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Health, healthcare and politics

The following is a transcript of the speech given by Leader of the Australian Greens Richard Di Natale at the Population Health Congress 2015 held in Hobart.

Today, as a Federal Senator and now the leader of a political party I want to talk to you about health, health care and politics. Like it or not, politics matters. The decisions politicians make fundamentally affect peoples’ health.

Sir Michael Marmot’s work on health inequalities has been the holy grail of health policy for the last 30 years, helping us understand that it’s the conditions of daily living that determine a person’s chances of maintaining good health.

Health doesn’t exist in isolation. It’s not simply the function of good healthcare. This became truly apparent to me when I was working in general practice and public health, particularly in the Northern Territory.

Working in an Aboriginal health service in the NT, I came to appreciate that writing a script to help treat an Aboriginal man with chronic diabetes or travelling for hours just to dispense eye ointment, was not addressing the reasons that made people sick.

I came to really understand that if we are to make real progress in health, we need to address those factors that lie outside the health system.

Our efforts as health professionals are futile unless we also improve people’s access to housing, education, clean air and water, secure employment, and participation in community life.

The reality is that inequalities in health arise because of inequalities in society. Reducing health inequalities is a marker of our progress towards a fairer society. At its core, health is a social justice issue.

And that is why I ditched my stethoscope and became a politician.

Like it or not, politics matters. The decisions we make every day impact fundamentally on the lives of all Australians and on the work that many of you do.

So let me outline, quite explicitly, some of those things that I believe are the ingredients for a healthier society and what I am trying to do in my role as the leader of the third major political party.

Studies show that by 2025 there will be around 37 cities with at least 10 million residents; and by 2050, says a United Nations report, 75 per cent of the world’s population will live in interconnected cities.

Urban planning plays one of the most important roles in enabling us to have healthy, happy, active lives. Many of the levers here lie with state and local government. Open space. Active travel. Public transport. Local services and amenity.

Some progress was being made under the previous government with the development of the National Urban Policy and a number of supporting programs, which focused on liveable, sustainable cities

The Greens have shown, through Scott Ludlam’s ‘Transforming Perth’ report for example, our commitment to healthy places.

The Federal Government is taking us in the opposite direction. They are funding roads over public transport and ignoring evidence-based advice. They have ripped funding out of homelessness services and on any given night in Australia more than 105,000 people find themselves homeless. That’s 1 in every 200 people. Over a quarter are children under the age of 18, most are victims of domestic violence.

There are solutions to poverty, homelessness and intergenerational inequity. With political courage we can reform negative gearing and the capital gains tax to fund homeless services and more public housing.

It’s not just about the physical environment. The society we are born into is just as important as our surroundings. In Australia we are facing rising inequality. There is a tendency for markets to exacerbate inequality.

Governments have a role to play here. We have a role to play with progressive taxation, income support for those with less, Newstart, good quality education and accessible tertiary education.

If we do nothing about global warming, then all the rest is background noise.

We are fundamentally changing the life sustaining systems that support us. Global warming impacts on every aspect of our lives, including our health. Global warming will lead to more extreme weather events like droughts and fires and natural disasters which result in injury and death. Global warming will also lead to more extremely hot days which will particularly impact on the very young and the very old.

Finally, let me spend some time talking about our health system. There is an ongoing debate in the federal parliament about whether health spending is sustainable.

We spend about 9% of our GDP on health. That’s below the OECD average and almost half what the US spends which sits at close 18%.

While the 9% we spend is up from 8% a decade ago, the proportion of commonwealth spending has actually been stable for several decades.

So I wonder why we don’t already think it’s OK to increase that expenditure to 10% if we view health as a public good.

I ask again, ‘what price do we put on good health?’

It is true that over the next decade we’ll see more demand on health care, which may take the proportion we spend on health closer to the OECD average, somewhere around 10% of GDP.

Some of that increase is a consequence of an ageing population but most of the projected increase in spending is fueled by new health technologies, new diagnostic imaging techniques, new treatments and new medicines.

So in a decade we’ll be spending close to the OECD average on health, about half what’s spent in the US and we’ll be doing that to give people access to health technologies that help people live longer, healthier and more productive lives.  I don’t consider that to be a crisis. I believe it’s something to celebrate.

The question of sustainability is a values question, not an empirical one. It’s sustainable if we choose to continue funding it.

I believe that the purpose of human progress, of continued economic growth is to be able to spend money on the things we value. Given that people almost universally identify good health as the thing they value most in life then what could be more important than spending that dividend of sustained economic grown on providing people with access to health care.

But we are at a crossroads. We are faced with some important choices. We can choose to give people access to universal health care so that they can live longer and healthier lives or we can choose to ration health care through price barriers such as co-payments in an effort to rein in health spending.

So my blueprint looks a little like this.

Let’s start with a much bigger investment in health promotion and illness prevention. Rather than dismantling the only health agency with a dedicated focus on prevention and taking money away from prevention programs delivered by state governments, which the current government has done, let’s increase our investment.

We know what works.  A combined Deakin and Queensland universities report found the 20 best prevention interventions would cost $4.6 billion to fund but return $11 billion in health savings. There’s a lot of low hanging fruit when it comes to serious public health issues like obesity and alcohol related harm.

Primary care and General Practice is the cornerstone of good medical care and is another cost effective investment. The focus of health policy over decades has been to try to improve access to primary care in an effort to better management of chronic disease and keep people out of hospitals. It’s better for patients and better for taxpayers.

