There are signs that the Federal Government is gearing up for health policy changes.  Early in March Peter Dutton, the Minister for Health, when addressing a conference of general practitioners, made it clear that health workforce planning was on the agenda.  Later he floated the idea of a co-payment for GP visits to deliver a price signal to consumers to deter excessive consumption associated with the growing practice of bulk billing.  According to the 7.30 Report on 18 March bulk billing has increased from 50% to 83% of GP visits.  The show featured Terry Barnes a former advisor to the current Prime Minister when he was Health Minister.  According to Barnes, not only is there a need to make Australia’s health care system more efficient, but also we need to lower the expectations of Australians.  Currently they want a Rolls Royce, he said, but we can only afford a Kingswood.

Barnes touched on medical waste.  It has been estimated that between one-third to one-half of all US health care spending is on services that lack evidence of producing better health outcomes than less expensive alternatives (Health Policy Briefs, Dec 13, 2012).  Causes are: not using best practice, lack of co-ordination of care, eg duplication of investigations, overtreatment, overly complex administration, inappropriately high prices and fraud.   On the 7.30 Report, Paul Gross, a leading Australian health strategist responded to Barnes’ comments by saying that a good way to address high health costs would be tackle adverse health events.  According to Goss one in ten admissions to hospitals are due to complications arising from previous treatments.

It is good to see the new government stimulating discussion on future proofing Australia’s health care system.  Hopefully it will lead to action.  For my money there has been very slow progress since the Productivity Commission released its 2005 report on Australia’s Health Workforce and the National Health and Hospital Reform Commission report was finalised.

But where is the medical leadership?  Time and time again in health we have seen that without the contribution of everyday clinical leaders – not the Ministers and Directors General of Health, but the Heads of Urology, or Gastroenterology, Paediatrics or Cardiology, in the Sir Somebody Important Hospitals dotted around the country – we are not going to see change.

Yet it is possible to engage these busy, committed professionals in innovation of health services.  Clinical-led programs to reduce medical waste in the USA and UK have been effective.

Medical colleges could potentially contribute more to health workforce planning and innovation in health services.  And the RACP, with its broad range of practice covering a variety of settings:  hospitals, workplace and other community settings, in particular.

Recently I have had reason to talk to trainees in the RACP.  These young post-graduates want different things to the previous generations of specialist doctors.  For a start, quite sensibly, they want a better work-life balance: both men and women.  Forget working 80 hours or more a week. They are interested in more varied careers, they want more options other than a railway track to super-specialisation.  In short they are open to re-thinking their roles.  We should run with this and start planning for more flexible roles and training programs by allowing trainees to select modules from a variety of streams.  Most of all we should teach tomorrow’s medical and other health leaders how to innovate health services.

Health innovation without clinical leadership may happen, but it will be the poorer for it.

Nick Talley, Chair, RACP Working Party on Governance Reform has issued a consultation paper on board reform. I think its strengths are that it has gone back to basics. The paper is not offering a couple of options to choose from. Instead it has gone back to the issues. Clearly the Working Party is open to receiving other ideas beyond the six options offered in the paper. Another strength is the structured consultation process proposed. This will see over 20 meetings held around the country to obtain input on this topic. As a piece of communication however, this is not a good document. It is too long and too complicated. I doubt that many members of the RACP will have the inclination or the time to wade through it. The proposals simply do not relate to our way. For example the section on diversity talks about gender, ethnicity etc, but fails to mention the single most important aspect of diversity for us – our diverse practice contained within the RACP. We need to comply with corporate law, but we need to work towards it in a way that relates to the needs of a membership based organisation. As a colleague who has extensive experience in working with such organisations said to me, ‘we are not dealing with products here, we are dealing with peoples’ professional lives’.

Nevertheless this work should be sufficient to stimulate some good conversations in the fora.

What do others think?

This week the Grattan Institute got some good coverage in the media for Stephen Duckett’s latest report Controlling Costly Care: A billion dollar hospital opportunity (http://grattan.edu.au/home/health).  In this report the authors argue that activity based funding by which hospitals are paid, could be made more efficient by removing outlying inefficient performers in determining the average costs.  Many people in the RACP would be aware that there is growing attention to the issue of ‘medical waste’.  One of the more interesting approaches has been to involve clinicians themselves in identifying ineffective treatments.  Programs in the USA and the UK have been established in which evidence and expert opinion are called upon to determine ineffective services which are then discouraged.  With the new Government starting to float policy directions for health surely it can only be a matter of time before medical waste comes onto the agenda, and why not? It seems a sensible approach to me.  If so, is this an area the RACP could play a role?

As I phone and email people to canvas views on the future the College it is clear that the role of the College and how it functions are issues of concern.  I spoke to someone in private practice, who is involved in some innovative health businesses, who does not think the health of Australia is business for the College.  He thinks that the College should stick to matters that directly affect the practice of members and their patients.  He agreed however that the future roles of our members in the health workforce of the future was important, and a good subject for discussion.  Another person I spoke to, from one of the Faculties was concerned that the management of the College had become too centralised, with insufficient support and budget for decentralised activities by the various groups that make up the College.

Caught up with Elaine Siggins, CEO of the Gastroenterology Society of Australia the other day.  She said that there is a lot of discussion in GESA about the issue of nurses undertaking endoscopy.  Some members are in favour and others are not.  Even the pro camp is divided:  some think this would best be done by nurse practitioners, who work autonomously and others think that it would be better to have practice nurses who work under supervision.  I recall presenting on UK nurse endoscopists at the GESA conference in 2005 or 2006, so it is good to know the conversation continues.  A comment I often hear is that most Fellows of the College devote most of their collective energies to their specialist societies.  However health workforce reconfiguration, such as the introduction of nurse endoscopists, is an issue common to many specialties.  Perhaps we should be coming together to have a broader debate, say on physician assistants.

Is this an example of where our College could be greater than the sum of its parts?

Recently I spoke to Paul Zimmett, a leading expert in diabetes in Australia and the rest of the world, and a Fellow.  As many of you will know he is very active in the creation of policy in this area at both State and Federal Government levels. I got the impression from him that the RACP was not currently an active player in this area.  Surely we have a lot to offer.  We have members who are doing research in this area, clinical experts – in both paediatric and adult medicine, public health experts in the promotion of healthy eating and physical activity, clinical experts in the management of the consequential diseases.

Is this an example of where our College could be greater than the sum of its parts?