written to my local MP on a health issue that affects podiatrists, my MP then writes to the health minister seeking clarification to the issue. MPs ignore their constituents at their peril, and this is politics 101. They desparately need your vote to be re-elected, and we endeavour to support any sensible arguments you raise.
Hopefully if you were to write separately to your state association, and 'cc' this to the APodC you would achieve a comparable result - though these are volunteer organisations.
In terms of content, many people have eloquently described how podiatrists can be more productive in the health system, and use their skills to full potential. But to summarise, I would be including comments about;
* limited prescribing for common podiatric conditions (infections, pain relief, acute inflammatory conditions)
* triage of foot/ankle pathology by podiatrists in public hospitals (like the UK)
* podiatric surgery services in the public system (like the UK, US)
* direct referral to relevant specialists (including pathology) to reduce waiting times for GPs and decrease Medicare costs (like the argument used to get ultrasound referral rights under Medicare)
* Extending the availability of Medicare rebates for podiatric services (eg acute diabetic foot, non-chronic conditions)
It is the role of your professional body to supply governments with the evidence to support these requests, but much exists in the literature (mostly for other non-medical professions) to justify these approaches.
Just my thoughts,
LL -
Form today's Australian. Should be required reading for all new graduates on the realities of the Australian health system...
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Let's just hpoe that this initiative isn't derailed.
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QUOTE from ARTICLE above:
"Of course, the doctors have a justification for such restrictions. As AMA president Rosanna Capolingua argued at the National Press Club yesterday, "GPs are the pivotal gatekeepers: the people who select the services that each patient requires to get the best health outcome possible, in the most efficient and cost-effective way.
"Without appropriate medical diagnoses and supervision, patients' problems won't be dealt with properly in the first instance. Missed diagnosis, false reassurance, misdiagnosis, delay in care, all cost dollars and time and human expense."
That made me laugh uncontrollably for several minutes. Most of the patients I see have been battling with their GP for years on management plans/treatments for the wrong diagnosis - maybe a case of the pot calling the kettle black?
Stephen this wont get de-railed, but it will be a prolonged fight you can bet on that. It is blatantly obvious that the days of the GP as we know them are limited. Even the medical profession has indoctrinated the GP as a sub specialty now in its own right! I'll let you all put one and one together to work out what that means.
If Roxon can pull this off it will be the single greatest political achievement in years. The problem is - can we as a profession keep up? Are we educated enough to be doing these advanced things? Do the majority of Podiatrists/Physio's want S4 drug rights? There is no doubt they could use it, but some just do not want the hassle. Has anyone asked them? What do we do with those who don't want the right? How do we segregate that part of the profession without offending anyone?
It would seem that whilst we are supposedly "dumbing down" the podiatry profession in some educational areas, we are trying to bolster it in others? Is this merely internal, self propogated, professional self destruction?
Undergraduate education? Foot Carers? Demise of undergraduate Podiatry programs? Changes in undergraduate program structures? Anyone want to throw their two cents worth in? Am I being too harsh here?
So many questions - so little answers.
I will step back and put my FLAME SUIT on, because I am sure the comments above will attract plenty of nasty posts!!
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Paul
There is little doubt that the potential reforms that are on the horizon will leave some (many?) in the non-medical professions feeling a little worried about their current skillsets.
However, as an isolated profession, we are not use to the massive resources in postgraduate training and education (outside of the university system) that medical practitioners have had almost the exclusive freedom to enjoy. Think of the National Prescribing Service, the Divisions of GPs, and the dozens of other organisations that exist to purely encourage life-long learning and skills development for medical practitioners. Once we are able to access these resources, and they are filling up our in-trays with new weekend courses and educational material - osmosis will start to kick in. Those old undergraduate subjects in pharmacology and pathology will start to clatter around in the brain and take on new meaning as one begins to actually USE this knowledge. Daily. No just once in a while...
A change of the magnitude that is being considered will require a least a generation or two to really come into its own. As new graduates enter the system, hopefully with the necessary background to get straight into enhanced scope activities (think professional development year anyone?), and the older providers drop off the perch, there will be a gradual phasing in of these capabilities.
More exisiting practitioners may be sufficiently motivated then to enter postgraduate university programs (or alternative arrangements!) now that there could be a useful benefit to these courses in service delivery, as opposed to the past - where really it was just another piece of paper without any meaning.
