On any international ranking, the Australian health system rates highly. In discussions with my counterparts overseas, the benefits of our system are envied and reinforced. But we are entering an era where there will be new and significant pressures on our health system.

The challenge presented by increasing numbers of frail and aged people in the community - together with those with multiple, complex and chronic health care needs - has to be tackled.

So the AMA sees the 2007-08 Federal Budget as an opportunity, especially in an election year, to strengthen the pillars of the health system to ensure the most needy and disadvantaged are looked after and the health of future generations is protected.

The AMA has singled out the battle against obesity and fixing Indigenous Health as priorities that the Government should not and must not avoid.

There has been a lot of talk around combating obesity but now it is time for action - serious action. It will require significant funding and unprecedented cooperation between all levels of government. Our kids deserve no less.

The appalling state of Indigenous health remains a sad indictment of our failure to address a major crisis in human health. Our international reputation and our national conscience demand a concerted coordinated effort to bring the health of Indigenous Australians into the 21^st century - and it must be done with commitment and compassion. Next year's 40^th anniversary of the referendum on self-determination provides the perfect backdrop for an Indigenous health solution.

Our third priority is aged care. A missing component of our aged care system is easy access to comprehensive health care from a GP or under the direct supervision of a GP. We present to Government affordable and practical solutions to give older Australians quality health care in their twilight years.

The other elements of this submission are all about planning for a medical workforce in the right numbers and with the right skills to keep Australians healthy, and making better use of the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Schedule (PBS) to ensure every health dollar delivers a health benefit to patients.

We also offer the Government a long term care scheme for people with severe disabilities to ensure money goes to people in need, for proper care, irrespective of how their disability arose, and not just those who can find someone to sue.

The AMA Budget Submission is all about quality health care for all Australians. We urge the Government to examine it closely and act on its recommendations.

Dr Mukesh Haikerwal
AMA Federal President

More action on obesity

The opportunity:
A recent Access Economics report found that 3.2 million Australians are clinically obese. The estimated total cost of obesity in Australia for 2005 was $3.8 billion. Of this, the specific cost to the health system was $873 million. Obesity is now a major health risk for Australians - one that threatens deteriorating health outcomes for the individual and very high costs for the health system.

How done?
The AMA is calling for the establishment of a National Nutrition Centre, which would have two core functions:

• Establishment and ongoing management of an independent National Nutrition Survey. This was last undertaken in 1995. Updated independent data is desperately needed
• Coordination and promotion of research findings relating to nutrition. This would include a yearly forum for Australian and international researchers to inform medical and allied health professionals and policymakers on topical nutrition issues and best practice interventions.

The cost:
A major funding commitment of a minimum $100 million per year, ongoing, for initiatives including:

• $20 million for a national nutritional literacy campaign
• $10 million over four years for a National Nutrition Centre
• renewed funding for the Healthy School Communities program (a component of the Healthy, Active Australia program), which involves funding of $5,000 per school, childcare centre, aged care home, hospital, and prison/correctional facility in the country
• $1.8 million a year for a scientifically-based, fully independent National Nutrition Survey.

More details?
Dr Margaret Chirgwin
Director, Public Health and Ethics Department
Telephone: 02 6270 5449
Email: mchirgwin@ama.com.au

Aboriginal and Torres Strait Islander health

The opportunity:
Increased access to appropriate primary care, including medications, for Aboriginal peoples and Torres Strait Islanders would significantly improve the health of the most disadvantaged Australians, while reducing, in real terms, the high burden of tertiary health care.

How done?
Well-evidenced primary health care interventions that have considerable potential are areas such as mother and baby clinics, better access to the PBS, and better pay levels and training for staff. A key element would also be to train more Indigenous people as health professionals. A National Rheumatic Heart Disease Control program would operate mainly through investment in comprehensive primary health care but would include investment in a National Register and would require national coordination.

The cost:
$460 million per year for primary health care, including:

• $20 million per year earmarked for Mums and Bubs programs
• $20 million a year to ensure pay parity for those working in this sector
• $3 million a year to increase access to PBS in all Aboriginal Health Services through extension of the s100 program and extending access to the PBS without a co-payment for those using GP services (would increase PBS spending by $50-100 million a year within three years).

