It’s the conversation that doctors and patients want to have, but many politicians are avoiding – how do we create a patient-focused healthcare system?
Airdate: 
Tuesday, February 24, 2015 - 20:30
Channel: 
SBS

Carly Stewart's seven-year-old son Lachlan has cerebral palsy, requiring treatment from up to eight different hospital departments. She says the biggest hurdle for her family is poor communication between doctors across these departments.

Two-year-old James Robins has cystic fibrosis, and requires consistent medical care. His mother, Katherine, prefers to use Hospital in the Home (HITH) wherever possible, because it gives James a sense of normality in his daily routine, and reduces his chances of contracting further infections.

Dr Charlotte Hespe has been in general practice for over 20 years. She says a doctor's primary focus is the patient, but feels their efforts are supremely hampered by an unnecessary amount of red tape.

Terry Barnes, the man who floated the idea of a GP co-payment in recent times, and a former advisor to the Howard government, is frustrated by the current debate. He feels that whilst the co-payment remains on the table, any chance at greater health reform is stymied by both professional and political forces.

The Federal Government's spending on health care was around $30.2 billion in 2012-2013, according to the Productivity Commission's Report, and this is set to rise from 4 per cent of GDP to 7 per cent by 2059.

As the government warns of unsustainable spending, we ask: how efficient could our health system be?

This week, Insight brings together patients, carers, nurses, health professionals, and economists, to discuss the challenges in reforming healthcare.

Saving money and helping patients: can the health system do both?

Presenter: Jenny Brockie

Producer: Paige MacKenzie 

Associate Producer: Saber Baluch 

Join the discussion by using the #insightsbs hashtag on Twitter, posting on our Facebook page

Transcript

JENNY BROCKIE:   Welcome everyone, good to have you with us tonight. Carly, your seven year old son Lachlan has cerebral palsy. How many health professionals would Lachlan see in a year say? 

CARLY STEWART: Oh, I think currently we see about eight or nine different departments at the Children's Hospital in Melbourne mostly doctors, sometimes physios or occupational therapists, occasionally speech therapists but generally doctors at the Children's Hospital.  We don't see our GP all that often except for referrals, we also see our private paediatrician just so that we can have a bit of an overarching view of where we're going with Lachlan, a lot of the paediatricians and doctors at the hospital, though very good, work in one modality. 

JENNY BROCKIE:   So how much do all of these people talk to one another about Lachlan?  

CARLY STEWART: Very little. It is getting better but very little. I'm usually the common thread in terms of making sure that we have, um, a plan that takes into account all of the things that's happening with him health wise and physically.

JENNY BROCKIE:   Isn't there a central record of everything that's happening in the hospital with Lachlan? 

CARLY STEWART: Um, they do have a central record. However, I believe there are still some departments that hold individual records. Um, and often when you see doctors they look at those areas that look to be relevant to them rather than whatever else might be happening in his life medically at that point in time. 

JENNY BROCKIE:   Katherine, you're nodding your head here. Your two year old son James has cystic fibrosis, similar story to, in terms of your interactions with the health professionals that he deals with?  

KATHERINE CLAY:  Ours is more within the hospital system.  James will see dieticians, physiotherapists, paediatricians, but often with his care I find that the communication is not there. I find that, um, his paediatrician will make a discussion with us that when he goes into hospital we will look at this, this, this and this, but then when we're actually in none of that happens.  And things I find are constantly missed and as a parent we have to be on top of his care constantly.  So it's then my responsibility to be his advocate, ring up, follow up. 

JENNY BROCKIE:   So you've got to keep your eye on everything all the time? 

KATHERINE CLAY:  Absolutely everything. 

JENNY BROCKIE:   And how often are you telling health professionals what other people have already told you and said? 

KATHERINE CLAY:  Constantly, but I don't always feel it's heard either. Sometimes they're disinterested in hearing that this has happened in that department and this has happened in that department. Would you?

CARLY STEWART: Absolutely. 

JENNY BROCKIE:   How well do the two of you feel they communicate with one another, all these people? 

KATHERINE CLAY:  Not well. 

CARLY STEWART: Very little most of the time. If we push for interaction, for example Lachlan needs a general anaesthetic for lots of procedures that we would normally just go to our GP or a local practitioner for, because of his movement issues, and we had to go in for some surgery on his leg muscles to release them and he needed a general anaesthetic for that. So we actually pushed to have the dental team at one point come in and do a mould of his mouth while he was asleep so that we could do some plates and some work that we were doing with them.

JENNY BROCKIE:   So you wanted everything done at the same time rather than him having two general anaesthetics or whatever? 

CARLY STEWART: Absolutely, yes. 

KATHERINE CLAY:  I've asked for similar, yeah, he was having a CT scan so I asked for a bronchoscopy, yeah, because I thought the same. If he's going to be under anaesthetic well let's look at what else needs to be done. 

JENNY BROCKIE:   The interesting thing about these stories is  you're the ones taking the ownership and doing the monitoring all the time of what's going on, rather than the doctors talking to one another or the other people involved in the cases talking to one another, yeah? John Dwyer, what does it tell us about the way the health system works at the moment? 

PROFESSOR JOHN DWYER, UNIVERSITY OF NSW:  Well, when you hear these stories and they're obviously common stories, we know that a child with a complex condition is going to have to need the skills of a number of specialists, but there should be, there should be, there has to be a captain of the team and ideally that should be the general practitioner who is orchestrating all this for you. But in complex cases like this, often we set up in the hospital, we set up a casework manager who is there to help you tie together all of these things, someone that works with mum, works with dad, that, that knows everything about the patient is crucial. 

JENNY BROCKIE:   But it's not happening for a lot of people? 

PROFESSOR JOHN DWYER:  We hear all the time and it's true that we do not have a patient focussed health care system. It's, you could argue that it's more provider focused than it is patient focused. 

JENNY BROCKIE:   And why do you think that is?  I mean why do you think health professionals haven't just taken it on themselves to talk to one another? 

