The Peak Body Representing Allied Health in Australia



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ABN 60 083 141 664



The Peak Body Representing Allied Health in Australia


Submission to the Primary Health Care Strategy Discussion Paper

February 2009

Further information:

Bo Li


C/o AHPA

PO Box 38, Flinders Lane

Melbourne VIC 8009

Email: office@ahpa.com.au

Website: www.ahpa.com.au




AHPA members:

Audiological Society of Australia, Australasian Podiatry Council, Australian Association for Exercise and Sports Science, Australian Association of Social Workers, Australian Institute of Radiography, Australian Orthotic and Prosthetic Association, Australian Psychological Society, Australian Sonographers Association, Dietitians Association of Australia, OT AUSTRALIA, Services for Australian Rural and Remote Allied Health Inc, Society of Hospital Pharmacists of Australia, Speech Pathology Australia, The Orthoptic Association of Australia and incorporating AHPARR (AHPA Rural & Remote).



About AHPA - Overview

Allied Health Professions Australia (AHPA) is the national peak body for major health professions and their representative bodies other than medical practitioners, nurses and unions. AHPA works to represent the interests of the allied health professions sector, particularly to the Federal Government; and to provide a vehicle for liaison and discussion between the professions themselves.

Members of AHPA are national organisations representing health professionals who have a role in the private and public health sectors, including public hospitals, involving direct client contact, or managing or educating such health professionals. Collectively, organisations within AHPA represent about 50,000 university-trained health professionals. Each organisation has internal systems and networks for liaising with its members, ensuring that AHPA has input from health professionals right across Australia who together provide a vast wealth of expertise. This submission reflects the areas of agreement across the AHPA professional groups.

Introduction

Australia currently has approximately 90,000 allied health professionals; together with doctors and nurses, they provide the essential skills on which Australia’s health system is based. Best practice management of certain conditions is unachievable without the specific contribution of allied health professionals.

AHPA’s vision for primary health care in Australia is based on an equal and collaborative partnership between all the health disciplines, including general practice, nursing and allied health, focusing on delivering the right intervention to the health consumer at the right time in the right place and in the most cost-efficient manner. It is also widely recognized now that primary and preventative health care can play a crucial role in reducing both the presentation and re-admission into acute care and associated costs in an ageing population with increased prevalence of chronic conditions.

To improve health outcomes throughout the community, Australia’s primary health care system must offer an effective, comprehensive and timely response to people’s total health needs, through direct access to expert multi-disciplinary health care.

This approach needs to be underpinned by new models of care based on equity of funding and increased in access to services based on available evidence and quality research.

Allied health professionals are tertiary-qualified, autonomous health care professionals who offer consultations directly to the public. They offer a high level of expertise in their fields. The current system overly restricts access to allied health, especially for those without appropriate private health insurance and it is timely for it to be reviewed. While it is generally acknowledged that multidisciplinary care is important, particularly for chronic and complex conditions, the Medicare CDM items have not been as effective as they could be.



What are the key elements of an enhanced primary health care system?

AHPA has identified the following key issues which it believes are the key elements of an enhanced primary health care system. It must:



Be based on recognition that health is not merely the absence of disease

30 years after the Declaration of Alma Ata (1978), there is still reluctance to recognise the true definition of health as inclusive of social and environmental determinants, and thus requires intervention of governments and professionals at all levels. The disproportionate attention and therefore funding of acute “illness” services is both costly, in terms of specialised care, and inequitable due to concentration of such services around major population areas rather than populations of specific needs. In contrast to an “illness” model of care concentrated around hospitals and clinics, many allied health professionals are working under a “health” or “wellness” model of care in their local communities where restorative and preventative interventions are provided to health consumers at a fraction of the costs associated with hospital care and often with longer-lasting positive outcomes.



Provide comprehensive, appropriate and timely responses

People, particularly those with chronic conditions such as diabetes, can maintain their health and avoid hospital stays if they have access to comprehensive, timely and appropriate primary care. This requires access to direct and affordable services across the full spectrum of allied health professionals, nursing and general practice.



Meet people’s total health needs

Primary health care needs to offer more than symptomatic treatment of obvious health problems. It is important to identify and where necessary deal with all the factors which may underlie ill health; these can include mental health problems, relationship difficulties, socio-economic factors, poor health literacy and/or various addictions. The allied health professions cover a wide spectrum of expertise, and can make a crucial contribution to supporting people’s ‘whole of health’ needs.



Include direct access to expert multi-disciplinary health care

Allied health professionals are tertiary-qualified, autonomous health care professionals who offer consultations directly to the public. They offer a very high level of expertise in their field. Although there is general acknowledgement of the importance of multi-disciplinary care, particularly for chronic and complex diseases, the arrangements for this set out in the Medicare CDM items have not been as effective as they could be. Patients need prompt and direct access to expert multidisciplinary care – ‘the right service from the right provider at the right time’. They clearly need better access to allied health.



Deliver services through a full, equal and cooperative partnership between health professionals

For primary health care to be more effective there needs to be a full, equal and cooperative partnership between allied health professionals, nurses and GPs. This must be based on mutual respect for the diversity of professional skills and the specific expertise of other health professionals, together with a working knowledge of other disciplines so that appropriate referrals can be made. A collaborative working partnership must also be established and maintained with patients, their medical specialists and their support networks, such as families and community services.

