Andrew Laming (Bowman, Liberal Party) Share this | Hansard source

Australia has indeed a fine history of public health. It is worth recounting briefly as we debate the Australian National Preventive Health Agency (Abolition) Bill 2014. As we consider the future of the Australian National Preventive Health Agency in this country, this is another example of yet another agency, well meaning, filled with talented and committed people but which is, ultimately, unaffordable.

In the years it existed, ANPHA failed to carve out its own space, supported by states and territories, its information not requested by jurisdictions. Ultimately, there is a certain impotence about collecting data which no-one uses. One of the great frustrations in the health system is that there are up to a dozen data-collecting agencies. There is no doubt that that cannot be good for managing an individual's health.

We know that over time, more so now, public health has shifted its emphasis from infectious diseases to diseases of lifestyle, obesity, diet, lack of physical activity, alcohol abuse and smoking. These lie at the core of what determines how long we live.

Everyday observers would probably say, 'Surely, just being healthy in and of itself is reason enough to lead a healthy existence.' But, alas, no. There is a need for both services to support health and ultimately public communication to remind people of the benefits, and significant investment. So we have a $130 billion health system to do just that. Australia is a developed economy and invests about 45 per cent of that in just two per cent of the population. The challenge for us is trying to extend disability-adjusted life expectancy as far as we can. We are now No. 2 in the world. But at some point we have to work out where along the life continuum is the best place to brief interventions from professionals that can change the course of our life. Ultimately, let us not forget what public health's limitations are. Ultimately, we all have to choose a door to pass through at the end of our lives. That time must come eventually. Public health may offer us a slight extension, it may improve the quality of that life but, ultimately, when that time comes those First World health expenses cannot be avoided—the need for that heart procedure, the long-term care if one suffers from dementia or those expensive treatments to slightly prolong life and reduce suffering if you contract terminal cancer.

For these three great doors, public health is trying to extend the quality of life and obviously reduce suffering as long as we can. It sounds quite heartless, as a health economist, to say that what we really want is to live a long, pain-free, productive life but in the course of that demise and decline that we do so as inexpensively as possible. That is the honest, laid-bare rationale behind health economics. So what do we have? We have a four-pillared health system of MBS, PBS, public hospitals and private health. It is the envy of the rest of the world. We still spend less than 10 per cent of our GDP on health care but achieve outstanding results. That is in no small part due to the people who now work at ANPHA, committed professionals, as I have said before, who have worked in a number of roles before they came to ANPHA, took on that opportunity because the previous government presented that to them. It just seemed at one point, having already had AHPRA and APPRA and running out of acronyms, this government had to call it the Australian National Preventive Health Agency because they were running out of options. But in the three years they had they committed an enormous amount of goodwill and intellectual energy to the task.

In trying to address social determinants that lie around these health risk factors, we know that we can move to education in the early years, we can look at the quality of housing, we can look at the amount of physical activity people are engaged in, we can look at a whole range of personal behaviours, but ultimately publicly funded professionals cannot kick a door in and tell people how to lead their life. So it is a frustrating job for people working in public health to try and find interesting ways in to a person's life, be it Summernats or a football game or sponsoring an app. You can see that some of these appear clumsy from the outside and sometimes wasteful, but in the end decision makers in this chamber have to say, 'Is the dollar best spent there or is it best spent making sure that that old bloke can get his knee done?' And we have to make sure that young children turning up to casualty are seen in a reasonable time. We have to make sure that people who need an operation for a hip can get it. We have to make sure that life-saving surgery can continue in well-funded hospitals. This is that terrible Hobson's choice.

In making that decision we need to have a clear way in which we proceed. We can never stop funding a hospital, we can never stop funding the subacute that transitions people out, we can never stop funding the aged care that delivers the transition for our seniors. But we have to then work back and say, for those who regularly are in and out of our hospitals with chronic disease, who can we best support to reduce those visits to hospital, those unnecessary trips back, the surgery that goes wrong, their mishaps within hospitals that could have been avoided? Nations overseas are becoming quite vicious about the way they will not fund wasteful health expenditure.

In Australia we are privileged to have the answer to the question I have just posed. It is our 35,000 general practitioners, some of the highest trained public officials or recipients of public funding in the country. Training for no less than 10 years, their job is within five to 10 minutes to be able to deal with the health concerns of a concerned and often unhealthy Australian. They do it every day, all day, in every corner of this country. They are the linchpin, the cornerstone of our health system. We must support them in every way. So if they are working in increasingly complex team based arrangements to share information, to identify the people that need the health care most, to make sure that the people who are most ill get the most time, we need a quite elaborate and sophisticated health system to meet that challenge. If we are going to have public health interventions, they need to be cheek and jowl with general practitioners, because that is the front line.