PROFESSOR JOHN DWYER:  It's somewhat historical but in Australia our health professionals tend to work in silos rather than working together in teams, it's not, not, the system isn't ideally focused with the patient right at the centre of everything. We know how to change it but we need to change it. 

JENNY BROCKIE:   Okay, we'll talk about how to change it a bit later. Ran-Jana, what do you think?  I mean you're an oncologist, is it fair to say that health professionals don't talk to one another enough about individual patients?  They don't work together enough?

RAN-JANA SRIVASTAVA:  Look, I think, you know, Jenny, patient centred care is the buzz word in modern medicine at the moment. But I think we do fall short of ideal patient centred care. Not…

JENNY BROCKIE:   Why?  What's stopping it from happening? 

DR RANJANA SRIVASTAVA, MONASH HEALTH: I think there are a number of factors. I think that modern medicine is very busy, it's very pressured. Also care is very fragmented and people have various commitments so they work in the private sector, they work in the public hospital, so sometimes it is simply the fact that they're not physically present to have these contacts with other doctors. 

JENNY BROCKIE:   Okay, what do other health professionals here think?  Why do you think it's, why do you think we have these stories? Terry? 

ASSOC. PROFESSOR TERRY HANNAN, LAUNCESTON GENERAL HOSPITAL:  Patient centred care is the patient having their own record and these people here should have their own record and to that each encounter data and information is entered to that and they take it around the system with them.

JENNY BROCKIE:   And why don't they? 

ASSOC. PROFESSOR TERRY HANNAN: Because the system doesn't allow them to. 

JENNY BROCKIE:   And why doesn't the system allow them to? 

ASSOC. PROFESSOR TERRY HANNAN: It's predominantly paper based, isolation specialist based, time restrained, therefore these are the factors why the patients and their families need to own the record. 

JENNY BROCKIE:   Saxon Smith, you're from the Australian Medical Association, you're also a dermatologist? 

DR SAXON SMITH, PRESIDENT NSW AMA: Yes. 

JENNY BROCKIE:   How would you feel about patient having control of their records, why shouldn't they have control of all their medical records? 

DR SAXON SMITH: No reason why they shouldn't ultimately. When you look around the rest of the world there are great models of electronic medical records that travel with the patient. We often look to Scandinavia where the systems they have for a patient medical record they come out with a unique identifier when they're born and it follows them for the whole of their life. It's accessible for every health practitioner whether it's in a hospital setting or in a community setting and you're able to improve that conversation because it's a unique thing to that patient but also it's a computer system that goes across those boundaries. In Australia…

JENNY BROCKIE:   Okay, but let's just get back to what have now? 

DR SAXON SMITH: In Australia it doesn't work. 

JENNY BROCKIE:   I know we've got a system and we'll talk about that in a minute too, but I just want to get down to the really basic thing of just picking up a phone and saying to another doctor "I've got this patient here, you've got the x-rays, can I have them?" You know, how often is that happening? 

DR SAXON SMITH: Personally I do that every day. 

DR CHARLOTTE HESPE, GP NSW:   I'll come in as a GP.  There's no doubt we do it. I think one of the problems is the fragmentation of the communication systems.  I'm constantly battling about how to get results across barriers.  So for instance, if we're just talking about the x-ray, I've got a patient in front of me, I've had them had an x-ray done, they've got a fracture, I want to bypass the A&E department, I want to go straight to the orthopaedic surgeon, so you do the phone calls, find the orthopaedic surgeon in the surgery, goes yes, well I want to see the x-ray. The x-ray was done in a private facility. He can access an x-ray from a public facility in the operating theatre, not one from a private facility because they don't have the mechanism to send it across. How stupid is that?

GPs are actually pretty damn good at having electronic records. I get everything is in my file electronically. I will, but I cannot generate a referral electronically because none of the specialists that I refer to actually can receive it. Some of them can send stuff back to me but the ones that can send back put their hands up in horror when you say I'd like to refer to you electronically, it's like oh no, no, no, no, don't do that, that's scary. 

JENNY BROCKIE:  Okay, well what does all this mean for patient welfare? 

KATHERINE CLAY: Frustration. 

JENNY BROCKIE:   Sorry? 

KATHERINE CLAY:  Frustration. 

JENNY BROCKIE:   Terry? 

ASSOC. PROFESSOR TERRY HANNAN:  We're just establishing the whole reason why these people need to own their record. They take it across the system. What are we trying to do? 

JENNY BROCKIE:  But what's in the way of that happening? 

ASSOC. PROFESSOR TERRY HANNAN:  The whole, Lucien Leap put it beautifully - the whole culture of medicine is against the patient having the record. It's slow to change. We are…

JENNY BROCKIE:   Why? 

ASSOC. PROFESSOR TERRY HANNAN:  It's predominantly, as a physician, able to say about my colleagues, that it is a culture of the profession. 

JENNY BROCKIE:   And what is that culture? 

ASSOC. PROFESSOR TERRY HANNAN:  It is slow to share information, slow to believe that we are imperfect in our communication, slow to recognise we don't know it all, slow to acknowledge that the tools we have, which are still predominantly paper based, are totally inadequate and creating more errors and poor quality outcome. 

JENNY BROCKIE:   Okay.

DR CHARLOTTE HESPE:   To challenge that again, again in primary health, one of the big barriers, from my perspective, has not been the willingness or the desire to share, it's been these bureaucratic red tape, like I work across a geographical area that is administered, they have one system and then just right next door they have another system and they can't talk to each other. 

JENNY BROCKIE:   Okay, but do you think the point that Terry's making about the culture in some areas of medicine being slow to change, reluctant to give up information, do you think that's a fair point?  Saxon, do you think it's a fair point? 

DR SAXON SMITH: I think there's a generational shift and part of that, you know,  and please don't take offence to this in the sense that the younger generation are trained slightly differently in that you'll go to a medical school, often you'll have an interview based entrance exam, the style of teaching has moved from a very didactic style to problem based learning and interacting with everyone and recognising the fact that you don't know that conversation and centring patient more into the centre piece of what it should be, about them. 

JENNY BROCKIE:   Carly, why were you shaking your head then? 