LL -
Agreed entirely Tony - but you know that we are always on the same page. :)
I was more interested in comments on the current undergraduate climate around the country (being as diverse as it is) and the way in which everyone thinks this is being managed? Universal Undergraduate training anyone? Board examinations anyone?
Lots to think about and lots more to do!!! -
This sounds outstanding to me! I don't know how many of you have had patients say to you that they didn't know if they should be seeing you or their GP, to then have to refer back for AB's or MRI etc.
If we ever hope to get anywhere as a profession we really need to be seen as the experts in our field and from what I've seen at some of the most recent conferences we have a long way to go. It's disappointing that CE has had to be made compulsory to get so many people to attend.
I suppose my point is this....Ms Roxon can give us all the power in the world, but if the majority of Pods out there are happy to just cut toenails then an increase in scope of practice will not get us very far, considering our numbers.
We need to continue to evolve and maybe this will be a major first step (no pun intended), so bring it on. I'm with you LL, structured and recognised post grad education is the way to go to make sure that we make the most of these opportunities when they arise. I'll be writing to my local member.
No more calls for an increase in alcohol tax, please. Is there an assessment tool available for that?? -
Hi everyone,
Very keen on podiatric surgery, would like to hear your thoughts on the future of pod surgery in Australia, in regards to sx training/practicing and how it will fit into the proposed health reform????:confused::bash::empathy:
Cheers. -
Its good to live in interesting times.
Paul you are right that non-orthotic advanced skills that will be required will find most podiatrists falling short of the mark. I went down the path of surgical registrar, masters, 4 yrs surgical assisting to come up against the very big GP wall. I was politely told off the record if I finished my qualifications to become a surgical Pod that I would be black listed by all the GP's and would have no access to any surgical facilities. Yes this will be a hard long and dirty fight that many fat dumb and happy orthotic pods are poorly armed to fight. -
Hi Colin,
Did this political bullying :boxing:result in you ceasing your surgical career? Very unfortunate if so. -
I won't comment on Pod Surg training and rights in Aus as others know my opinions - suffice to say - its a tough and dirty game to be in and in all honesty, one must consider their priorities in life before undertaking such a thing! -
Surgical career ended for many reasons, open-heart surgery being one and a sore head from hitting walls but I am a very staunch supporter of the advancement of podiatry.
We are the only allied health professions in Australia that dare pick up a scalpel as opposed to orthotics. The physio's are yet to slice and dice but they do assure me that if and when they decide too that we will be there poor cousins and we can go back to cutting toenails. I transgress. Why we wish to reduce the sub speciality of the lower limb down to putting plastic into shoes is beyond me. We need to have excellent generalists that do everything including minor procedures (soft tissue) and physical therapy (which orthotics is just one of the tools). The average Pod that I come across these days has a very rudimentary understanding of the benefit of appropriate surgery. If we argue to the minister that we are the lower limb specialist then I hope we step up to the mark and shoulder a bit more of the burden that this really means. -
Education at the level of the division of GP's, requires "co-operation". Something that local podiatrists do not have. An undercurrent of animosity and competition exists between private podiatrists (and this appears to be the world over- not just in Australia).
Not until we make a concerted effort to break down these professional barriers, will post graduate education become more appealing. I would love to able to refer a patient to a colleague who sub specialises in a certain field. This, with today's culture cannot happen.
All of the GP's in my division get together regularly at social events. I work in the vicinity of podiatrists I was good friends with at uni, and we no longer speak. This to me is absurd. -
Unfortunately I've heard that before. It seems that their are people out there that will put personal ambition above integrity. People do what they deem necessary to get ahead. Whether it's right or not. That makes it difficult to work together.
The problem we face is that as a profession, we seem divided by those that are happy with things as they are and those that believe that to continue and survive as a profession we need to utilise our specific skill set, to make sure that we are the best health care professionals in dealing with the lower limb. I think that postgraduate qualifications are the only way we can do that.
One of the advantages that Dr's seemed to have over many other professions for a long time was the sheer length of their degree. I have a very good friend who is a GP and was asked by a pt what was the difference between Dr's and nurses, to which she replied "about 3 years". And to specialise they need to do around 6 more years in their chosen specialty.
That's where the 4 yr degree course did give us some leverage. But I do understand that the uni's are looking at a postgraduate Masters as a qualification in the future, so a 3 yr degree is a stepping stone to that.