Other initiatives, including:

• $2.8 million per year for five years to progress a national rheumatic fever eradication strategy
• $16 million per year for the implementation of the Australian Indigenous Doctors' Association Healthy Futures Best Practice Framework.

More details?
Dr Margaret Chirgwin
Director, Public Health and Ethics Department
Telephone: 02 6270 5449
Email: mchirgwin@ama.com.au

GP services in aged care facilities

The opportunity:
Residents of aged care homes are among the sickest and frailest of Australians. They have higher needs for general practice care than their counterparts of the same age and sex living in the community. The numerous barriers faced by general practitioners (GPs) who care for patients in aged care homes have led to a situation where fewer GPs are prepared to visit the homes, causing a critical shortage of GP services within some homes. Restructuring the relevant Medicare Benefits Schedule (MBS) item numbers for attendance at aged care homes will improve access to medical services in these facilities.

How done?
MBS items for attendance of patients in aged care homes must be restructured to reflect innovations that exist in other areas of the MBS that have been demonstrated to contribute to high quality team based care. Such a restructure of the relevant MBS items must deliver the capacity for GPs to delegate some tasks to their practice nurses and other clinical staff. The new items must reflect the complexity and the significant amount of clinically relevant non face-to-face time involved in providing medical care to residents of aged care homes.

The cost:
$9.7 million per year, subject to more detailed cost and structure modelling that should be undertaken by the Department of Health and Ageing in consultation with the profession.

More details?
Ms Julia Nesbitt
Director, General Practice and e-Health Department
Telephone: 02 6270 5431
Email: jnesbitt@ama.com.au

Long Term Care Scheme

The opportunity:
A national unified scheme to provide necessary care to persons with severe disabilities, however caused, would provide equity of access to essential services to those persons irrespective of the cause of their disability. This would relieve pressure on individual health and community care authorities throughout Australia, promote consistency in the quality of care, and save resources in the insurance and legal sectors by providing alternatives to litigation for those with no other means of affording the cost of their care.

How done?
A number of models are possible, but the key element will be a nationally co-ordinated and consistent system where all those meeting certain criteria (such as age, degree of disability, duration of disability) are able to access appropriate care provided directly or indirectly by government.

The cost:
A shared Commonwealth/State responsibility, which may possibly be supplemented by savings from the insurance industry. Costs should largely be met from the efficiencies resulting from national co-ordination and the reduction in legal costs, but an injection of some $400 million is essential to coordinate reform and establish initial infrastructure.

More details?
Ms Sarah Byrne
Legal Counsel
Telephone 02 6270 5423
Email: sbyrne@ama.com.au

Combined Medicare/PBS safety net

The opportunity:
In terms of holistic health care, access to a medical practitioner under Medicare and access to high quality pharmaceuticals under the PBS cannot be separated. Measures to improve access to one must also improve access to the other. Australians want greater certainty about access to health services and greater certainty about out of pocket costs. Government wants simpler systems that are more easily administered.

How done?
Combining the Medicare and PBS safety nets will improve access to Medicare and PBS services and can be achieved at a reasonable additional cost if we are to ensure no-one is worse off. Thresholds can be set to ensure additional Government expenditure is responsible and that access is enhanced. Government would administer only one safety net so red tape would be removed.

The cost:
$20 million in implementation costs

More details?
Mr John O'Dea
Director, Medical Practice Department
Telephone: 02 6270 5463
Email: jodea@ama.com.au

Consultant physician attendance items

The opportunity:
Serious problems are emerging in terms of access to Consultant Physician services due to workforce shortages. The shortages are widespread and include such sub specialties as geriatrics, general medicine, renal medicine, rheumatology, haematology, endocrinology, respiratory medicine and cancer medicine. These have been documented to the Government in a comprehensive submission from the Australian Association of Consultant Physicians. These are sub specialties that are largely consultative-based and, as the Productivity Commission has observed, MBS fees in these areas are relatively poorly funded compared to procedures.

How done?
The basic challenge is to lift the relativities of consultations for Consultant Physicians compared to procedures. This will solve workforce and access issues over time. Restructuring the consultation item in the MBS to recognise the greater complexity of consultations will be necessary. These items have not been looked at since the 1970s and are in need of urgent overhaul.