CARLY STEWART: I don't disagree there are some doctors that are making that shift but I have very clear memories before, before the Children's Hospital went paperless, of hiding in the toilet with my son's file because they didn't like to give it to you and they didn't like you to look at it. 

PROFESSOR JOHN DWYER: I think the other elephant in the room, and many meetings that I've been to about our frustration over the last ten years of the slowness to introduce an electronic health record, this so frustrating because this isn't modern Australia but just 4 percent of people surveyed who said they were worried about privacy has had our politicians in stitches about the whole thing and that has definitely held back the development of a patient controlled electronic health record.   

JENNY BROCKIE:   Okay, Nick, you're a GP as well, I just wonder what you think about this? 

DR NICK BRETLAND, GP WESTERN AUSTRALIA:  I agree absolutely, there are significant administrative blocks. I've had great trouble getting hold of important x-rays from public hospitals because in order to do so, my patients have had to sign a disclaimer and a waiver and a request that we then have to fax in and eventually..

JENNY BROCKIE:   Fax? 

DR NICK BRETLAND:  Fax, and eventually the report will come back and that's very frustrating.  

JENNY BROCKIE:   Fax?  I'm sorry, that's just bizarre. 

DR CHARLOTTE HESPE: Every doctor has to have a fax machine and of course that's so much more confidential than, you know, than anything else because there's all the office staff standing around and anybody could be standing there and grabbing that very highly confidential document off the fax machine. 

DR NICK BRETLAND:  My biggest frustration was when we were trying to get registered for the electronic health record so that we could upload all this stuff so everybody could carry their own record, there was no electronic mechanism for doing it. You had to fill in forms with paper and post them in for an electronic health record. 

JENNY BROCKIE:   You're not serious? 

DR NICK BRETLAND:  Of course I'm serious. 

ASSOC. PROFESSOR TERRY HANNAN: And in 1996 this state legislated that faxing of any medical material is illegal.

JENNY BROCKIE:   Wow, okay, a bit of a mountain. 

DR NICK BRETLAND:  One of the interesting blocks that the medical profession have no control over I'd like to see removed. 

JENNY BROCKIE:   Candice, tell us your story because you've got rheumatoid arthritis; you've had it for sixteen years, is that right? 

CANDICE KRIEWALDT:  Yes. 

JENNY BROCKIE:   What's your experience of the system with all the people you have to see? 

CANDICE KRIEWALDT:  Well I find that I have to really navigate it myself. So none of my health practitioners are in the same place, they're all over the place really and I find that I'm trying to interpret their information, remember it, keep a record of it, have a printed record, and then when I go to the next practitioner, you know, recall it to them accurately.

JENNY BROCKIE:   Is there any contact between them about what to do about your case?

CANDICE KRIEWALDT:  Between the GP and the specialist there's contact, I'm not sure how frequent, yeah, but between all the other professionals, yeah, information that I've, you know, they've printed for me which is not every appointment I get things printed, results, I've sort of got a haphazard record that I sort of try and piece together and take it with me. 

JENNY BROCKIE:   So you're trying to put together your own? 

CANDICE KRIEWALDT:  Myself, yes. 

JENNY BROCKIE:   And do you find that you're getting tests done more than once?

CANDICE KRIEWALDT:  Yeah, I did have an example, I'd been seeing a previous specialist, wasn't happy with their treatment, I'd finished off with them and had gone off medication completely. I was very unwell, I couldn't walk, was bedridden, I'd lost a lot of weight as well. Then I went to see, sometime after that went to see a new specialist and I'd requested, I'd been calling already for my health record from the previous specialist, that wasn't provided to me. Not sure exactly why. I was trying to qualify for a new medication that has to be approved by the PBS and I had to, some of the medications had to be, I had to fail three medications before I'd be eligible for the new one.  I knew that I had at least two of them were not effective and had adverse side effects. 

JENNY BROCKIE:   You'd already tried them? 

CANDICE KRIEWALDT:  I'd already tried them, failed them, there was a record of that. My other doctor had a record of but that wasn't being provided so I had to try the other medications that, you know, I knew that they had bad side effects.

JENNY BROCKIE:  So you had to try them again? 

CANDICE KRIEWALDT:  Had to try them again because I had to have evidence that they had failed and weren't effective.

JENNY BROCKIE:   Okay, what about testing? How often are people getting tested more than they need to, like two doubled up?  

PROFESSOR JOHN DWYER:   I can give you two examples, one in Launceston, within a month of opening the acute medical unit, one corridor across from the Emergency Department, there are a million dollars of unnecessary blood tests. In Canada in 2005 with 5 percent of chronic kidney disease patients the unnecessary testing cost $4.4 million but each test only cost $4.40 each, and for the whole of the Canadian economy $1.27 billion of unnecessary blood tests costing $4.40 each. 

JENNY BROCKIE:   So why is that happening?  Again is because of our lack of communication? 

PROFESSOR JOHN DWYER: Because we don't have the tools to correct our decision making. 

JENNY BROCKIE:   How much is it costing do you think Stephen overall?  I mean you're a health economist, how much waste is there in the system as a result of all of this? 

STEPHEN DUCKETT, GRATTAN INSTITUTE:  So there's certainly a lot, but I would say there's probably 5 percent of the health system at least is probably this duplicate testing waste that's occurring.  

JENNY BROCKIE:   5 percent did you say? 

STEPHEN DUCKETT:  Well, I don't want to go too high because you know, then you say well…

JENNY BROCKIE:   So how much money would that represent, 5 percent? 

STEPHEN DUCKETT:  6 or 7 billion dollars. 

JENNY BROCKIE:   That's a lot of money.     

DR RANJANA SRIVASTAVA: Jenny, can I speak of that as well. So with multiple testings I think there are a couple of other factors. There's a lot of healthy illiteracy, in fact it's rife. So I think partly duplication happens because when you don't have a unified system and the patient can't tell you what they've had and where they've had them, then sometimes you need to repeat those tests. The other thing is I think, as we've discussed, when doctors works in silos you kind of don't want to get in other people's way and so one doctor does their test of tests and another doctor does their set of tests and often the patient is left disempowered and out of this loop and they just go along and have the test that's been requested. 

