Prepared by Dr Tim Woodruff, President, Doctors Reform Society

 

The Doctors Reform Society is an organisation of doctors and medical students which formed in 1973 to support the introduction of a universal health insurance scheme (Medibank). It is an organisation which continues to advocate for a health system and a society which aims to address all causes of poor health outcomes for all people irrespective of income, socioeconomic status, race, culture, and geographical location.

Terms of Reference

On 8 April 2020 the Senate established the Select Committee on COVID-19 and referred the following matters to it for inquiry and report on or before 30 June 2022:

the Australian Government’s response to the COVID-19 pandemic; and any related matters.

 

 

Thank you for the opportunity to comment on this crucial and ongoing issue. The following is about the response to date and the response as the pandemic evolves and we adjust to the new normal.

The Economy

The pandemic has brought to the fore a realisation firstly that a healthy community helps the economy and secondly that having many Australians with an inadequate income severely compromises the economy. This inter-relationship between an adequate, secure income, health, and the economy must be remembered as we progress our response to the pandemic.

Health

Those in the health field talk about the two major determinants of a healthy community. Firstly, timely affordable access to quality health and preventive care is required. Secondly, we talk about the social determinants of health (SDOH), the conditions in which people are born, grow, live, work and age. Inadequate income, poor education and resulting lack of understanding about illness prevention, domestic violence, homelessness, and discrimination are just some of these important determinants.

The Australian Governments’ Response

The Australian Government’s response to date has resulted in avoidance of the disastrous explosion of cases, which might have overwhelmed our health system. It is to be commended for putting together a team of medical advisors and listening to their advice. That advice has had a strong scientific evidence base despite it requiring assumptions because of the novelty of the virus.

Benefits and Costs

This response has come at a huge economic cost much of which is unavoidable. What has been apparent however is that the Government clearly recognised that the Newstart Allowance was not sufficient to contribute to preventing an even greater economic challenge than we have. The Newstart Allowance was 40% below the poverty line. In the Australian population, 13% currently live in poverty, 17.4% of kids are being raised in poverty, and 40% of children in lone parent families live in poverty (ACOSS 2016). Now most of those fellow Australians receive the Job Seeker payment. It is now a little above the poverty line. No one is saving money on this allowance. Little is wasted. It is being spent and is helping to maintain the economy. Those who have recently lost their jobs will be spending every cent as they try to manage their pre-existing financial commitments.

Future Income Benefits Cuts

From a health perspective, this massive increase in income for our most disadvantaged is overwhelmingly positive. Poverty in rich countries like Australia is very strongly associated with health and social problems (Wilkinson and Pickett). If Job Seeker is reduced to a Newstart level, there will be a return to poverty for the recipients, which will help no one. Whilst in theory the savings might mean we repay the national debt faster than otherwise, recipients will be less healthy, less able to seek work, will spend less, and will place increased demands on health and social services. There may be a net economic loss. There will certainly be a decline in health outcomes.

Alternatives for a More Secure Future: Income Support

The provision of the Job Seeker payment has not surprisingly, been troubled with long queues at Centrelink, inadequate phone response capacity, and major problems for those who have difficulty managing complicated paperwork for whatever reason. How much easier would it have been if we had had a basic income guarantee (BIG)? This is an idea supported across the political spectrum including the conservative capitalist Nobel Prize winning economist Milton Freidman, the Productivity Commission Page 69), and Brian Howe, retired Hawke Government Deputy Prime Minister. No Centrelink queues (with or without physical distancing). No hours on the phone trying to contact Centrelink. No days or weeks waiting for the phone call from Centrelink. No demeaning experience of trying to interact with an organisation with such a focus on stopping rorting that humanity is lost. Even with BIG, huge changes would still have been required. It would however, have been much simpler, faster and less traumatic for all involved.

Alternatives for a More Secure Future: An Integrated Health System

When the trajectory of the pandemic in Australia was upwards there was a major concern regarding the capacity of our health services to cope, both in the community and in hospitals. Some publicly subsidised private hospitals continued to use vital PPEs for elective surgery whilst others were threatening to close for financial reasons despite the real possibility their beds, staff, and equipment might be needed if infection numbers rocketed. Instead, they won a $1.3 billion pay-check from taxpayers before it was clear they would even be needed.

