- On March 8, 2019
- March / April 2019
We must continually strive for a health system that is patient-centred, equitable, integrated and innovative.
In the months leading up to the State Election, residents in NSW signalled health would be a key election issue in deciding how to vote. On the Federal stage, analysts also predicted health would be an important political battleground.
Ahead of the elections, AMA (NSW) prepared a comprehensive election policy that calls on Governments to strategically invest in health at what may be one of the most critical junctures in our nation’s history.
Australia has one of the best healthcare systems in the world, but we face unprecedented challenges as population growth collides with waves of baby boomers hitting 65, and the increasing prevalence of chronic disease. Overweight and obesity numbers continue to climb and we need unique whole-of-society solutions if we are to effectively alter the current trajectory. We need to adequately resource our public hospitals, and we need to concentrate on strengthening our primary care sector to alleviate the pressure on hospitals. We need better planning and a workforce strategy that addresses current shortages. We also need a system that utilises the best technology available.
AMA (NSW)’s Vision for a Healthier NSW outlines election policy priorities for both the State and Federal Government. It concentrates on three areas: Healthy Hospitals, Healthy Systems, and Healthy Communities.
1 HEALTHY HOSPITALS
A significant portion of the NSW Government’s Election Commitments 2015-2019 for Health focused on infrastructure. The Government pledged to spend more than $5 billion to build and upgrade more than 60 hospital and health services over the following four years.
Redevelopment of our State’s ageing hospitals was much-needed. The renovation of Prince of Wales Hospital, for example, was the hospital’s first substantial upgrade in two decades.
However, whilst we have bigger buildings and more physical beds, workforce shortages mean hospitals are not operating to their full potential and patient care is compromised as wait times increase.
Hospital emergency departments are swamped by increasing numbers of patients. The increased demand is affecting the ability of medical professionals to cope, and patient care is being compromised. There is no longer reserve in the system and doctors fear hospitals are at breaking point. We need better solutions, and we need to address workforce shortages.
Transformation and strategic planning is necessary if NSW is to adequately meet the future healthcare demands of residents. There are currently 31 specialties listed as ‘oversubscribed’ (more applications than training positions).
Conversely, there are 19 specialties currently ‘undersubscribed’, and just three listed as ‘in balance’ – endocrinology, obstetrics & gynaecology, and public health medicine.
Careful planning needs to be done to ensure NSW Health meets its objective to deliver ‘the right care, in the right place, at the right time.’
AMA (NSW) also recommends greater support and funding for GP training in hospitals, as a means of improving care for patients.
Workforce projections show the following specialties will be in shortage in 2025 compared with their current position, if recent trends in supply and demand continue:
- Obstetrics and gynaecology
- Anatomical pathology
- Diagnostic radiology
- Radiation oncology
The situation is particularly dire with respect to psychiatry and surgery. With regards to psychiatry, to meet the expected undersupply projected by 2030, the new intake would need an average annual increase of 3.3%. In terms of surgery, it is conservatively estimated that 264 new surgeons will be needed each year between now and 2025. That is, in addition to the 184 new surgeons currently graduating each year, a further 80 will have to graduate alongside them.
Aside from positions of shortage, NSW needs a workforce plan to ensure new specialists are able to access appropriate appointments in our public hospitals. These should be new, substantive positions to ensure a continuation of the public and private service model.
In 2012, the NSW Government introduced a new wages policy which has severely restricted any prospect of modernising the Public Hospital (Medical Officers) Award.
The changes in policy and regulation prohibit NSW Health from changing conditions of employment which will
increase salary-related costs by more than 2.5% without equivalent cost offsets. The independent arbiter – the Industrial Relations Commission of NSW – is also restricted and not allowed to change Awards or make orders which are inconsistent with this policy.
While this policy has implications for all hospital doctors, the impact has been most significant on doctors-in-training. This is a major barrier to creating a safe and fair working environment for doctors-in-training.
The Coalition Government has taken steps to improve industrial arrangements, particularly in relation to the impact of excessive hours of work and improved policies relating to unrostered overtime. However, issues such as access to appropriate facilities (accommodation, common areas, sleeping spaces) within hospitals, financial support for training, and access to leave, remain unsolved.
We call on the parties to recognise the important contribution of doctors-in-training in terms of both service delivery and as part of our future specialist workforce. To support this, the industrial arrangements for doctors-in-training should be improved to:
- Allow doctors-in-training to conduct a work value case to assess the current value of their contribution to the NSW public health system.
- Provide doctors-in-training with access to exam and conference leave. NSW is the only state in Australia to provide no support to doctors-in-training for professional development. Every other state provides doctors-in-training with dedicated leave. Access to such leave would allow for better planning by health systems and would recognise the stress associated with undertaking exams.