Can anyone tell me where our interstate brothers and sisters stand with prescription rights? Last I'd heard Queensland had just given pod surgeons that right. NSW was just about to resubmit after the election, I think. Any ideas what sort of qualification we would need for that ie graduate certificate/diploma? Are any of the undergraduate degrees submitting proposals re pharmacology, anticipating a possible breakthrough regarding prescription rights? -
In NSW however we are really no closer. We have submitted the document, however it has not had an extremely good airing. I know that APodA(NSW) is now chasing this at regular intervals, but as you can appreciate in the political world time moves extremely slowly.
My personal opinion is that we need to focus about this on a National Board level as we are about to all become one big melting pot. When the Boards amalgamate the real interesting question will not be "when will NSW Podiatrists get prescribing rights?" It will be "what will happen to the states that currently already do?" I.E. Vic.
As for qualifications/courses - its anyones guess really until the National Registration takes place. This could take any number of forms and is dependant on many peoples input.
Intersting times ahead. Its a numbers game - have the numbers and you will win the battle. Maybe its time we started sharing resources with Physio's, Chiro's, Nurses etc.. who are all in the same boat as us. Take nurse practitioners in NSW for example - they have similar restrictions to Podiatrists in terms of drug use, and their situation is not much different. Maybe make them allies and use group power to push forward. I know the Health Minister in NSW was keen prior to the election at getting all allied health limited S4 rights - Roxon migh just be on the right path. -
Thanks Pauly B. I know that in SA that nurse practioners have had a breakthrough with the AMA and that is what the uni has based it's Pod Master's pharmacology course on so that the same battle doesn't have to be waged again.
So in around about way I guess we can see how if we combine forces against the dark side we may get better results.
I agree that we will have to wait and see what happens with national registration. I expect the difference between undergraduate programs may be an issue then. -
LL -
I agree. But speaking specifically of SA, they have used the Nurse practitioners course to prevent having to go up against the AMA again and then seek individual course approval. As individual states we will most definately have to start again.
Would it be better for us to combine forces? Most definately!
I do know that UoN undergrad program has made a major effort to account for the pressumed future approval of prescription rights. Which is great to see and they should be commended for. This will make it easier when the time comes for the powers that be to see new grads ready and waiting.
It's only through dynamic and progressive development of these and post grad programs, that we will be ready for any increase in scope of treatments WHEN they arrive.
:drinksLast edited: Jul 1, 2008 -
In Victoria, the legislation was enacted 12 months ago (July 1st 2007) and since then the registration board has been in dialog with the DHS bureaucrats ironing out what drugs pods will be allowed and what both the educational and experiential requirements will be. We are almost there!! Drug list almost finalised with a split between generalists and specialist pods (currently this group will only include ACPS fellows, but has the potential to grow as the Advanced Practicing High Risk Foot Podiatrists formalise things over the next 6-12 months). Education: Approved Pharmacology units, that are standard in most 4yr courses now, plus a 30 hr update, plus Advanced Life Support training. Experience: either recognition of prior experience (having worked in a hospital environment) or a mentoring approach.
Still not finalised, but soon!Last edited: Jul 2, 2008 -
Hi All
I have been reading this thread with interest, as a I'm a UK pod seeking to migrate to your lovely country!
Over here (as no doubt most of you realise) there has been a massive increase in non-medical prescribing/issuing of drugs in recent years. But has there been a corresponding increase in medication errors? I think not! (I can honestly say that when I issue POMs I check & double-check because I don't want to lose my bits of paperwork that give me the right to provide the drugs for my patients!) There must be evidence from this neck of the woods that could be used as a comparator.
Of course, the way the UK health system is set up (i.e. mostly public) was the biggest driver for change; with Blair and his 'labour' friends keen to reduce prescribing costs...
I really hope that this opportunity to provide Australian citizens with appropriate care delivered by AHPs is taken by the current government. As far as I'm concerned, the fact that I am now able to provide my patients with appropriate ABs has increased their confidence in me & reduced the burden on their GP. (Of course, over here GPs don't just hold the keys, they get paid to put them on a keyring, then paid again to prove they've put them on a keyring!)
Sarah -
Doctors do not have monopoly on care: Roxon
From Sydneys paper - SMH.
[link]http://www.smh.com.au/news/national/doctors-do-not-have-monopoly-on-care-roxon/2008/09/19/1221331206981.html[/link]
"DOCTORS face pay cuts if they insist on doing work that nurses could perform just as easily. The message, to be delivered tonight in a speech by the Health Minister, Nicola Roxon, is likely to anger the medical profession."