With the greatest respect to many of us in this chamber who know no more about the health system then when visiting hours are at the local hospital, until you have worked and sat in a room with a general practitioner you cannot possibly begin to understand the complexity and the challenge of fixing this problem. With the greatest of respect, asking people to sit at shopping centres and encourage people to go in walking groups just sets up a weird kind of adverse selection where the worried well, the people we least need to worry about, start consuming public health resources. It is only the general practitioner who sets up that chronic disease management plan and knows that the extra time and money is best invested right there. If the general practitioner knows when that needs to be, with the greatest of respect, we do not need to be chasing young, fit people and telling them that the way they lead their life is no good. It is simply not an effective use of public resources. I have no problem with highly expansive and elaborated primary health care and health promotion as long as we get the tertiary end right, but at present the tertiary end is in many cases a shambles. General practitioners send their patients to a specialist. Letters come back in hard copy. There is no record available to the ambulance. They turn up at hospital and have all of their tests replicated. These most simple challenges to our health system are still in many cases beyond us. That must be our focus—we must get that part right.

Only one or two per cent of our population are in this category: high need, complex, chronic disease patients, usually with limited resources. Their entire calendar is devoted to marking off when their next health appointment is. When you health calendar and diary takes over your social calendar and diary, these are people that genuinely need extra investment because that will keep them out of hospital for longer and able to enjoy their life. It is not the focus to be putting out apps to people and counting your successes in downloads. No downloading of an app will stop a person smoking. It is the cigarettes that you do not smoke that fixes your health. We are winning with cigarettes but there is still long way to go with diet, exercise and alcohol. So let us start counting outcomes, not inputs. This is the great Labor myth: how much money we spent, how many apps got downloaded. But you know what? We never checked how many people stopped smoking. We did not write that in because if we did we might prove the waste of money that it was. Sure, you downloaded the apps. That is exciting stuff. But nobody has stopped smoking, they kept smoking. Australia's drops in smoking rates were under the Howard government and the clear warnings on 30 per cent of the front and 80 per cent of the back brought in by the current Prime Minister. Australia's smoking results are the one positive trend that we see in public health. All of the others are potentially heading the other way.

If we are designing this for Australia we need to come right back to general practitioner, the average GP working full-time, 25 patients a day, 150 a week, working till 6 pm at night with barely enough time to spend with people who truly need it and virtually no super-clinical coordination of the extra services that the GP needs to do it right. That post stroke rehabilitation nurse who could be in seeing five of that GPs patients needs to be easily accessible to truly make a difference. They do not exist in every practice but they have to be easily accessible to the GP. That support to help them to do their job well is what matters. You do not need a five-storey building to do that. What you need is a care navigator sitting in the large practices identifying the 100 most high priority patients for that extra coordination and support. That can be SMS reminders, it can be calling them back in but not to see the general practitioner, that can be to do all sorts of help promotion activities, but let it be run through general practice.

We did not invest all this money in general practice only to set up a parallel entity like potentially, as we will debate later this year, the role of Medicare Locals. I have no problem with the staff of Medicare Locals. Many of them are highly talented people, but they had no commissioning and no direction. They were simply unleashed by the previous government, who knew so little about a health system that they figured Medicare Locals would work it out for themselves. What we are left with are large entities, employing sometimes more than 100 people with large amounts of money in the bank and unable to spend it. I will do my best to stimulate again the Parliamentary Secretary to the Minister for Finance, who is at the desk. He has a Medicare Local in his electorate and he must be genuinely concerned whether they are satisfactorily supporting his general practitioners. We must connect the information from specialists and from local public hospitals to support a GP's work, that is the essence of public health. That is what we call front-line services.

Right now, we have not had a satisfactory state buy-in for very good reasons. For the last 10 years, states have been slowly pulling back their services to in-patient related work and they are very happy to vacate the public health space to the Commonwealth. That presents us with a significant cost-shifting challenge. But, ultimately, the Commonwealth is arguably best placed to do primary health care. We are funding the general practice system already. We are putting enormous amounts of investment into vaccination. The last thing we need are three levels of government trying to do all of that at the same time. The last thing we need is a large Medicare Local over here and a large community health building over there, and none of these people know what the others are doing. That is the risk of Labor's monolithic bureaucracies getting involved in the health system and the millions of dollars that follow those dreams.

I anticipate that the people working in Medicare Locals, and potentially ANPHA, will find a role much closer to the front-line. It is where they need to emphasise their work. If we can get the tertiary, recurrent, complex patient area right, the big savings accrue mostly to state governments. If we can reduce the need for unnecessary admissions and procedures, that will be a saving for state governments. The problem is in state public hospitals where there are long waiting lists and it is effectively a ration system. Basically the faster they work, the quicker they go broke. So they have this enormous challenge where they need support from general practice to do everything possible to avoid unnecessary and poorly timed admissions. That can only be done if we identify our high-risk patients in every general practice, share that information with the local hospital, cooperate within that region and then play the efficiency game, and do as well as we can with those patients to reduce total health expenditure. If you get them right and we get tertiary health prevention right for the sickest Australians, then let's return here and let's have a debate about a role for ANPHA, for primary health initiatives and prevention. But right now that money is not well spent in that area, so long as we have poorly coordinated and fragmented tertiary services.

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