- Provide doctors-in-training with financial support towards training. Doctors-in-training in the ACT are able to access up to $6,124 per annum in training expenses; in South Australia, they can access up to $8,000 per annum. In NSW, doctors fund even the most basic of training requirements.
- Ensure appropriate arrangements for supporting doctors-in-training while they are on-call. There are no current protections for NSW doctors-in-training on-call. Victoria and WA have detailed Award protections to limit excessive hours and on-call and call back requirements. NSW should review and implement best practice policy on on-call, call back, and protection from excessive hours.
- Unaccredited registrars should not be rostered on less favourable terms than accredited registrars.
- Doctors-in-training should have rights to specified facilities, including break rooms, sleeping spaces, and secure accommodation.
Doctors’ health and wellbeing
The restrictions created by the wages policy also impacts the health and wellbeing of doctors-in-training.
AMA (NSW) conducted its second annual Hospital Health Check survey last year, which surveyed 1351 doctors-in-training in NSW about conditions at their hospitals.
Doctors-in-training gave two different hospitals a failing grade in reference to staff wellbeing. These are notable not just because they are failing grades but because they are the first Fs awarded by the HHC in NSW.
Westmead and Wollongong were both given Fs for wellbeing, which relates to bullying, support for mental health issues, and reporting of inappropriate behaviour.
Clearly, more work needs to be done to improve wellbeing in NSW. Doctors’ health and wellbeing isn’t just an issue for junior doctors, but is something all doctors at any stage in their career may face. While we acknowledge the efforts to reform National Law and the commitments of Ministers, AMA (NSW) recommends NSW review a new model governing mandatory reporting to remove the barriers for doctors with mental illness seeking proper medical care.
2 HEALTHY SYSTEMS
There is a strong need for integration and collaboration on the delivery of health services in NSW. Healthy systems involve taking a strategic approach to health planning, as well as building the technological infrastructure to support better communication.
AMA (NSW) recognises the benefits of the NSW Government’s policy to devolve authority and responsibility to Local Health Districts (LHDs). This transfer of management has allowed LHDs to deliver healthcare services appropriate for their local populations and removed unnecessary management.
However, certain health services require a coordinated approach.
Specifically, AMA (NSW) has identified the need to create a framework for these crucial services:
- Obstetric transfers
- Interventional radiology
There is a strong need for integration and collaboration on the delivery of these health services.
The health system needs strategic planning, with an emphasis on forecasting service requirements as the population of NSW grows.
Children and families in NSW deserve quality care that can be delivered close to home.
The crisis in paediatrics was identified in 2008 by Peter Garling SC in his report to the Special Commission of Inquiry, which noted:
“The specialist children’s hospitals become overloaded, and this delays the delivery of tertiary care to the babies and children who really need it. Surgery and other types of treatments are consequently being delayed.”
In 2014, NSW Health developed the “Surgery for Children in Metropolitan Sydney: Strategic Framework in response to the Garling Report.
However, the problems first noted more than a decade ago continue to plague the system.
AMA (NSW) strongly recommends an independent review into paediatrics be established to examine how to best deliver services in NSW.
We live in an information age where there should be no excuse for delays in clinical decision-making because of delayed access to important information.
Patients and doctors expect a system that allows healthcare providers to communicate with each other in a glitch-free, secure and seamless fashion.
Continued reliance on old technology is compromising communication between healthcare providers. The State and Commonwealth should work together to plan for and invest in a comprehensive IT strategy that integrates hospital and specialist, GP and other health practitioner services.
The fax machine
The health system’s ongoing reliance on the fax machine as a secure means of communication is confounding, given the technological advancements that have been embraced by Australian society in almost every other facet of life.
The transmission of information through fax machines is secure, but security and patient privacy cannot be guaranteed once that information has been printed on paper and left on the fax machine in-tray. Hospital doctors often need the same information faxed multiple times because they have not been sitting at a fax machine when the information was sent through and someone else has picked it up accidentally, misplaced the paper, or thrown it out.
A modern health system demands a means of communication that is instant, secure, paperless, and allows for two-way communication. At best, fax machines meet half that criteria. AMA (NSW) recommends the State Government relegate the fax machine to medical museums.
In addition, AMA (NSW) recommends the State Government look at alternatives to pagers, which are also considered relics of a bygone telecommunications era. From a practical standpoint, pagers do not facilitate two-way communication thus limiting their appeal in light of better alternatives. They are also not a fail-safe back up. Should other devices be used to replace pages, investment into Wifi is needed to ensure doctors can reliably connect.
Anecdotal evidence suggests doctors are using alternative methods, such as WhatsApp, to communicate. A secure application, which could be used within hospitals to share necessary patient details and photos, should also be a priority. Ideally, the solution would enable users to send photos securely to a hospital’s medical records department to upload into a software product such as Cerner.