Unfortunately there seems to be a view that there are too many visits to GPs. While it is true that some visits to a doctor might not be necessary patients often don’t have the expertise to make an assessment about what illnesses need medical care and what illnesses are self-limiting. Making that assessment and providing reassurance is an important function of general practice. The problem with co-payments is that they are a blunt tool, while they might deter some visits that might not be deemed necessary they also deter necessary visits, sometimes resulting in expensive hospitalisation and higher costs. If you’re on a low income, you’re more likely to have lower health literacy and higher burden of chronic disease which compounds the problem. We also know that some people will simply choose to use Emergency department as GP clinics.

That’s not to say primary care is perfect. There are things we can do better.

I am concerned about the growing corporate creep into healthcare. The Deeble Institute just published a paper that addressed the growing corporatisation of health care in Australia.

I know here in Tasmanian there is pressure on General Practice to maintain existing work structures with the removal of retention grants. I get calls from doctors talking about the pressure they are under to provide a service to those who are most marginalised at the same time as corporate providers are lining them up with offers to come and work in an environment where pathology referrals are the priority.

We may not have to look at the US experience to see what happens if we put profits ahead of health outcomes. In dentistry we have 90% of the providers yoked to health insurers with just 10% left to work in the public system. It’s a scenario that means there are 650,000 people on 18 -24 month waiting lists.

Primary care is often fragmented and uncoordinated. The attempt to improve this through Medicare Locals by the previous government and more recently through the unnecessary change to Primary care networks by the current government is a worthwhile effort and should be supported.

We also need to develop better models for addressing the huge and growing burden of chronic disease. It’s time to start looking at population based funding to complement fee for service for GPs in primary care. We must address the deficiencies of fee for service, it’s not the right model for chronic disease.

We should be funding what works. A lot of what we do in medicine adds very little value. We need to take a tough look at what we currently fund and make changes. A number of things come to mind – Vitamin D testing in general practice, knee arthroscopies, complex prostatic surgery and the proliferation of sleep studies. All areas we should be looking at.

Too many MBS item numbers haven’t been assessed for years and are funded based on old technologies and we need to get better at assessing new health technologies. We should develop a process for funding medical interventions that is as rigorous as the PBS.

One of the great challenges in health care is to address the perverse incentives that shift costs between different jurisdictions in health. I simply can’t make any sense of the change in funding for our public hospitals. The National Health Reform Agreement wasn’t perfect, but at least we made a start in injecting more transparency in the way our hospitals are funded. It’s hard to see how ripping up the HRA with 50/50 costs met and ABF won’t return us to the bad old days of the blame game. I think the time has come for a single funder for our health system.

Time and again I point out that health funding arrangements are unnecessarily complex; they lack coherence and transparency, and involve duplication of funding in some areas.  There is an imbalance between the funding responsibilities of the Commonwealth and state and territory governments across the health sectors.  The current health funding system makes it almost impossible for governments and policy makers to decide how best to fund healthcare.

Healthcare consumers should be able to access the appropriate services, treatments and high standard of care.

The Australian health system should be built around the simple objective: the right treatment, at the right time, with the right practitioner.

The issue often neglected in health reform is the degree to which individuals are protected from financial hardship when they access the healthcare system. Out-of-pocket health spending comprises 18% of total health spending in Australia, and continues to rise.  For dental care, out-of-pocket spending comprises 56.8% of total dental costs. Co-payments for medications are amongst the highest in the OECD and continue to rise.

These gaps in financial protection mean that some Australians experience significant financial hardship as a result of healthcare costs.

As for health outcomes, significant disparities also exist in terms of financial protection. People who have more chronic health conditions experiencing greater levels of financial hardship (30.5% of those with 5 or more chronic health conditions spent over 10% of household income on healthcare, and 18.6% spent over 20%). Those on lower incomes spend a higher proportion of income on healthcare than those on higher incomes. In 2009, the majority of with mental illness reported that they often had to choose between paying for health care and other essentials such as food.

Out-of-pocket costs not only cause financial hardship, but also prevent people from accessing care in the first place. In 2010, 8% of people had serious problems paying medical bills or were unable to pay at all, and 36% of Australians felt that they would not be able to afford needed health care. 30% adults and 14% children avoid dentist due to costs, with higher avoidance by those without private health insurance. In 2009, 54% of people with mental illness were unable to afford recommended treatments, and 42% had not filled prescriptions due to cost. In 2011, more than 92% of GPs encountered patients who had difficulty paying medical expenses; 64% believed that patients had suffered adverse outcomes as a consequence.

What price do we put on good health – at the moment it’s about $150 billion but there are real savings to be made such as reforming our drug purchasing process, bargaining harder on generic drug prices, and encouraging drug substitutions.

Under current public hospital funding arrangements, the “national efficient price” pays extra for complex patients, regardless of whether the complexity is caused by things that happened after the patient was admitted or whether they arrived at the hospital in that condition. Why do we still pay more to hospitals which have higher rates of mistakes or mishaps? I have spoken about other examples of waste earlier and getting rid of waste sounds easy, but every dollar of health spending is someone’s dollar of income, and there are plenty of vested interests who want to keep their revenue stream.

Richard Di Natale

Dr Richard Di Natale is the leader of the Australian Greens. He was elected to the federal parliament in 2010 and is the Greens' first Victorian Senator. His portfolios include health, multiculturalism, youth, gambling and sport. Prior to entering parliament, Richard was a general practitioner and public health specialist. He worked in Aboriginal health in the Northern Territory, on HIV prevention in India and in the drug and alcohol sector. His key health priorities include preventative health, public dental care and responding to the health impacts of climate change.

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