""Doctors must and will remain central to our health system. But to date, professional resistance and government funding have prevented the development of a health sector in which services are delivered not only by doctors, but by other health professionals who are safe, potentially cheaper and, most importantly, available," Ms Roxon says in notes for the speech."
Finally some politician see's the light in this country!!! Well done Roxon! -
Paul
Yes I read this in the Australian today.
Very much looking forward to seeing the transcript of the speech after tonight...
She certainly sounds unrelenting in her attitude to the status quo!
LL -
Hey LL,
I wouldn't normally follow ANY political debate domestically ! However, thanks to you for raising the issues involved here.
Please post again on the issue....
Have a great weekend...:drinks -
Julian said: ↑Hey LL,
I wouldn't normally follow ANY political debate domestically !Click to expand...
Unfortunately our profession in this country is essentially apolitical, apathetic and unsophisiticated in relative terms. We have a lot to learn from our American colleagues about being actice participants in the political process (including financial support to political parties - heaven forbid!).
I know, for example, the APMA has spent considerable sums on supporting the Democratic party in the US in the upcoming election. I am sure if APodC spent a few thousand dollars to attend a politcal fundraiser here and there, we would see a lot more forward progression on all of the issues we have been discussing of late. ;)
The squeaky (but financially generous) wheel always gets oiled....:rolleyes:
LL -
LuckyLisfranc said: ↑Paul
Yes I read this in the Australian today.
Very much looking forward to seeing the transcript of the speech after tonight...
She certainly sounds unrelenting in her attitude to the status quo!
LLClick to expand...
Perhaps there are some numbers we could use from our UK collegues??? They seem to have started using S4 drugs without any hiccups!!!
Cheers,
Dr. Sal (Podiatrist) -
Just received the attached PDF today - compulsory reading!
A couple of interesting extracts:
10.2 Endorsement as qualified to prescribe scheduled medicines
Clause 1.32 of the IGA (Attachment A), states:
State and Territory drugs and poisons legislation will, at the discretion of States and Territories, provide a mechanism through which suitably qualified registrants of the nursing and allied health professions may be authorised to possess, administer and prescribe scheduled medicines, with :
a) responsibility for determining the qualification requirements and endorsing qualified individuals residing with the relevant board, and
b) authorisation for particular professions (or sub-groups within professions) to obtain, possess, use, sell or supply (administer or prescribe) medicines to be granted under State and Territory drugs and poisons legislation.
Therefore, the intention is that the registration legislation work in combination with State and Territory drugs and poisons legislation to identify and authorise suitably qualified practitioners to prescribe scheduled medicines.
Proposal 10.2.1: To give effect to this, it is proposed that the national legislation make provision for a prescribing endorsement for those boards that regulate the nursing and allied health professions. This will link to various authorities conferred on identified practitioners under State and Territory drugs and poisons legislation.Click to expand...
Proposal 8.1.1: With respect to the use of courtesy titles, such as the title ‘doctor’ or ‘professor’, it is proposed that these not be legislated as protected titles, nor reserved for use only by members of one or a number of regulated health professions.
Therefore, unregistered persons using such titles would risk prosecution only where use of a courtesy title could, in the circumstances, lead others into believing the person is qualified and registered under the Act in a regulated health profession when they are not.Click to expand...
LLAttached Files:
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Thank you, LL. Very much appreciated!!!
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Here's the transcript of Roxon's speech.
Speech “The Light on the Hill: History Repeating”
20th September 2008
Nicola RoxonIt is an honour and a pleasure to be here tonight to deliver a speech in memory of one of the Labor Party’s greatest leaders, and just as importantly, one of this country’s greatest leaders.
When Ben Chifley spoke to the NSW ALP Conference in 1949 he uttered some words which have never been bettered in their clear description of the aim of the Labor movement:
“a movement bringing something better to the people, better standards of living, greater happiness to the mass of the people. We have a great objective - the light on the hill - which we aim to reach by working the betterment of mankind not only here but anywhere we may give a helping hand. If it were not for that, the Labor movement would not be worth fighting for."
They are words which every Labor politician carries in their heart. Tonight I want to talk to you about my passion for health, and why I believe that good health policy is at the heart of Chifley’s vision of “bringing something better to the people”.
Health has long been part of the labour movement. One of the reasons workers originally formed friendly societies – and in turn trade unions – was to provide themselves and their fellow workers with financial support and care if they were sick or injured.
Workers understood that good health was essential to an individual’s ability to earn a living. And this remains just as true today - health has a direct impact on workplace participation, productivity, and national prosperity more generally.