Compatibility and speed
Compatibility between existing software systems appears to be lacking. The amount of time wasted trying to access relevant patient information is a source of significant frustration among hospital doctors and administrative staff.
Examples of this include the incompatibility between PowerChart and eRIC, which has a different eMEDS system. Another example is eMaternity, which isn’t compatible with PowerChart. It’s not just a nuisance for clinicians – there is a real danger that vital patient information will accidentally be omitted when clinicians are forced to switch between systems.
The utility of software programs is compromised when they don’t work seamlessly together. Clinicians note that in some circumstances it’s slower to use electronic documentation systems than it is to write clinical notes on paper.
Time lost logging in and out of programs is another complaint. Despite widespread use of Cerner across hospitals, many computers don’t have the application installed locally. As a result, clinicians must access Cerner via a Citrix system. Valuable time is wasted, as each interaction with the software takes an additional three to four minutes. In an era of instant connectivity, and in an environment where response to patients is time critical, this delay is unacceptable.
Any new system should be designed with clinician input and developed to accommodate workflows. Clinician approval of systems is also key to the success of future systems.
In addition to investing in infrastructure, AMA (NSW) suggests there needs to be a similar investment in training.
Most laboratories have the capability to send results electronically, but not all do. As a result, doctors report it is sometimes quicker to retest, rather than chase results via fax or mail. Making it compulsory for labs to transmit results electronically would significantly cut down on some of the redundancy within the system. This failure to use available technology is also a problem for some hospitals which have the capability to send discharge letters electronically to GPs, but do not have updated details of the recipient.
While it is easy to identify what doesn’t work, AMA (NSW) acknowledges that it is harder to find solutions to these problems.
One area to pilot a shared IT solution would be in maternity shared care. This care is often shared over GPs, hospital clinics, hospital and private pathology, hospital and private radiology, and sometimes private specialist practice.
Women still carry around a yellow card and providers are required to duplicate entry of data onto their individual systems. This duplication is a waste of time and effort. A platform that works seamlessly across all providers’ systems would be a good solution.
3 HEALTHY COMMUNITIES
There are many aspects to building healthy communities. Increasing the availability of nutritional food, opportunities for exercise, wellbeing awareness – these are just a few of the critical components to maintaining the overall health of NSW residents. Just as critical as providing and supporting these aspects of health, is the need to ensure access to these essentials is equal, and extends to residents in rural and regional communities, Indigenous Australians and those in the justice system. Underpinning all of this is a strong primary care sector.
Primary health care (PHC) is the frontline of the healthcare system and the first level of contact. It is scientifically sound, universally accessible and constitutes the basis for a continuing healthcare process. It provides comprehensive, coordinated and ongoing care by a suitably trained workforce comprised of multidisciplinary teams supported by integrated referral systems.
Strong primary care is central to an efﬁcient, equitable and effective health system.
General practice is the cornerstone of successful primary healthcare, which underpins population health outcomes and is key to ensuring we have a high-quality, equitable and sustainable health system into the future.
Australia needs a comprehensive national primary care framework to improve patient care and prevention. There should be formal agreements between the Commonwealth and States to improve system management; and new funding, payment and organisational arrangements to help keep populations healthy and to provide care for the increasing number of older Australians who live with complex and chronic conditions.
The Commonwealth needs to deliver real resources to frontline GP services. Whereas spending on general practice services represents around 8% of total Government spending on health and this proportion has remained relatively stable despite a growing workload, this figure should be lifted over time to around 10% as part of an effort to re-orientate the health system to focus more on general practice, with long- term savings to the health system anticipated in return. Simple reforms to Australia’s health system could help save more than $320 million a year on avoidable hospital admissions and provide better care for people with diabetes, asthma, heart disease and other chronic conditions.
Integrated care is a much talked about buzzword in health policy, but remains a lofty ambition. Attempts to implement integrated care are often relegated to pilot projects that are too small, too under-resourced, too vague or too undermanaged to be effective as a system-wide approach to innovative healthcare. To successfully provide coordinated, seamless care, NSW needs to develop a practical approach to implementing integrated care programs across the State, and back these programs with adequate funding and resourcing.
Rural, Regional and remote health
A major funding commitment from the NSW Government is required to enable regional LHDs to address the inequities between regional and metropolitan access to specialist services.
The relative spend per individual through the Medicare Benefits Schedule in 2014-15 is $536 in remote areas, compared to $910 in major cities. This is equal to approximately 10 MBS services annually for people in remote Australia compared to 17 MBS services for people in major cities.
The National Rural Health Alliance suggests, “if the difference in MBS spending between the major cities and remote communities was made to remote health providers for service delivery, it would provide an additional $193.7 million per annum based on the 2015 population estimate. Such funding could be used to expand alternative models of health service delivery which have been implemented in remote communities.”