JENNY BROCKIE:   And they don't want to argue with the doctor. 

DR RANJANA SRIVASTAVA: True. 

PROFESSOR JOHN DWYER:  Stephen's figure of 5 to 7 billion dollars I think is probably on the conservative side. There are people who are talking about, I think it was as high as 20 billion dollars a year of low value, low hanging, for not terribly useful things that people are doing. For example, the number of MRIs that are done for people with low back pain; the number of people who have arthroscopies in private hospitals every day which are really going to tell -  provide no information. The number of vitamin D tests that we do has gone from a few thousand a year to hundreds of thousands a year. 

DR SAXON SMITH:   2 million in 2012. 

JENNY BROCKIE:   2 million vitamin D tests? 

DR SAXON SMITH: Yes. 

JENNY BROCKIE:   Has there a sort of burst of vitamin D deficiency or what?

DR SAXON SMITH: Well, if you're testing for something. 

DR CHARLOTTE HESPE:   Saxon, too good with sunscreen.  DR SAXON SMITH: No, it's more you design a test, people check it, it becomes a fad. 

JENNY BROCKIE:   But are they necessary? 

DR CHARLOTTE HESPE:   No, they're not necessary.  If you change what you're going to do, no, that's the craziness of the vitamin D.

JENNY BROCKIE:   And how much is that costing the system then? 

DR SAXON SMITH: $140 million for 2012. 

JENNY BROCKIE:   Okay, let's just talk about E-Health for a minute, launched in 2012 by the previous government.  In the current budget there's $140 million which is going to be spent on E-Health. How is the system working at the moment? 

FEMALE: It's not.  

MALE: It's not. 

JENNY BROCKIE:   It's not.  Okay who'd like to start that conversation? 

KATHERINE CLAY:  I can certainly tell you that I'm tech savvy so I've gone on and made sure my on-line E-Health Registry for our family is up-to-date but when  I opened James' E-Health record I expected that possibly it would have his x-ray scan, admissions, drugs, anything like that, the fact that he has cystic fibrosis.  I thought that perhaps, you know, if there was a car accident I've stupidly assumed that maybe people could go onto the computer and see this person has this condition or this concern but there was nothing in there at all. So I've updated his, like daily medication, but I've recently looked again and it's not updated at all. Not once.

JENNY BROCKIE:   Do you use it Carly, E-Health? 

CARLY STEWART:  No, look we did look at it, but because we've periodically gathered history from the hospital and from our private specialists, I felt like I had access to all of the history that we needed at that point in time. 

JENNY BROCKIE:   So you'd done all the work? 

CARLY STEWART: Yes. 

JENNY BROCKIE:   Candice, what about you, do you use E-Health? 

CANDICE KRIEWALDT: I find it full on and I also found it, yeah, hard to use and didn't seem that effective.

JENNY BROCKIE:   Can we do a show of hands here?  How many people have gone to the E-Health.gov.au website and registered for E-Health? One person in the front row - anybody else? - One person over here. - No one else. Okay, why not? 

FEMALE: What is it? 

JENNY BROCKIE:  What is it?  Good question, what is it?  Tell us what it is. 

DR CHARLOTTE HESPE:  I can say what it is from a GPs perspective, it's very, very frustrating and that’s the problem. What it is actually just a summary sheet of your medical diagnoses that have ever been made that are relevant, so all your key diagnoses, all your current medications, allergies and your immunisation status.  

JENNY BROCKIE:   But who controls it? 

DR CHARLOTTE HESPE: Okay, so the GP is actually supposedly the gate keeper. So you sign up for it, you then go to your GP and you and your GP tidy up your electronic health record so again you have to have a GP that's got a computer with a health record that's up to date, with all your information, you then press a button on your, my little computer which then goes bllll… and find the IHI which is the individual health identifier and uploads just a summary sheet. Okay? It is then just a momentary snapshot of their medical history at that point in time. 

CARLY STEWART: To be honest as a parent of a child who's got complex issues and needs to a see a number of people, a snapshot for us can change in a heartbeat. So that level of information that sort of summary is not particularly useful to us.

DR CHARLOTTE HESPE: The summary is useful if it's constantly updated and somebody with a chronic illness who is seeing their GP regularly, I update their file, you know they'll have been in hospital, I'll get the summary,  I'll change the medications, I can then update the updated file. So that's useful because then when you next fall into hospital there is an updated file there.

ASSOC. PROFESSOR TERRY HANNAN:  I keep coming back to this point, let them cart it around, let these lovely parents fill out the record,  do all and transmit it to us, make it available to us. The research is showing that patients are actually better at this, doing this than us. 

KATHERINE CLAY:    Can I just say it's actually very hard to always get the information? 

ASSOC. PROFESSOR TERRY HANNAN:  I beg your pardon? 

KATHERINE CLAY: It's not always easy to get the information. So not all the information is on a discharge that goes to the GP but like I find it I'm always trying to collect and collate James' blood test results, x-rays, reports from the CT, and I've recently emailed and asked for copies of all the reports and I've had no response, and that's common. 

ASSOC. PROFESSOR TERRY HANNAN:  I think your point there is that's the structure of the model is wrong, you should be able to do that and you should be able to get it. 

KATHERINE CLAY: Absolutely. 

ASSOC. PROFESSOR TERRY HANNAN:  So we need to go back and know what we've been able to do. 

DR CHARLOTTE HESPE:    And the GP should be able to get the results of those tests by not having the barriers to being able to access them. I can't access the test results. 

JENNY BROCKIE:   Yes, Ian? 

DR IAN MADDOCKS:  Can I make a Luddite sort of comment here because it seems to me the technology is making it too difficult for us. Fifty years ago I worked in Africa in paediatrics and the mother would bring her child in and she'd go down her bosom and she'd pull out a handful of paper which was her patient health record.  She held it and I would write my notes on it and give it back to her and she'd stuff it down her bosom again. When I was working in outpatients when I'd seen a patient I would write a letter, I used to use carbon paper, I would write a letter about what the consultation had been about and I'd give to the patient to take back to the GP because we had a record and we had a record.