Still today health status is one of the greatest markers of inequality in our society. And while there have been many amazing medical advances since Chifley’s time, we now face a new set of challenges which threaten to entrench that inequality, while slowly destroying the health and prosperity of our community.
As you’ll see, tackling this new set of challenges in order to address age old inequalities in health status has set me on a path not dissimilar to some of my Labor forebears – who faced determined resistance in their efforts to provide cheaper medicines and universal health care – elements of our health system which have come to seem like cricket, or the Aussie BBQ – part of the fabric of our nation.
But tonight I want to explain to you why I believe the changes we’re pursuing – the next generation of health reform – will be just as important in strengthening our health system as the reforms Chifley embarked upon in pursuit of the Light on the Hill all those decades ago. And you’ll see that in order to deliver those reforms, some of the battles Labor fought in the past may now have to be fought all over again.
PBS
Take the Pharmaceutical Benefits Scheme, or PBS – which today provides around 700 drugs and more than 3,000 brands, free or at little cost, for millions of Australians every week.
It was Ben Chifley, under John Curtin, who took the stance that the new wonder drug penicillin – discovered by an Australian scientist - should be made available to all Australians - and pressed ahead with a benefits scheme to subsidise it.
The British Medical Organisation – the precursor to today’s Australian Medical Association – rose up in anger. Arguing that the Pharmaceutical Benefits Act was the first step towards a nationalised medical service, they took their opposition to the High Court, and won.
In the referendum that followed, voters agreed to give the Commonwealth powers to provide pharmaceutical, sickness and hospital benefits, and medical and dental services, with the proviso that this did not involve ‘civil conscription’.
As you know, Australians don’t like voting “yes” in referenda. Only 8 out of 44 have been successful. In this case, the public ignored the caution of the medical profession, and voted to endorse access to cheaper medicines.
By the time the Pharmaceutical Benefits Scheme came into operation in 1948, it had been passed twice, overturned once; and had been the subject of a national referendum and a constitutional challenge.
In 2008, the PBS is the envy of many nations, and is supported by the Liberals and the AMA. But what now seems like the height of common sense, took a long, determined, and quite political fight by Labor to embed in Australian society.
And for that, we have Ben Chifley to thank
Universal health care
Let’s turn then to Medicare. Everyone knows that it was Labor’s Gough Whitlam who achieved universal health care for Australians. But it was Chifley who put it on the national agenda. Much like the PBS, Chifley’s plans for health met firm resistance.
The Australian Dictionary of Biography states that Chifley’s attempt to introduce his health scheme “foundered on the intransigence of the British Medical Association in Australia”.
In this instance, his plan for a “free, comprehensive” health system was not to be. It was not until the election of the Labor Government in 1972 that a proposal for universal health insurance was revived.
In just 3 years, the Whitlam Government changed the face of the country. Whitlam and his Ministers granted indigenous Australians self determination and land rights, made tertiary education accessible to all, and introduced equal opportunity laws for women.
These were all major reforms. But ranking alongside any of them in its enduring impact on Australia was the Whitlam Government’s introduction of a universal health insurance scheme – the precursor to Medicare.
From the beginning, Whitlam’s proposal was met with strong opposition. As soon as his interest in a universal health insurance scheme became public, the Australian Medical Association voiced its disapproval.
Doctors’ groups waged an intense propaganda campaign against universal health insurance, comparing the Whitlam Government to a Nazi regime. They even raised money for what they called a “Freedom Fund”.
A set of bills to implement a universal health insurance scheme was drafted. Over the course of two years the bills were defeated by the Senate three times – the Liberals blocking their passage. Universal health insurance was among the measures on which the Governor-General granted the double dissolution of 1974.
It was only when Whitlam was returned with a victory, having campaigned heavily on health, that the bills were finally passed, on the thinnest of margins, at the first and only joint sitting of both Houses of Parliament.
The doctors didn’t rest though. They established a campaign to “fight socialist medicine and protect the freedom of doctors and patients”. They raised funds to lobby MPs. They mobilised their members.
But by this time the public was pretty determined in their support for universal health care, and by 1975, the Liberals were too afraid to try to remove it altogether.
They did try to trim back the proposal – but the election of the Hawke Government in 1983 reversed the tide once and for all with the introduction of Medicare to provide all Australians with access to quality health care, regardless of their financial means. John Howard said at the time that Medicare was an “unmitigated disaster” which had “raped the poor” – a position his Government later reversed, claiming it was the “best friend that Medicare ever had!”.