The cost:
$200 million a year.

More details?
Mr John O'Dea
Director, Medical Practice Department
Telephone: 02 6270 5463
Email: jodea@ama.com.au

Specialist training in private clinical settings

The opportunity:
A number of key reviews of medical training have highlighted the educational imperative to allow specialist trainees to undertake formal, recognised training in private clinical settings. Expansion of specialist training into private clinical settings will also play a role in boosting the capacity of our training system to respond to massive increases in medical student numbers.

In July 2006, the Council of Australian Governments endorsed the need to take this important step.

How done?
Provide joint Commonwealth/State funding to establish a program to expand training into a broader range of clinical settings, commencing on 1 January 2008.

The cost:
Commonwealth contribution of $225 million over four years.

More details?
Mr Warwick Hough
Director, Workplace Policy Department
Telephone: 02 6270 5488
Email: whough@ama.com.au

Restructure the GP consultation items for quality care

The opportunity:
Through a range of measures including the establishment of 'extended' item numbers under the mental health package and pregnancy counselling items, as just two examples, the Government has acknowledged the limitations of the current GP MBS attendance items in delivering the highest quality care for patients. A new structure, combined with a sustainable system of indexation, will provide the capacity for GPs to deliver the highest quality care, particularly in prevention and management of chronic illness for an ageing population.

How done?
Adopt the recommendations arising from the report of the Attendance Item Restructuring Working Group (AIRWG) for a seven-tier structure for GP attendance items. AIRWG urged a restructure in the interests of quality care.

The cost:
Potentially cost neutral

More details?
Ms Julia Nesbitt
Director, General Practice and e-Health Department
Telephone: 02 6270 5431
Email: jnesbitt@ama.com.au

GP referral to magnetic resonance imaging (MRI)

The opportunity:
The Federal Government can save around $40-42 million dollars by allowing GPs to refer directly for Magnetic Resonance Imaging tests (MRIs).

How done?
Permit GPs to order MRIs without referral to a specialist for morbidities for which the guidelines recommend MRI as the preferred investigation. The current limitations require that GPs refer patients to a specialist for referral for an MRI. This means that a GP who does not feel a specialist referral to be appropriate at this stage is limited to investigations less appropriate than the MRI. Research to assess the impact of allowing GPs to order MRIs directly was undertaken by the Family Medicine Research Centre, University of Sydney, on behalf of the AMA in 2006. The literature suggests good GP compliance with the guidelines where they are allowed to order MRIs directly.

The cost:
The 2006 study undertaken for the AMA by the Family Medicine Research Centre, University of Sydney, concluded that by allowing direct GP ordering of MRIs there would be a 75 per cent reduction in current ordering of CT scans where an MRI is clinically appropriate. This and other changes to diagnostic ordering and specialist referral would deliver savings of around $40-$42 million to the Government.

More details?
Ms Julia Nesbitt
Director, General Practice and e-Health Department
Telephone: 02 6270 5431
Email: jnesbitt@ama.com.au

Support for Procedural GPs

The opportunity:
Many GPs are struggling to access sufficient clinical experience to maintain their procedural skills. This is particularly the case when local public hospital services are closed or downgraded. In addition, the current Training for Rural and Remote Procedural GPs Program includes an artificial two-day cap on Emergency Medicine training.

How done?
The Commonwealth should fund the establishment of specific training posts for procedural GPs, allowing them to rotate through these posts in order to maintain their skills and learn new techniques.

The cap on Emergency Medicine training, within the Training for Rural and Remote Procedural GPs Program, should be abolished.

The cost:
$8.4 million over four years to support the establishment of training posts.

The abolition of the cap on Emergency Medicine training is expected to be cost neutral due to current program underspend.

More details?
Mr Warwick Hough
Director, Workplace Policy Department
Telephone: 02 6270 5488
Email: whough@ama.com.au

Support for training in general practice settings

The opportunity:
As the number of medical students and interns continues to grow, it will become critical for more training to be provided through general practices. GPs already provide supervision and training to students and registrars, but this work is time consuming and costly and must be better valued. Properly supporting general practice training is vital to ensure the quality of our future workforce.