Now there are some aspects of communication that are very sensible. We've now got telephones, we're no longer using faxes, we've got the electronic stuff but it doesn't seem to be working. These people whom we've heard from are experts in the care of their children of themselves and they ought to have the record. Now the thing is we don't give them the respect that they deserve. 

JENNY BROCKIE: Why won't doctors give it to them? 

DR IAN MADDOCKS: With the culture of medicine. We, we've talked about silos and we are caught in our particular little specialities.

JENNY BROCKIE:   Ian Maddocks, you've worked in palliative care for a long time. Where would you like to be if you were terminally ill? 

DR IAN MADDOCKS:  At home. 

JENNY BROCKIE:   Why? 

DR IAN MADDOCKS: Because I think that's the best place to die, over the last 25 years I've done a lot of home visits and I've seen a lot of people die at home and there's no doubt in my mind that that is for most people the best place for them to take their final breath, with the love of their family around them, with the sense of being in control of their own situation and it works very well. 

Now doctors have almost stopped doing home visiting in many parts of Australia and we've got nurse practitioners who are coming up as people who could do this perhaps just as well very often but more ready to go into the homes, but they're not being paid enough do that at the moment so there's not a great deal of thrust for them to take up that particular role. But most people would like to have care close to where they are or in their own homes and having to shunt around to specialists who very rarely know anything about what happens in a home.

JENNY BROCKIE:   And why do you think that is, why do you think that is, that that doesn't happen so often? 

DR IAN MADDOCKS:  Well it's partly that culture that constrains us into our specialist view of the world and we tend very often to ignore the general practitioner a bit, send them the odd letter and so on but you don't really communicate all that well with them sometimes.

JENNY BROCKIE:   Are there many people do you think who don't need to be in hospital who could be cared for at home? What do you think? 

PROFESSOR JOHN DWYER: The biggest inefficiency in the entire health system is the fact that we have hundreds of thousands of admissions to hospital, an average of more than $5,000 an admission that could have been avoided if there'd been a community intervention in the three weeks before someone went to hospital. The University of Melbourne in 2012 finished a study where they said there were 7 million bed days in public hospitals occupied by people who wouldn't have needed that hospitalisation if they'd got the appropriate care in the community. 

JENNY BROCKIE:   So why aren't they getting the appropriate care in that three week period? 

PROFESSOR JOHN DWYER:  Because the infrastructure isn't there to look after them in the community.

JENNY BROCKIE:   Nick? 

DR NICK BRETLAND:  Well I just want to respond to that. I'm a GP, the majority of my work is with elderly parents and within residential aged care complexes, I do a fair amount of palliative work. One of the difficulties is that a lot of us don't do house calls because it's not funded. The payment for a GP to come out to see a patient in the home is less than a call out fee for a plumber and you're not allowed to add travel time to that. But I'm very lucky where I work, I have a significant number of occupational therapists, physiotherapists, community nurses who I can call in to help keep people at home. I see one of the prime aspects of my job is keeping people out of hospital. They're nasty places for sick old people. 

KATHERINE CLAY:  Can I just say, everyone's talking about the end of life and aged care but my child had six admissions last year so it's not the end of life and it's not aged care, we're talking about young people as well. And we've used hospital in the home twice out of the six admissions and like the academic evidence shows that …

JENNY BROCKIE:   Explain what hospital in the home is. 

KATHERINE CLAY: So hospital in the home means that generally when someone's has cystic fibrosis and they need what's called a tune up, it's basically IV antibiotics, usually two different antibiotics over a fourteen day period  and so you would usually be in hospital for that entire time. However, on hospital in the home, they can actually come home after about five days and they come home on IV antibiotics hooked up to them and we had a nurse visit us once a day who administered one of the antibiotics and then changed the canister for the other antibiotic that ran for twenty four hours into James. But…

JENNY BROCKIE:   And what was that like compared to having him in the hospital? 

KATHERINE CLAY: Well it was amazing because first of all we had our own food and he's able to go to the beach, he can have a bath, we can be in our own routine, our own beds.

JENNY BROCKIE:   So far preferable for you? 

KATHERINE CLAY: Yeah, the IVs don't get done at 11 o'clock at night which is the time one of them gets administered in hospital. But…

JENNY BROCKIE:   So does it cost less Stephen to do this? 

STEPHEN DUCKETT:  Absolutely. 

KATHERINE CLAY: It costs less to his health as well more important than financial because the evidence shows that antibiotic resistant bacterial infections are often caught in the hospital setting so the less time we're in hospital the better. 

JENNY BROCKIE:   Are there people here though who have reservations about being looked after at home with support people rather than going to hospital? Do any of the people….

DR RANJANA SRIVASTAVA: I don't have personal reservations and I also believe that hospital in the home is good, but I do look after elderly people in particular who feel more secure in a hospital environmental although the evidence points otherwise, as we have discussed. 

JENNY BROCKIE:   Does the evidence point otherwise, that it's not a safe place to be?

DR RANJANA SRIVASTAVA: Hospitals aren't.  Yeah, I mean in the case of an elderly population you are more at risk of confusion, falls, fractures, you name it. But it can be quite difficult to convince many people because a lot of people feel that by placing them on hospital in the home you are turning them out of the hospital.

JENNY BROCKIE:   Ann, you're a nurse, what do you think about the hospital in the home idea as a nurse? 

ANN RITCHIE, REGISTERED NURSE:   I think it's got some extremely good merit, like you're at home, in your own surroundings, you've got your own tellie, your mum and dad are there for children or for the elderly. As far as hospital in the home for palliative care it's wonderful.

JENNY BROCKIE:   And as nurse yourself going out to do that, I mean how do you feel about going into people's houses? 

ANN RITCHIE:   Like when I did community nursing, God forty years ago, I had no concerns about going into anybody's house, never even thought. Nowadays in certain areas I'd be a little more reticent to go in by myself and I know a lot of the community mental health nurses are a lot more reticent to go in. 