And so what we have seen, over time, is a clear cycle – Labor introduces a signature health reform; it is opposed by the conservatives, and by the medical profession; as it gathers public support, the fight is won; and the Liberals are forced to accept that the reform has won community support and a firm place in Australian society.
Today, Medicare – and its goal of providing universal access to health services for all Australians – is no longer just a program. It is now central to our sense of our selves as a nation and as a people. Again, we have our Labor forebears to thank.
Crossroads
We now stand at a crossroads. Both the PBS and Medicare are being challenged by demographic and economic trends. Without pursuing further reforms, the work that has been done by our forebears will quickly be eroded.
Without change, Australian Government spending on health is projected to almost double as a proportion of GDP over the next forty years, with spending on medicines projected to grow the fastest of all health factors.
At the same time, the invasion of our lives by chronic diseases like diabetes and heart disease – and the early death that they bring – threatens the sustainability of Medicare, and poses new challenges for the way we think about delivering health care.
Finally, in discussing the challenges facing Medicare, we must also confront the ways in which Medicare has failed us. As part of considering how we design our health system to confront new challenges, it’s time to accept that for all the benefits Medicare has delivered to millions of Australians, year in year out, there are still major health gaps we have yet to close.
We know that health is a major indicator of inequity. If you want to judge how affluent a suburb is, you could check its tax returns – or you could look at its medical records. Rates of diabetes, of heart disease, early deaths, infant mortality, how many teeth a person has left – all are clear markers of socio-economic status.
We like to think that we left class back in the twentieth century, but inequality continues to stare us in the face. To put it another way – Medicare has achieved a lot, but it has not achieved all we need it to. Just one example of the vast differences in mortality from cardiovascular disease across socio-economic groups makes the point.
Dr Gavin Turrell, a senior research fellow at the Queensland University of Technology, found that over just two years, thousands of deaths would have been avoided if every area in Australia had the same mortality rates as the most advantaged 20 per cent of areas.
Among men aged 25 to 64, almost 20,000 died before their time – because they happened to live in the wrong suburb. Similar contrasts can be discerned between rural and urban health – something that Chifley would certainly have turned his mind to.
For example, deaths from coronary heart disease and diabetes are higher in rural and remote areas. For prostate cancer, mortality in regional and rural areas is 21 per cent higher than in capital cities.
The sad fact is these facts won’t shock any of you. We all know that people with less money will die earlier. We all know that if you are less educated, you are more likely to get sick.
These facts won’t shock you – but they should. And it is of course a vicious cycle. Poor health thrives on inequality, just as inequality thrives on poor health.
This has two lessons for health policy. First, that health policy can’t exist in a vacuum. As is most clearly demonstrated by our approach to Indigenous health, we know we must simultaneously work on improving housing, education, and employment.
Second, that investing just in hospitals can play only a very limited role in addressing disadvantage. It can do a great deal of good, but the chance at early intervention, and a better life, has been lost. It is the notorious ambulance at the bottom of the cliff – not the fence at the top that stops the fall in the first place.
This means that not only is prevention a key weapon in the arsenal of health; it must also be at the forefront of reform for social democratic governments across the world, as we strive to redress inequity.
It is not only a tool of health policy; it is a crucial aspect of our wider fight against disadvantage. To intervene at a point that might actually make a difference, we must focus our efforts on prevention – teaching kids, no matter where they come from, healthy habits; educating young adults, as their bodies begin to slow, about what they can do to avoid diabetes; giving older adults the tools to prevent heart disease.
I’m passionate about this – because it will help turn around disadvantage and give people a real go at a fulfilling and productive life.
At the moment, though, Medicare and the PBS can’t help us make that leap to prevention in our health system. Our workforce, the way we fund health, and much, much more will also need to be reshaped if we are to prevent, not just cure, the illness and accidents that can afflict us all.
This must be part of the next generation of health reforms, and it is the key to achieving Chifley’s vision of bringing something better to the people.
Given the vast complexity of this agenda, I can’t go through each of the early commitments we have made or each part of our strategy to bring about this change – whether it be our new $10 billion health infrastructure fund, incentives to get nurses back into our hospitals, or the work of the Health and Hospitals Reform Commission.
But having outlined our vision, for which we have Chifley to thank, I want also to explain part of the framework which will govern our approach to achieving Chifley’s vision.