Despite record numbers of Australians entering medical programs over the past 15 years, and a commensurate and considerable expansion of graduations – we still face a rural doctor drought.
Failure to put in place strategies that will attract and retain medical graduates to positions in rural and regional NSW is not only a loss to those residents, but a waste of the money invested in medical education.
A regional and rural workforce strategy must be: safe, secure, supported and supervised.
Almost half of Australians will experience a mental health disorder in their lifetime, and yet mental health services remain underfunded, badly resourced and poorly structured.
In many communities, public hospital emergency departments are the only service option for people experiencing an acute mental health crisis. However, public hospitals are not adequately resourced to address the needs of mental health patients. People with acute mental and behavioural conditions are not treated within the clinically recommended timeframe of 30 minutes; AIHW figures reveal 90% of people presenting with acute mental health crises left emergency departments within 11.5 hours, and almost 7,000 people who sought help from emergency departments for their acute mental and behavioural condition left before finishing treatment.
Long delays in treatment reflect shortages in mental health staff and constraints on admission capacity of hospitals. Additional and timelier access to acute care in public hospitals is required.
AMA (NSW) suggests transition care services need better support. Step-up and step-down high acuity residential care and resourced coordinated services under appropriate medical oversight are important alternatives to inpatient admission or for earlier hospital discharges.
Mental health workforce
AMA (NSW) backs calls for increased numbers of funded psychiatrist trainee places, along with an increased investment in workforce training and support for other mental health workers, especially mental health nurses. Of particular concern is the maldistribution of psychiatrists, psychologists and other mental health service providers in regional areas.
Other frontline workers, including Emergency Department staff, GPs, paediatricians, psychiatrists as well as psychologists and mental health nurses must be supported.
There remains an unacceptable disparity in health outcomes for Aboriginal and Torres Strait Islander people. AMA (NSW) is committed to working in partnership with Aboriginal and Torres Strait Islander groups to advocate for State Government investment and co-ordinated strategies to improve health outcomes for Indigenous people.
The AMA has called on the Federal Government to commit to equitable, needs-based expenditure that recognises the Aboriginal and Torres Strait Islander burden of disease is 2.3 times greater than the non-Indigenous burden.
AMA (NSW) supports the principle that Aboriginal and Torres Strait Islander people have a leading role in identifying and responding to the nature and challenges of Aboriginal and Torres Strait Islander health, and that the medical profession has a responsibility to partner and support these efforts.
Unprecedented growth in NSW’s prison population is affecting medical professionals’ ability to adequately address their healthcare needs. Of particular concern is the inability to cope with patients with mental health needs. Furthermore, improving healthcare for prisoners benefits the wider community and reduces recidivism.
The disparity in health between prisoners and juvenile detainees when compared to the wider community is stark. They are a highly vulnerable population. Prisoners and detainees have significantly higher health needs than the general population. They face higher levels of serious health conditions such as cancer, heart disease and diabetes, as well as poorer dental health, and a higher prevalence of disability, communicable diseases, and mental illness.
Many of those who become incarcerated have fallen through the gaps in access to community-based health and social services, including services for mental health, substance use, disability, family violence, and housing. Imprisonment can exacerbate and further entrench the social and health disadvantages that led to their imprisonment.
There is an opportunity to reach people in prison who have previously been unable to access health services. Addressing these health inequalities in prison has wider benefits for the general population, as improved healthcare to those who have been in custody reduces the likelihood that they will re-offend.
The steep increases in prison populations have put tremendous pressure on the system, and the risks that this imposes on both prisoners and staff cannot be ignored.
Funding has not kept pace with the increase in the prison population, and inadequate medical staff-to-patient ratios are compounded by lack of access to beds.
There are insufficient forensic mental health beds in NSW – particularly medium secure and low secure beds. As a result, forensic patients are detained in prison without receiving appropriate treatment.
Obesity is a national crisis and deserves a response that is commensurate with its prevalence and impact on individuals and society. Overweight and obesity was responsible for 7% of the total health burden in Australia in 2011, 63% of which was fatal burden.
Eating habits and levels of physical activity are influenced by many factors, including the health and behaviour of parents, genes, weight at birth, wealth, the social environment, the availability of healthy food and opportunities for activity.
As a result, a multi-pronged, whole-of-society approach is needed to adequately address this burgeoning problem.
Australia needs a strategic national plan to combat obesity that is coordinated by the Federal Government. The plan must outline specific national goals for reducing obesity and its health effects.
Government has the unique ability to influence and regulate people’s behaviour through the use of taxation, financial penalties and incentives, subsidies and market interventions, policy and legislation, which can all be used to steer people into making healthier choices.
In addition, Governments at all levels should use available policy, regulatory and financial levers to improve overweight and obesity rates in the community.