The National Rural Health Alliance’s annual dinner in Canberra last night was pumping (please see bottom of the post for details of the revolutionary chanting that was going on).
Just a few weeks ago, rural health barely rated as an election issue.
Yesterday the three independents met with NRHA leaders for their advice on what to demand for rural health in their negotiations with Julia Gillard and Tony Abbott. The trio apparently wanted precise, achievable and measurable outcomes – and not a wish list that might come to nothing without the backing of the states.
Apparently they were told that the number one issue for rural health is affordable access to broadband. And that it needs to have reach into remote areas, where the need is greatest. Broadband is not only important for delivering health and education services; if communities don’t have it, they will struggle to attract health professionals (and probably other workers too).
Dental health was also high on the list of NRHA priorities. Dr Jenny May, who has just been re-elected chair of the NRHA and is currently a resident of Alice Springs, knows Tony Windsor well from her time in Tamworth, where she has previously worked for some years.
It seems a touch ironic that we might finally get some political focus on health equity as a result of the hung Parliament, after more than two years of health reform labours failed to propel equity concerns to centre stage. Mind you, the rural urban divide is not the only example of health inequities, and it would be a shame to lose sight of some of the other areas of need.
Meanwhile, below are two posts offering various perspectives on health election issues. Dr Richard Lunz, a NZ-trained doctor working in occupational medicine in Victoria, calls for fairer treatment of overseas trained doctors, while Timothy O’Leary from Planning for a Healthier North (an alliance of health care providers in Melbourne’s northern suburbs) suggests that we may be headed for incremental reform, no matter who wins government.
A Kiwi’s letter to Australia
Dr Richard Lunz writes:
Congratulations on your election. It seems you have given the two main parties a ‘no-confidence’ vote!
Time for the independents and The Greens to set the main parties straight for a new path for a measured, evidence-based approach to policy and planning
I am a doctor working in Health Policy, Occupational and Environmental Medicine and Farmers/Rural Medicine.
But I am also an overseas-trained doctor (OTD) and or an International Medical Graduate (IMG) – or a doctor with a non-Australian primary degree.
I also happen to be a Kiwi, but once again my primary degree is the issue. This means I cannot work in some areas or in some parts of the health sector.
This despite 20 years in medicine and with several degrees from Kiwi and Aussie Universities. And having registration from the UK and NZ and having worked here in Australia before!
My concerns are simple.
1) Rural, remote and indigenous health is suffering a chronic shortage of doctors.
2) Since 1997, s19AB of the Health Insurance Act (1973) has placed a huge part of the burden of this healthcare on the shoulders of overseas-born doctors. This has produced sub-par health outcomes and the situation now is worse than 13 years ago.
3) Forcing overseas-born doctors to work in areas not of their choosing is discriminatory and contravenes s10 of the Racial Discrimination Act (1975).
The solution to the problem of regional health provision lies in:
a) minor changes to current legislation to accomodate equity and non-discrimination
b) thoughtful and proper usage of the glut of medical students due to qualify over the next few years
If you wish to discuss this further – with more detailed information – I would be most happy to share the last 20 years of my work with you.
Dr Richard Lunz
(Readers who wish to contact Dr Lunz can do so by leaving a comment on this post).
Whither health reform?
Tim O’Leary, Executive Officer, Planning For A Healthier North writes:
A Gillard (plus independents) government will use the National Hospitals and Health Reform reports as a basic map to implement some, but not all, of the proposed reforms. The details of many of the reforms have not yet emerged.
Some of the key hospital reforms suggest that in Victoria much hospital business would be business as usual, at least on the ground. Primary Care reforms in the reports have many facets with the Primary Health Care Organisations/ Medicare Locals being the most immediate in the last few months. To oversimplify, Medicare Locals would involve some combination of existing Divisions of General Practice and Primary Care Partnerships coming together with a population base of between 300,000 – 700,000.
The short term (2011 – 2012) impact was to be limited and structural but the longer term had at least some potential to facilitate improvement to primary care planning, coordination and delivery.
An Abbott (plus independents) government has not, so far, declared the NHHRCreports unacceptable but has clearly stated that Primary Health CareOrganisations/Medicare Locals would not proceed, Divisions of GP would remain and be strengthened, MBS rebates for long GP consults be increased,rebate for Practice Nurses extended and GP after hours funding increased.
The GP Superclinics program would be dumped.
It is possible that an Abbott-led government would still look to the NHHRC documents as an influence on policy and implementation but with a different emphasis, different structures and certainly some program name changes.
The Abbott position on local governance boards for hospitals is in line with thegeneral spirit of NHHRC reports if at present somewhat much more local inscale than the proposed Local Health Networks. An Abbott government would require the renegotiation of the just signed COAG Agreement.
The three independent members from up North have all indicated that health is an important priority for them, although whether that extends beyond more resources to rural and remote areas remains to be seen.
The Greens, who will have a seat in the lower house and significant influence in the Upper Houseafter July 2011, have always taken a keen and relatively well informed interest in health policy and services.
Even after the next few weeks the possibility of being one or two by-elections, or a disgruntled member, away from a change of government means that our view of any certainty around federal policy will be altered.
However, it is likely that future major change in health will be incremental and by broad consensus rather than polarised and oppositional as in the past. The Dutch, who interestingly also require 76 seats to form a government, have worked this way for decades.
Incrementalism versus revolution in health reform?
The NRHA’s Gordon Gregory had a bit of fun with this old debate at the Alliance’s dinner last night. He led four versions of a protest chant:
A chant for the incrementalists
What do we want?
When do we want it?
In due course!
A chant for the big bang theorists
What do we want?
Buggared if we know
When do we want it?
A chant for the metaphysicals
What do we want?
When do we want it?
A chant for the prevaricators
What do we want?