JENNY BROCKIE:   So you haven't got the infrastructure of the hospital around you? 

ANN RITCHIE:   Yes. That safety net is not there. 

JENNY BROCKIE:  Would it mean that you wouldn't want to do it? 

ANN RITCHIE:   No. Yes. 

JENNY BROCKIE:   Yes? 

ANN RITCHIE:   Yep.  I don't think I'd particularly at my age particularly want to put myself in that situation where I'm not sure where I'm going or that something could be on the other side of the door. I've done all the hard yards, I don't need to do that now. 

JENNY BROCKIE:   Okay, Laura, no, no, no, I want to hear from the nurses and from people who would be in this situation too. Laura? 

LAURA GRANT, REGISTERED NURSE:   Sorry, I have quite limited experience of such placements. Most of my work has been in the hospital, in emergency where we've got security guards on-call any time we want them. I have done a couple of days of placement with a community nurse and certainly I felt very nervous as we got into the car and drove off into the great unknown that is the patient's household.

JENNY BROCKIE:   See I think this is really important to talk about as part of this discussion because it's all very well to say oh, how lovely,  you know, people are in their nice homes, and those reservations are very real, presumably other people would have them. How do you address that? 

STEPHEN DUCKETT:   For a start it's an occupational, health and safety issue, you shouldn't have people going by themselves into an unknown place to provide anything, be it nursing care or whatever, and the staff have to be protected, have to be in a safe working environment, and I think most community nursing services now have two people in the car for these services.  

DR IAN MADDOCKS: The whole emphasis has to move away from hospital in the home to care in the home. What we're talking about is setting up an infrastructure where people can have an intervention before they need the more dramatic hospital type…

JENNY BROCKIE:   Type care where it's at home or in the hospital.

DR IAN MADDOCKS:  We should explain what we're talking about with this medical home model because it's been mentioned a number of times. At the moment the culture is we go to the doctor when we're feeling sick. The rest of the world, there's plenty of evidence that when you switch the culture around so that you regard health professionals as people with whom you will enter a mutual contract to help you and your family stay well.  A medical home is a practice that has a number of different professional skills available to people who enrol in the program. 

JENNY BROCKIE:   Would be prepared to not just work in hospitals and in their rooms but to go to people's houses? 

DR IAN MADDOCKS:  It doesn't have to be doctors - we've got nurse practitioner roles who are able to help there. We're doing quite well. We used to have small hospitals. Adelaide's lost all of it's small private hospitals, community hospitals where people could have care for fairly simple things.

JENNY BROCKIE:   Okay, you mentioned nurse practitioners. Let's talk about nurse practitioners, you're one of them Chris, what exactly is a nurse practitioner? 

CHRIS HELMS, NURSE PRACTITIONER:  Right, so a nurse practitioner is a Registered Nurse who has advanced clinical education and training in the assessment, diagnosis and management of chronic conditions which have traditionally been treated by medical professionals here in Australia. 

JENNY BROCKIE:   What sort of things? 

CHRIS HELMS:   Well for example for my own practice I treat anything from coughs and colds, sinus infections, et cetera, to things like diabetes, hypertension, high cholesterol, heart failure, et cetera. 

JENNY BROCKIE:   You sound a bit like a GP? 

CHRIS HELMS:   And in fact I've heard that before.

JENNY BROCKIE:   What is the difference? 

CHRIS HELMS:   Yeah, the qualitative difference is first of all I tend to spend a great deal of time, a longer time with my clients than a typical GP consult for the same condition and that's because probably 50 to 75 percent of my consultation time is spent on assessing, diagnosing and managing the actual condition that they're presenting with. But the other 25 to maybe even 50 percent of the time you know some place between 25 and 50 percent of the time I'm actually provided education about the illness. I'm trying to talk to them about well, okay, you've come in with your complaint of high blood pressure and you're still smoking and you're very overweight so let's talk about those conditions.

JENNY BROCKIE:   And how can you afford the time to do that? 

CHRIS HELMS:   Well that's actually a very interesting question because right now in Australia, nurse practitioners are struggling to actually…

JENNY BROCKIE:  Who pays you? 

CHRIS HELMS:  Well depends. The nurse practitioners can work in the public sector or the private sector. I happen to work in the private sector and right now I recently did a report on the financial impact of hiring a nurse practitioner to work in collaboration with general practitioners in general practice and it showed that it's, it's extremely difficult to maintain financial viability because the reimbursement is not adequate. And so, you know…

JENNY BROCKIE:   So do you claim through Medicare?  

CHRIS HELMS:   I claim through Medicare, yeah. 

JENNY BROCKIE:   So what can you, what can't you do that a GP can do? 

CHRIS HELMS:   So what I can't do is, for example, if somebody comes in and I evaluate that there's probably a gland, a thyroid disorder for example, there's a nodule on somebody's neck and I perform some blood tests, those blood tests indicate that they have a problem with their thyroid, it's under functioning but I can't order the actual diagnostic test which is used to help supplement the diagnosis. 

JENNY BROCKIE:   Okay, now there are 1100 nurse practitioners registered in Australia at the moment. What do doctors think of their increasing role?  Ranjana, what do you think? 

DR RANJANA SRIVASTAVA: So Jenny I work as an oncologist, I work in the public health system where I work closely with a nurse practitioner.  I think they're worth their weight in gold. I've give you some examples. Before the time we had nurse practitioners, say a patient who's having some chemotherapy tablets, comes out in a rash, their skin is peeling or they're getting intense nausea and vomiting, they would -  they might try to contact their oncologist which is quite difficult in the public health system sometimes, or they would front up to the Emergency Department.

Once you show up to the Emergency Department it's extremely difficult to leave and so my, our patients carry the nurse practitioner's number, they will call the nurse practitioner who brings the patient in, into her clinic which she runs on her own, or she's able to offer high quality evidence based phone support. 

JENNY BROCKIE:   How much training do you do by the way? 