Imagine if instead of using public taxpayer funds to increase the capacity of private hospitals over the last 20 years, we had instead put that money into public hospitals. Sixty percent of elective surgery in now done privately. If most of that was being done in an enlarged public system, we would have a huge increase in bed and ICU capacity easily accessible without any need to pay more money to the private hospital industry.

Imagine if instead of allowing public mental health funding to remain at staggeringly low levels compared to the documented needs, we had used taxpayer funds to develop an integrated community and hospital system of care. The tsunami of increased mental health issues developing as this crisis evolves would at least have been manageable. Despite the commitment of extra funds now to address this crisis, those funds are being spent in a system, which is not a system but a maze of poorly co-ordinated service providers.

Imagine if instead of allowing residential aged care to be subject to market forces and run by Boards  with little understanding of health, there had been a health principled base for aged care underwritten by  adequate Aged Care Funding Instrument (or other) payments and adequate health informed governance systems. Staff would no longer be on low wages and casual, with perverse incentives to work when they are sick. Residential aged care would no longer be a potential source of infection (all sorts including COVID). Our community would no longer be exposed to agonising decisions about palliative care for the elderly in underserviced environments or in overstretched hospitals not designed or equipped to deal with dementia and aged care. At the moment, either way our senior citizens are likely to die lonely and uncomfortable deaths.

Now is the time to consider an independent single funder for health care tasked with funding and integrating prevention, emergency services, primary health care including dental care, and hospital services using health professionals working in expanded more relevant  practices.

Such an organisation must have a remit to fund services which can be demonstrated are effective and which are integrated with other services. Implementing this reform is a long-term project. It could start with controlling all new funding and gathering the data required to establish services based on need across the country and across the health service spectrum. Health service education would be tailored to support this implementation by coordinating education between professions.

Alternatives for a More Secure Future: Essential Medical Supplies and Data

During this crisis, we have been confronted by major challenges relating to supplies of medicines, vaccines, diagnostic testing reagents along with equipment and personal protective equipment. There may be challenges with respect to the equitable distribution of COVID-19 vaccines as they are developed. These problems largely relate to patent laws, which are structured to favour the owners of patents even at the cost of preventable patient suffering and death. The Australian Government has the power to over-ride patents in the interests of public health. It should! (Gleeson and Legge)

In addition, the European Union has put forward a draft resolution for the World Health Assembly for a global pool for rights on data and knowledge that can be of use for the prevention, detection and treatment of COVID-19. The Australian Government should support this measure.

Alternative for a More Secure Future: Telehealth

The advantages of telehealth in this crisis have been very obvious. No more crowded virus loving doctors’ waiting rooms, no unnecessary exposure of patients, medical staff, and medical office workers to rampaging viruses. Patients have frequently found it so much more convenient to address simple issues. Relatives don’t have to take the day off work to bring elderly patients in for a simple quick visit. We already use the technology to enable specialist services to non metropolitan areas.

There are however a variety of concerns.

Sadly there are doctors who are keen to see patients quickly and are not as thorough as we might hope. In general practice these doctors are sometimes identified by the Professional Services Review Board (PSRB) which is able to see Medicare rebate usage. Unfortunately the PSRB is seldom able to identify specialist over-servicing because specialist practice is so varied and the statistics fail to identify outliers.

• Phone and to a lesser extent video calls miss important visual cues.
• Patients clearly sometimes feel the pressure to finish the consult much more than when in person
• Accidental/ incidental issues are less likely to be uncovered than in a face to face consultation
• Fee for service medicine itself is a barrier to the provision of comprehensive integrated care with multiple providers, dealing with patients with multiple morbidities. Doctors and other providers do this every day in public hospitals. On a salary, the decision to ring patients, videoconference them, or ask them in for a face to face consultation is based almost exclusively on what would be in the patients’ best interests. Getting paid doesn’t matter. Telehealth will further entrench fee for service medicine to the detriment of the health system.

What can be done?

We have many salaried doctors and other health professionals. We need more. Aboriginal Controlled Community Health Centres give us one well established model of how this might be done in general practice. Victorian Community Health Centres treating patients generally in more disadvantaged locations provide another model for general practice. Public hospitals, which have been critical to dealing with this pandemic demonstrate that salaried health care can and do provide high quality care without constantly looking to find ways to increase income.