Buggared if we know
When do we want it?
In due course!
No wonder health reform can be such difficult and unrewarding work….
Dr. Lunz: Section 19AB imposes a ten-year moratorium on overseas-trained doctors. This means OTDs have a choice: they can work privately in an “area of need” (rural, remote, outer suburban, and urban areas out-of-hours), or they can work in the public system anywhere in Australia.
Australian graduates since 1996 have the second option only, until full specialist training is completed, then we can work anywhere, but the training often takes the best part of 10 years anyway, so it’s not such a big advantage.
So I agree their is discrimination, but it is complex and doesn’t always favour the locals. OTDs can do rural private work before completing postgraduate training as above, also OTDs can (in some specialties) obtain hospital consultant posts with lesser qualifications than locals.
s19AB discriminates based on place of birth. This is simply legally/morally wrong.
Once overseas-born doctors have attained the required qualifications or experience in Australia why should we be treated differently to our peers – from whom we are professionally indistinguishable?
In addition to this, in purely pragmatic terms, the policy of using overseas-born doctors to shoulder rural/remote work has not worked well at all. It is time to change.
Australian graduates train and then have freedom to be employed anywhere of their choosing.
Foreign graduates train, prove their standards and are then heavily restricted for a quarter or more of their remaining career. Ironically, this is true of Australian trained foreign medical students who – in addition to the moratorium – are now placed last on the list for intern jobs!
All of this is quite wrong and the silence of my peers over years is pretty poor show.
Re: Broadband for all, including rural areas:
Interesting post by Sean Kaye, a senior Australian IT executive. It first appeared on his personal blog, Sean on IT, in response to an article in iWire 23/8/10, entitled NBN where do we go from here?
Kaye says : “I do think that the majority of Australians want a strong National Broadband Network. I think we can infer that the majority of Australians want this network to close the gap between rural and urban Australians in terms of technology availability. That said, I don’t think the majority of people want the Labor Party’s NBN either. ”
His detailed comments are worth a read, and can be found at http://www.itwire.com/it-policy-news/government-tech-policy/41338-nbn-where-do-we-go-from-here.
His key points are:
•If you’re going to be a bear, be a grizzly: We may as well aim for Fibre-to-the-Home (FTTH). Effectively though, NBN Co needs to rapidly deliver Fibre-to-the-Node (FTTN) and through tax policy and legislation, the last mile should be the responsibility of customers and the private sector
•Continue with the plan to nationalise the Telstra copper network, open up the exchanges and pay them the $11 billion or whatever was agreed in the Heads of Agreement
•We establish some Universal Service Obligations that work for both rural centres and remote regions of the country that commit us to delivering them great broadband services now and into the future
•Instigate an immediate strategy to fibre up every single school, hospital, regional health facility and GP Super Clinic in the country within the next three years
•Deliver a business plan for NBN Co which is publicly available, takes into account the new requirements and is tabled before the end of the year.
My comments on all of that are that, frankly, I think that whichever Party gets the “nod” from the Indpendents to govern, the expensive NBN put up by Labor is fraught with potential waste and incompetence, and will most likely be “amended” into a more practical public/private ( Telsta) mix of design and constuction. ( hey- you really think they could organise it NBN anyway as it now is, remebering the inflammable home ceilings & million dollar school tuckshops debacles!).
Sean Kaye’s suggestions make sense and in the long run everyone would be a winner!
The 10-year moratorium is ridiculous and needs to be scrapped.The College of GPs in Australia is a band of clowns, frankly.A colleague of mine, aussie born and bred, trained in New Zealand for a while.She was not given full registration as GP from the College and made to jump through the rural program.That’s an australian citizen, folks.I’m not kidding.
As to rural health and broadband, yes, broadband in Australia is ridiculously slow, but do not expect the Internet to fix the problem of lack of rural GPs.Nurse on call is an example of how and why medicine over the phone or a computer is never going to work, don’t waste any more money on a similar misconception.
Yesterday I was accepted as an Australian Citizen.
I am as Australian as my Australian-born colleagues, the governor-general and in the same position as Julia Gillard & Tony Abbott…….but I cannot freely choose my place of work.
Is this the equality of citizenship?
I think it is justified to differentiate between australian-trained and overseas-trained, acquired citizenship doesn’t change where you got your initial medical degree.And I say that as an OTD.But once you have shown equal knowledge and skill by sitting the equivalent australian exam, there is no justification at all to send you off to the Simpson Desert for 5 years, or refuse you access to medicare benefits for 10.
I do not even think that differentiation is justified based on location of undergraduate degree. This is for two reasons.
1) The reality is that differentiation is being made on place of birth – inside or outside Australia. It is unreasonable to expect an 18 yo to up sticks from their home and move to Australia to study (even if that were logistically and financially possible).
The simple fact is that 99.9% of people gain tertiary degrees in their place of birth. Therefore: discrimination based on place of undergraduate degree = discrimination based on place of birth….thus contravening s10 of the Racial Discrimination Act.
2) My undergraduate degree was from Imperial College – which ranks as the 6th highest university in the world on The Times international university rankings. The highest Australian university is in 16th place.
This shouldn’t become a ‘pissing contest’ – but, if it has become so, the quality of my undergraduate degree outstrips the local degrees!
Why, then, should I be subject to restrictive conditions based on the location of my undergraduate degree.
It is simple to use WHO medical school lists & evaluations of international supervision of medical schools to compile a list of undergraduate degrees that are directly equivalent to Australian ones. This has actually happened in New Zealand already, as of 2010.
It does not take a genius to realise that the UK system is directly equivalent to the Aussie one (indeed the system here was based on the UK medical education system)!
The dropping of the AMC exam for UK graduates is a tacit acknowledgement of that fact.