CHRIS HELMS:   You have three years of your baccalaureate Registered Nursing program and then you have to have a minimum of five years Registered Nursing experience, then you need to get post graduate qualifications and then finally you can get into a Master’s degree in Nurse Practitioner program which in general lasts about two years and…

JENNY BROCKIE:   So how many years all up? 

CHRIS HELMS:   About ten years. 

JENNY BROCKIE:   About ten years, okay. 

DR RANJANA SRIVASTAVA: The nurse practitioner I work with has had thirty years of oncology nursing experience. She is far more valuable to many, many patients I think than a ten minute consultation with their oncologist. 

JENNY BROCKIE:   Okay.

CHRIS HELMS:   The other problem with nurse practitioners however is that a lot of them actually work in these trans boundary models where they're actually helping assist with the translation between the hospital and the home and keeping people in their homes. Unfortunately nurse practitioners here in Australia are only operating at about 40 percent efficiency because of national state based and local restrictions in their practice. So it's actually quite frustrating. 

JENNY BROCKIE:   Okay, Saxon, what does the AMA think about nurse practitioners and them having an increasingly independent role in health care? 

DR SAXON SMITH: Well we're a strong advocate for practice nurses and have been. You may not be aware… 

JENNY BROCKIE:   But that's different to nurse practitioners? 

DR SAXON SMITH: I'm being very appropriate with the language because if you may remember about three months ago the government tried to cut the rebates around the ability to fund your practice nurse which provides the role that Chris is talking about, and it's a very distinct entity. 

JENNY BROCKIE:  No, but ten years training is a bit of a different role I think, isn't it, to…

CHRIS HELMS:   Absolutely. I mean the kind of care that I'm providing is not as a role of a practice nurse.  I'm a nurse practitioner working in primary health care and I work with practice nurses and we work as a team.

JENNY BROCKIE:   I want to go back, this is really important because these sort of things become, you know, issues around what we support and what we don't support and I just want to clarify that with you Saxon, do you or do you not support the idea of nurse practitioners writing scripts, doing the kind of things that doctors, that GPs would do? 

DR SAXON SMITH: The AMA's position is that we do not support of role of an independent nurse practitioner. We support the role that they can have in that practice nurse setting, where they can have extended role, they can provide all the education that Chris is talking about but as part of that team. 

JENNY BROCKIE:   But why don't you support them having a more independent role? What's the basis of your objection to the idea of them having more of an independent role? 

DR SAXON SMITH: Well the question is why are they existing? And they're existing because you have a model of health care which means that an interaction for a GP is limited by time because that's how you're funded. 

PROFESSOR JOHN DWYER:  But the main point is anti-integration. You see we are talking…

JENNY BROCKIE:   Hang on, I just want a response from Chris and then I'll come to you. 

CHRIS HELMS:   I guess I feel that, you know - it's unfortunate that the idea of, first of all, a medical home is being perpetuated. I feel that it should be a primary health care home because it implies that people are actually working together in concert with each other. That may be a nurse practitioner, that may be a physiotherapist or a dietician.

JENNY BROCKIE:   Okay. Terry Barnes, you've been listening to all of this and I'm really keen to bring you in on this discussion because you've advised Tony Abbott on health when he was Health Minister. I think you raised the idea of a GP co-payment as one option or one thing to look at, is that right? 

TERRY BARNES, POLICY CONSULTANT:  I raised a model of a GP which is a little different to what actually came out. 

JENNY BROCKIE:   Different to what came out but from your point of view, how, how much more efficient could the system be without having to go to something like a co-payment to raise funds? 

TERRY BARNES:  Well I think when we look at the overall cost of the system and its sustainability over time, we have to be able to finance it and basically the whole principle of the co-payment comes down to the notion that if you have the means to contribute to the cost of your care you should be reasonably expected  to do so as long as it is a fair and modest contribution I think what has really frustrated me, particularly in the last couple of months, is that the debate about the co-payment has absolutely swamped the tougher conversation that we should be having about how the system should be working, how it should be financed, how people should get access to it. 

JENNY BROCKIE:  But that's because it's been prioritised above having that other discussion? 

TERRY BARNES:  But that's the problem of the politics of the issue Jenny.

JENNY BROCKIE:   But why is it, why aren't we hearing that dialogue? 

TERRY BARNES:  That's because it's a lot of the time it's experts talking about to other experts about things that interest experts and not enough is heard about things that interest patients as consumers and as users of the system. 

JENNY BROCKIE:   I should point out we did invite the Health Minister and the assistant Health Minister tonight but no luck there unfortunately. It would have been good to have them in the room but keep going. 

TERRY BARNES:  I think how the health system is paid for is a high priority, but it is more than just a single measure of the co-payment. The fact that our debate is reduced to that I think has been counterproductive to a good conversation. But it's also politicised it in a way that makes it very hard to make progress. 

JENNY BROCKIE:   Given that we know that there are problems with financing the system and where the money’s going to come from and you know, rising health costs and so on, how much money could we actually save from some of the things that we've talk about tonight? I mean Stephen you're a health economist, have you done numbers on where the savings lie? 

STEPHEN DUCKETT:  We've done lots of numbers, I mean we've done some work on hospital efficiency and we identified a billion dollars’ worth of savings that we made on just making hospitals more efficient. Half a billion dollars on changing the staffing and using staff better in hospitals so there is money to be saved.

DR IAN MADDOCKS:  The Health Minister in South Australia has just said that he's going to shut the repatriation hospital.   Now I think if he saves all that money by all those beds and could put that money into community care we would actually see something very useful happen but who knows what he's going to do with the savings? We don't know. 

PROFESSOR JOHN DWYER: The debate we should be having is not about a co-payment which the government, it's not Terry's fault but the government actually confused everybody by saying we can't afford Medicare but the $5 co-payment, well first the doctors could have it and then we'll put it into a research fund which wouldn't have helped,  would have been good for a research fund but wouldn't have helped the bottom line of Medicare, and you have a Health Minister just looking at Medicare rather than the whole of system and realising that working with the states in our fractured system to put more money into Medicare you would save a bucket of money by reducing hospital expenses. 

JENNY BROCKIE:   Okay, Terry. Sorry, over here, yeah Carly? 