The Prime Minister has described our Government as occupying “the Reforming Centre”.
That is, we believe neither in the primacy of the market – in the treatment of people as economic units – nor in Government as the source of all wisdom.
Instead, we must strike a balance between well-designed markets that encourage innovation, and government intervention that guarantees the basic services upon which we all depend.
We must move beyond old contests – like the fight against government intervention in health services. And we must move beyond false contests, too – like the imaginary trade-off between a greater role for nurses and safe, strong patient care; or the battle between public and private health; or the division between State and Commonwealth health responsibilities.
These false divisions – often the sites of dramatic political battle - have created significant problems in the way that health services in this country are delivered. They have led to government regulation which is often poorly matched to its alleged aims, and ensured that the health landscape is dotted with badly designed markets.
By leaving old contests and false contests behind, we can focus on real challenges instead – how can we make health care more accessible? How can we shift from a focus on hospitals to a focus on prevention? How can we use health policy to tackle disadvantage? How can we deliver health care that is better quality?
Ultimately, better outcomes are what is important - and I doubt they will come from leaving markets behind or arguing for full public ownership or nationalisation. Instead, we need to ask whether we can design markets more effectively – and how we can strike the right balance between the market and government intervention to deliver the outcomes we need.
There are several areas I could use as examples of where existing markets are working ineffectively and inefficiently – to the cost of us all – and in which the balance between government and the market is currently askew.
The first area in which we must strike the right balance is in providing incentives for individuals to engage in prevention. Even when we have delivered the best health services we possibly can, we are fundamentally looking at an issue of cultural change – shifting behavioural patterns.
Government can and should help in providing the right settings, but we also need to develop ways of encouraging people to invest early, and effectively, in their own health – and getting these incentives right will be a tough challenge.
This is closely tied to the second question - how to use our health workforce effectively. If we can get this right, we can improve access to health care for people in rural and disadvantaged communities, help to tackle inequality, and make prevention far more central to our health system.
This is the next step in the evolution of health in this country. Getting it right will involve us looking at how we pay which health professionals.
Right now, the market for doctors’ services is free in many ways (with rural health often suffering as a result) yet highly regulated in others. GPs are paid for the number of patients they see or services they deliver – not for any health impact the intervention might deliver. The current Medicare structure means a GP will receive more money for seeing ten patients in an hour than they will for seeing three patients, each for longer periods.
In other words, there is a financial disincentive for GPs to provide the type of longer, intensive visit that prevention demands – like teaching somebody how to lose weight, keep fit, and avoid diabetes.
At the same time, a GP stands to benefit equally from providing care that demands their complex knowledge and training, and a simple act like refilling a prescription for, say, the birth control pill – an extremely economically inefficient proposition!
There is a longstanding historical anomaly here. Our health system, including funding for health services, is organised almost entirely around doctors, despite the fact that many services are now safely and ably provided by other health professionals – nurses, psychologists, physiotherapists, dieticians and others.
Of course, in considering any changes, patient safety and clinical quality must always remain absolutely paramount. Doctors must and will remain central to our health system. But to date, professional resistance and government funding have prevented the development of a health sector in which services are delivered not only by doctors, but by other health professionals who are safe, potentially cheaper, and most importantly, available.
In delivering change, pricing signals are likely to be needed. Doctors will need to be prepared to let go of some work that others can safely do. To ensure this transition, there needs to be an incentive for doctors to eschew less complex work, and focus on the work that does require their high level skills and expertise. Or if doctors don’t want to let go of it, to accept being paid less for devoting their highly skilled and heavily trained selves to less complex tasks than they might.
With doctors weighed down by the urgent needs of acute care, as well as unnecessary administration, we need to consider how we can unburden them of some of this work where it is safe to do so, and whether it is possible for nurses or others to take on some of those burdens – and, if so, how we make this an attractive proposition.
And in doing so, we will not only be redressing the historical bias towards medical intervention and acute care, we will be redressing the historical bias against the traditionally female nursing workforce. A few good Labor principles all tied up in one set of reforms!
This is a long term aspiration of mine – not one that can be delivered in a single Budget or without great care But it is also one that will need leadership within the professions, not just government.
Along with shifting our health system to focus on prevention, these sort of workforce changes are a key part of what I describe as the next generation of health reforms – and will be crucial in delivering better equity in health, as well as alleviating the threats to the sustainability of our system.
Reforms are needed in our hospitals as well – and this is the third area in which we see the potential for significant reform.