Whilst some might suggest we might limit telehealth to video consultations rather than allowing telephone consultations as has happened with the crisis, such a decision clearly discriminates against those who cannot manage or access the technology. Such people are already the ones who tend to get the least quality health care.

Listening to the Science: Climate Change

It is reassuring that politicians have sought out and accepted scientific advice on how to address the current health crisis. A key lesson to be taken from this response is the importance of evidence and science and the need for greater acceptance of the science of climate change which has the capacity to wreak even more havoc to both our health and our economy over time than this pandemic.

COVID-19: An Opportunity for a Better Future

Hopefully, we will not be going back to a world where welfare recipients are demonised, job seekers are punished, and vulnerable people with a poor education, a mental illness, a drug addiction, or any number of other life challenging conditions/situations are regarded as lazy useless sub-humans. Experience in other countries has shown that it is just these groups which are least equipped to deal with a pandemic. It is these groups which may harbour a resurgence at any time (e.g. migrant workers in Singapore).

It is time to move to a progressive, kinder, caring society which sees every person as valuable, which maximises everyone’s very variable capacity to contribute to society, and which enables rather than hinders the integration of our most vulnerable brothers and sisters.

Jobs need to be secure, not just any job. Income needs to be adequate, not held low in an unsubstantiated belief that that gets people working again in a productive way. Income and wealth disparities need to be reduced. We need to recognise the stark correlation between health and social problems and income.

As we manage our way through this crisis, it is time to think about an integrated, comprehensive, equitable health system. It would be good for the economy. Further, it is time to look at restructuring our society to recognise and address those factors outside the health system, which affect health and therefore affect our economy and our individual well-being.

 

 

 

The Doctors Reform Society of Australia is concerned about the potential adverse health and societal impacts of two aspects of the Budget Savings (Omnibus) Bill 2016.

1. The bill proposes a $1.3 billion cut to the Australian Renewable Energy Agency (ARENA) over the coming 5 years. Many renewable energy researchers believe this likely to have serious negative impacts on renewable energy science in this country.

As a health organisation, we recognise the serious threat that climate change poses to health, both now and increasingly in the future. International health researchers believe climate change to be the biggest global health threat of our century. We believe that Australia needs to play a vigorous role in mitigating climate change. Clean energy technologies will be a vital part of such mitigation.

Cutting funding to such mitigation efforts would be a serious false economy.

2. The bill proposes to cut $4.40 per week from the energy supplement to Newstart recipients. New Newstart recipients receive a payment significantly below the poverty line, and this new cut would reportedly take these people 32% below the poverty line. International evidence finds that less generous unemployment payments are associated with poorer return-to-work outcomes. Inequality and poverty are important drivers of poor health outcomes.

We ask that the committee strike these budget measures from the bill. Indeed, we believe Australia should go further than this, and increase support for renewable energy and unemployed people.

Yours sincerely

Dr Brett Montgomery

on behalf of the Doctors Reform Society

 

Thank you for the opportunity to respond to your draft report. It is an impressive document with extensive recommendations covering access to appropriate evidence based integrated patient centred care, improved governance, funding models, improved data collection, and other important determinants of optimal care.

This submission is therefore mainly about the gaps in the report recommendations and/or those recommendations with which we disagree or which are insufficient to address the issue.

Social Determinants of Health

The report appears to acknowledge the importance of the social determinants of health e.g.

“700,000 people in Australia have been in income poverty for at least the past four years. Unemployed people, those with disability and Aboriginal and Torres Strait Islander people are at higher risk of income poverty and deprivation.

People experiencing financial stressors, such as low income or poverty, and/or compromised financial security, such as being unemployed or having excessive debt, are at increased risk of developing a mental illness.

Data shows that people living in the most relatively disadvantaged areas of Australia reported significantly higher levels of psychological distress and mental illness than those living in the least disadvantaged areas.”  Page 122, Vol 1.

It then goes on to discuss the scope of the inquiry, indicating that the terms of reference essentially gave the Commission carte blanche to address any issues which seemed appropriate.

However the Commission has then limited itself to

“focus(ing) on improving the way systems and government services can support people with mental illness across all walks of life, and contribute to population wellbeing”. Page 123, Vol 1.

In fact it has limited itself even more than that because it has failed to address relative income inequality which is directly related to government services in the case of Newstart, ‘robodebt’, and the Parents Next program.