CARLY STEWART: With the $5 co-payment, or whatever co-payment they're talking about at the moment, that's going to push us back into hospital.  Because of Lachie's position, we're prime candidates for being admitted when he doesn't need to be, you give me that $5,000 from that hospital bed I'll keep him healthy at home. Because that $5,000 will pay for me to have respite, to be able to get a good night’s sleep, it will pay for my mental health care plan, it will pay for my son to have the support he needs in terms of physio and occupational therapy and speech therapy so that he can become a bigger contributor in our community and participate more fully in our community. I just think it's absolutely ridiculous. 

TERRY BARNES:  Well I think we have actually have to go beyond the co-payment. Again I think this is part of the problem, we're focusing, obsessing about that. I think what we…

JENNY BROCKIE:  Well we're not, we've spent the whole night talking about everything but.  

PROFESSOR JOHN DWYER:  It's all the government's talking about Terry. It hasn't put forward one single idea for changing the infrastructure to improve the health. 

JENNY BROCKIE:   Okay, let him finish. 

TERRY BARNES:  But that's the point I actually wanted to make. I think that part of the problem we have is that the funding of health care runs decades behind the times. It really is a 1970's approach to how we look at the system - basically a system that is still designed by doctors for doctors. 

JENNY BROCKIE:   Saxon, your response to that? I mean…

 DR SAXON SMITH: It's not a system designed by doctors for doctors.  But if we just to the co-payment issue, it's not only the issue around forcing those on a lower socio economic scale back, or chronic diseases back into the hospital system. It was accompanied with a cut to the Medicare rebate in our general practice and our ability to have coordinated, you know, wellness based model so you can have your nurse practitioners, you can have your occupational therapists and your physiotherapists working in conjunction in that team model.  It was slashing that, so you're defunding Medicare. 

JENNY BROCKIE:   But Terry's talking about wanting an increased role for people other than doctors. 

PROFESSOR JOHN DWYER:  That's what we've been talking about all night. 

DR SAXON SMITH: A coordinated team based patient centric. 

DR CHARLOTTE HESPE:  And we've got to be careful that we don't fund the system that's becomes more dislocated and I think that's where Saxon is sort of saying where the AMA doesn't support say pharmacists doing primary health care and doesn't support practice nurses because you then have this siloing, continuously. 

JENNY BROCKIE:   Okay, but my question is does the culture have to change for that to actually work? Does the culture…

DR CHARLOTTE HESPE:  Well the culture can't change while we don't fund it.  We've got no ability to do it so at the moment everybody continues to do their little silos. 

JENNY BROCKIE:   Laura, what did you want to say, Laura? 

LAURA GRANT:   As a current medical student this model is what we are being taught in university right now. My university holds on-line forums that cover cohorts of nursing students, physiotherapists, occupational therapists, speech therapists and a medical student and we can all come in there and take the typical role that we could take.  So the medical student is the leader of the conversation but it's about teaching us to actually understand each profession and what they bring. So it's not just thinking, it's not simple and it's not siloed.

JENNY BROCKIE:   Okay, Terry, what do you think the political conversation should be about? 

TERRY BARNES:  That's a very good point and I think the political conversation should be looking at health, health care holistically, not just focusing on funding, not just focusing on who does what and I think the medical demarcation, the idea of doctors as gate keepers, as ultimate controllers, needs to be broken down a bit as well. But funding and policy has to actually encourage that to happen and I think this is where I'm a bit frustrated by the co-payment debate has hijacked all this goodwill that really needs to be there if we're going to make any progress. 

JENNY BROCKIE:   I'm a going to be very practical here and talk about tomorrow. If there was one thing that you could get them to do, you could get the politicians to do immediately, what would it be? Terry?

ASSOC. PROFESSOR TERRY HANNAN:  Get them to listen to those who've done it and made it successful. 

JENNY BROCKIE:   Overseas? 

ASSOC. PROFESSOR TERRY HANNAN: Yeah, for the classic example is the project that I actually worked with.  Think about 40 million people with AIDS, we have used an appropriate tool to control that epidemic within ten years as well as other diseases. How did we do it? We all collaborated, we got together and it continues to evolve to meet the changing medical needs of the communities and the patients with the E devices manage their health. 

JENNY BROCKIE:   Okay, Stephen what would you do? 

STEPHEN DUCKETT:  I think proceed incrementally, that is don't try and do a big bang change that's going to fix the system overnight. We've got time to address problems, we need to experiment, we need to see what works, assess it in the Australian context.

JENNY BROCKIE:   Charlotte? 

DR CHARLOTTE HESPE:  Take the co-payment off the table to actually allow the conversation to open up exactly as we've talked about, so that we can actually look at other health reform generally, rather than it just being focused on this nonsense. 

JENNY BROCKIE:   Saxon? 

DR SAXON SMITH: I agree we need to take what's on the table and been offered off the table.  We can now use this as an opportunity as a community as all health care providers go what is that we want for our health care?  What is our future direction? How can we make these models work and it needs to be that collective conversation, not a political tool. 

JENNY BROCKIE:   Carly, what would you want to change immediately? 

CARLY STEWART: The co-payment is obviously a great place to start but if we're looking at a group that's going to start looking at what these changes need to be, it definitely needs to have parent, carer and individual representatives, not just doctors so that we're actually at the centre of whatever these discussions are. 

JENNY BROCKIE:   Katherine? 

KATHERINE CLAY:  If it was immediately I would say let's take the model that we've heard about as I believe that would make everybody accountable, the doctors, the parents, the patients, straight away that we could all see exactly what was happening, yeah, all the different levels. 

CANDICE KRIEWALDT:   An on-line health system I think, accessible to the patient primarily that they can take where ever they want to go. 

JENNY BROCKIE:   So being able to get your own information easily? 

CANDICE KRIEWALDT:   Yes. 

JENNY BROCKIE:   Which was kind of where we started. Thank you all very much for joining us tonight, it's been fascinating, really worthwhile discussion, and it is all we have time for here but let's keep talking on Twitter and Facebook.