This may sound like heresy for a Labor Health Minister, but the truth is I am fundamentally agnostic about the division between public and private health. I believe the opposition between the two belongs firmly under the heading of “false contest”.
The nub of the problem is not that we have privileged one over the other, but that we have failed to use the competitive tension a mixed health market should provide to deliver the results we all deserve – by acknowledging the ways in which private health and public health can and do interact.
In other words, we have ignored the potential of the health market that exists right under our noses. What I want to do is look more closely at the health landscape and ensure we are using public investment wisely and private investment just as cleverly.
Let me explain how this should work. At present, the Commonwealth simply provides block funding to the States – with little incentive for the States to adopt innovative, effective practices in exchange for this money. We want to change that model dramatically – to fund States based on a combination of outcomes, activities and quality.
This will achieve two things. First, as with any classic market, it offers incentives for results – which encourages innovation.
Second, it allows the Commonwealth to direct its funding to where it will get the biggest bang for its buck. If private hospitals prove particularly adept at, say, elective surgeries, then we could consider redirecting more funding for elective surgery to private hospitals. This then has a flow-on effect. As other actors in the market – in this case public hospitals – lose market share, and therefore funding, they are forced to compete, either by developing different specialties, or by delivering better services. And that in turn drives further quality or innovation.
Similarly, public hospitals should be rewarded appropriately for the kinds of care they provide more effectively than the private sector – such as highly complex trauma care.
And of course this does not just have to be competition between private and public – it can encourage competition between public services, or between private health providers. The competition, though, will not just be about price and activity – quality and access must also be central.
As you can see, I do not take the view that public is necessarily good and private is necessarily bad – in both cases, it ain’t necessarily so. But to have that debate properly, we need to be prepared to acknowledge the true nature of private health in Australia. The fact is, in health, the private sector is not a true private sector – it is massively publicly subsidised.
This means that the industry has a special responsibility to be aware of not just their commercial interest, but the public’s interest too. To ensure the public gets something for its investment in private enterprise – for example, new ways of co-operating to provide services to those who are missing out will increasingly need to be explored.
In these three areas – prevention, workforce, and the provision of health services by both public and private providers – a confused combination of government regulation and badly designed markets can hamper our ability to deliver the health care that people deserve.
Which means health inequalities are becoming entrenched in our community.
I know that some people will protest at the very idea that health is a market. In part, they are right – it is not just a market. It is also a cornerstone of our compassionate society. In fact, this is the balance that defines the reforming centre.
What these few examples show is that both the market and the government have key roles in health – but we must be prepared to ask if we have the mix of intervention, regulation, financial support and incentives right. And especially to be prepared to keep asking what mix will enable us to provide quality care across the community and close significant health gaps in the process.
Chifley’s legacy - conclusion
This is very different, I know, to the language Ben Chifley would have used when talking about health. But the spirit is the same.
Chifley’s reforms – from post-war reconstruction through to free hospital treatment – were attempts to reshape our country for the future, and to improve the welfare of the men and women of Australia. They were new answers for a new time.
But they did not come easily. In his endeavours to strike out for something new, for that light on the hill, Ben Chifley met with stiff and determined resistance.
In short, he knew what it was to govern. The wonder of Ben Chifley was that he strode forward towards that light on the hill, whatever obstacles were placed in his path – and in doing so, he inspired the entire labour movement
This is the first Light on the Hill speech since Labor was victorious at last year’s federal election. It was a great victory. It is wonderful to be here when we sit on the correct side of the House.
But that victory, hard-fought as it was, is just the beginning. There is now much to be done. If we are to tackle inequality in this country, then reshaping health is crucial. If we are to ensure that Medicare fills the potential that Whitlam dreamed of, then there is much work ahead of us. If we want our kids to live longer, not shorter lives than us, we can’t afford to rest.
Like Chifley, we will meet opposition. But I firmly believe that it is the role of a politician not simply to allow the times to shape her, but to shape the times in which she lives.
It was George Bernard Shaw who said: “The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
On that basis, Ben Chifley was an unreasonable man – he was in fact the best of unreasonable men. I know that many of us politicians are called unreasonable from time to time. But if that is the price of change, then it is a small price to pay.Click to expand... -
LL,
Is there any reason, that you know of, that section 8.1 (Table 2) does not list "Podiatrist" as being a title to be protected?
Is this merely a result of podiatry being an after thought when being accepted into national registration scheme?
Your thoughts would be appreciated.
Clinton
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