How done?
The Government must consult with the general practice profession to determine ways of making training of students, interns and registrars more attractive and sustainable. This could include increasing training and supervision payments and providing infrastructure grants to facilitate practice expansion.

The cost:
$8 million in the first year

More details?
Ms Julia Nesbitt
Director, General Practice and e-Health Department
Telephone: 02 6270 5431
Email: jnesbitt@ama.com.au

Training and support of temporary resident overseas trained doctors

The opportunity:
We are not making best use of the 2,500 temporary resident doctors who come to Australia each year due to the lack of proper assessment, training and professional support. Better programs and support will lift productivity as well as the safety and quality of practice.

How done?
Better assessment (rapid assessment units), orientation and ongoing professional support, and better support for the families of temporary resident overseas trained doctors (Medicare, PBS, public hospital treatment, and public education).

The cost:
More than $47 million over four years comprising:

• $8.4 million over four years (assuming costs shared with the States) for training.
• $9.5 million over four years for Medicare and other entitlements.
• $4.2 million over four years for rapid assessment units.
• $25 million over four years for access to public education.

More details?
Mr Warwick Hough
Director, Workplace Policy Department
Telephone: 02 6270 5488
Email: whough@ama.com.au

Assistance for bonded medical school students

The opportunity:
Unfunded bonded medical school places are intended to boost the medical workforce in rural and regional areas. Overseas evidence shows that the Government's existing scheme will not lead to sustainable long-term increases in the rural medical workforce.

Unfunded bonding is based on conscription and offers no support and no incentives. It short-changes medical students and, ultimately, rural Australia.

How done?
The Government should introduce equitable return of service arrangements that include HECS relief, targeted financial incentives, and ongoing professional support for participating students and doctors.

The cost:
$24 million over four years.

More details?
Mr Warwick Hough
Director, Workplace Policy Department
Telephone: 02 6270 5488
Email: whough@ama.com.au

Rural Retention Program

The opportunity:
Generally successful rural retention programs are losing their effectiveness as the real value of incentives falls behind living costs and the costs of medical practice.

Existing retention programs do not extend to the specialist workforce.

How done?
Restore the value of these payments and adopt more sustainable indexation arrangements for future years. Extend eligibility to specialists.

The cost:
The additional cost would be $79 million over four years.

More details?
Mr Warwick Hough
Director, Workplace Policy Department
Telephone: 02 6270 5488
Email: whough@ama.com.au

Medical Specialist Outreach Program (MSOAP)

The opportunity:
MSOAP is an existing Commonwealth program that provides funding for outreach services in rural Australia. The program not only supports the delivery of key specialist services, but when properly integrated with existing services it can also help build the skills of local practitioners.

Despite extra funding in the 2004-2005 Federal Budget, MSOAP has already exhausted available funding through until 2008, and many worthwhile projects have been denied assistance.

How done?
Increase MSOAP funding by 25 per cent.

The cost:
The additional expenditure is estimated to be $15 million over four years.

More details?
Mr Warwick Hough
Director, Workplace Policy Department
Telephone: 02 6270 5488
Email: whough@ama.com.au

Rural hospitals

The opportunity:
Rural hospitals play an important role in delivering local services, training new doctors, and ensuring that local doctors can maintain their skills. The closure or downgrading of rural hospitals usually forces rural patients to travel much further for medical treatment and contributes to the de-skilling of local practitioners.

Through the Australian Health Care Agreements (AHCAs), the Commonwealth provides around half of the funding for public hospitals. It is time to use the AHCA process to make State and Territory governments more accountable for this expenditure, particularly in rural areas

How done?
The Commonwealth should work with the States and Territories to introduce a public interest test to assess hospital closures - one that addresses workforce, training, and community needs, as well as budgetary considerations.

The cost:
This initiative will deliver long-term benefits to local communities and contribute to a highly skilled rural medical workforce. In the long term, such a measure will be cost neutral.

More details?
Mr Warwick Hough
Director, Workplace Policy Department
Telephone: 02 6270 5488
Email: whough@ama.com.au