Another example of recognition of the problem and not making recommendations to address the problem is that of social stigma. Thus

“People likely to experience both social exclusion and poor mental health include those

on lower incomes and with poor access to material resources, …….” Page 93, Vol 1.

None of the more than six recommendations to address stigma are directed to improving incomes or access to material resources.

There is even a section on income support, which at least makes recommendations regarding an increased threshold for earnings before loss of the Disability Support Pension. But the reform objective stated below,

“Income support for people with mental illness and their carers that is accessible and does not discourage work, study or volunteering activity “Page 73 Vol 1

fails to mention that the level of support should be adequate and not well below the poverty level as Newstart is.

It is thus very disappointing that the Commission has chosen, at least to date, to avoid the potentially politically uncomfortable challenge of frank and fearless advice on the contentious issue of income inequality, housing accessibility, and the associated powerlessness of patients and their carers struggling with mental illness.

It is worth noting that a previous Productivity Commission paper stated that

“While Australia’s tax and transfer system will continue to play a role in redistributing income, in the longer term, governments may need to evaluate the merits of more radical policies, including policies such as a universal basic income.”

If the Productivity Commission can at least raise such ‘radical’ ideas, surely a report into mental health can recommend that income inequality and its associated features be directly addressed.

Relative income inequality will never disappear, but its degree is clearly correlated with social distress across a wide range of parameters including suicide, social exclusion, mental illness, and general well-being (Wilkinson and Pickett, The Spirit Level 2009).

Climate Change

There is no mention in the report of the words Climate Change. Climate change has and will have profound current and future impacts on mental health. These include the direct effects of warming-associated disasters (e.g. the traumatic and/or depressive nature of bushfires, heatwaves, storms and drought) but also more subtle, less direct effects. The latter include the mental health impacts of physical illness, of food and water insecurity, or forced migration, and of despair in the face of global environmental change. The mental health effects of climate change are predicted to disproportionately affect those who are already marginalised and thus most vulnerable.

To ignore this issue and its contribution to the mental distress experienced in Australia would seem to be totally inappropriate. Even without the recent extreme weather events, the increased droughts, record high temperatures, and decreased farm viability have contributed to an increase in mental illness and suicide in rural Australia.

Climate change is an issue which cannot be solved by mental health system policy alone. It requires broad international societal responses in many domains. However, it needs to be considered by any inquiry into mental health – so multifaceted are the effects of climate change that its importance must be recognised by inquiries into any of its consequences.

In previous submissions to other inquiries, we have argued that the Australian government, like many other governments, needs to significantly increase its ambition and effort in emission reduction in order to help to mitigate future climate change. With every fraction of a degree of warming adding to global health risk (including mental health risk), we believe emissions reductions should proceed as quickly as possible. The Productivity Commission should not shy from making such recommendations, too.

We also need to adapt as a society to the effects of that warming which is now unavoidable. More research is needed to better understand the links between climate change and how to best adapt. Amongst many other actions, we will need to build capacity to respond to extreme weather events, both in terms of practical support and more specifically mental and physical health effects. Steering our policies towards a more equitable society is not only good for mental health in a general sense, but also adds somewhat to our societal resilience to climate-related disasters.

Private Health Insurance

Whilst looking at funding models to improve community based healthcare, the recommendation “to increase the scope for private health insurers to fund programs that would prevent avoidable mental health-related hospital admissions does need reconsideration”. (Recommendation 24.5, Page 107)

The reasons for not permitting private health insurance to cover such care are the same as those preventing coverage of community visits to doctors. Firstly, such coverage would lead to a cost increase by those providing the services. That is very evident in the private hospital sector where such coverage is allowed. It is an ongoing battle between private hospitals, private doctors, and insurance companies who all seem to win whilst patients pay more. Secondly, such coverage would mean that providers who might have provided such services in the public system, will instead be tempted into private provision. That is why there are shortages of specialists in public hospitals. Thirdly, if patients and carers who have sufficient income to afford private health insurance can get services privately, they will cease to advocate for better public services. They are likely to be the most articulate patients and advocacy for the public system will be weakened.

The  recommendation should instead, be demanding adequate provision of such services through the public sector.

Summary

There are many excellent ideas and recommendations in this draft report. The two glaring omissions are the lack of recommendations on income inequality despite the acknowledgement of its importance, and the complete absence of the health effects of climate change.