Primary health care services should be organized and funded so that Australians have speedy, direct and equitable access to whatever health services are most appropriate to their needs.

Address workforce shortages

Allied health professionals are highly skilled, tertiary-trained professionals. An increasing number have post-graduate specialist qualifications and play a crucial role in health policy, research and management. Their skills, however, remain generally under-utilised and under-valued, with public policy primarily focused on medical solutions to health problems as outlined above.

To address the current problems of allied health workforce shortage and poor retention rates, particularly in rural and remote areas, comprehensive and regular workforce studies must be undertaken as a priority. Such studies should also help resolve issues relating to skills recognition, clinical education, career prospects, data collection, recruitment and retention.

Allied health professionals working in primary health care need a system of support. This starts with primary health care having a greater emphasis in entry level allied health education and also in continuing professional development. A career structure that will be successful in attracting and keeping allied health professionals in the publically funded primary health care system is needed. This structure must give recognition to the specific skills needed in primary health care and not assume that skills obtained in the acute care sector are always transferrable.

It is crucial that remuneration and conditions are improved to encourage skilled staff to remain in professional practice. Given the high proportion of females and part-time workers in some allied health professions, it is also important to provide family friendly employment conditions.

As a useful short-term measure to increase the supply of allied health professionals, AHPA believes there is a need for ‘attract back to practice’ initiatives, based on schemes which have proved successful overseas.



Improve Higher Education funding to help address skill shortages

At present, Australia’s health workforce shortage is being made worse by a crisis in allied health clinical and professional education. Public hospitals are no longer able to provide sufficient resources for allied health professional practice practicum (field work), because of their changing role within Australia’s total health system.

Allied Health Professions Australia would like to see the implementation of new models for allied health clinical and professional education that reflect today’s funding and structural realities.

In recognition of the delivery of health services by multi-professional teams, AHPA recommends the establishment and implementation of a national inter-professional education/inter-professional practice research and development agenda. This would include the funding of a national consortium to consult with all stakeholders to develop and implement nationally accepted Inter-professional Practice health professional graduate attributes and health professional practice capabilities; and to develop and implement core inter-professional education curriculum across all universities training health professionals in both theoretical and practical components.

AHPA believes that without additional higher education funding there could be a collapse in the supply of allied health professionals. Allied health courses, with their high clinical education component, receive only 55 per cent of the funding provided for medicine, dentistry and veterinary science, and receive 10 per cent less than nursing.

Clinical education of students is a legitimate and significant component of allied health training and must be properly funded at the level needed to produce competent practitioners. Currently clinical education of allied health students does not receive designated funding and largely relies on the goodwill of senior practitioners and their employers.

Students undertaking professional practice practicum in rural and remote settings are especially disadvantaged by this lack of funding, as they need to self-fund travel, accommodation and other associated costs. They also often forego income from their city-based part-time jobs.

Significant funding is available for clinical education for medical students and AHPA believes that funding for clinical education should be the same for all health professions.

The benefit would be more and better trained allied health professionals, to ease Australia’s chronic health workforce shortage and contribute to the Government’s many new health initiatives.

How could primary health care be enhanced to better support prevention activities?

In order to improve quality of life and reduce the burden of disease and current hospitalisation rates in Australia, AHPA believes that a greater investment in preventative health strategies is required. Australia has a strong political focus on hospitals and on high level clinical activities. A better balance between preventative and remedial services would ultimately lead to reduced hospital admissions and to savings in Government expenditure.

Allied health professionals play a major role in preventing and managing a number of the key factors in relation to the increasing burden of chronic diseases including: the increasing proportion of the population which is overweight or obese, lifestyle factors – such as smoking, poor nutrition and lack of exercise – which lead to health problems. An enhanced primary health care system needs to incorporate funding capacity to enable these services to be expanded to enable people to access them at the right time and right place.

Keeping older Australians healthier for longer

Allied health professionals can be particularly helpful for older people dealing with chronic diseases such as arthritis, diabetes, osteoporosis, cardio-vascular diseases, malnutrition and mental health issues. In too many cases, it is the lack of appropriate allied health care for treatable conditions which leads to people being admitted to hospitals and residential aged care before they really need to be.

In addition, older people need affordable access to allied health primary and preventative care, in order to maintain wellness and delay the onset of chronic diseases. There is good evidence that community-based programs, such as strength training, gentle exercise, healthy nutrition and social support groups can help significantly in keeping older people fit, healthy, happy and out of hospital.

With limited public health dollars, how could priorities for accessing primary health care services be determined and targeting of public resources improved?

Medicare – Improvements Needed To Tackle Chronic Disease

Allied Health Professions Australia (AHPA) urges the Federal Government to improve Medicare-funded access to allied health professionals for people with chronic conditions and complex care needs. There is clear evidence of the benefits of allied health interventions for chronic disease, both for patient wellbeing and reduced treatment costs.

AHPA believes changes to the Medical Benefits Scheme (MBS) are needed to:


  • Improve the treatment for consumers with chronic illness

  • Make GP referrals to allied health professionals easier

  • Increase the number and length of allied health consultations where needed

  • Increase the range of allied health services covered

  • Provide rebates for prevention interventions

  • Introduce an evidence-based system for new Medicare items.

Improve the treatment for consumers with chronic illness

Medicare currently provides rebates for allied health professional services under very restrictive conditions, for people with chronic conditions and complex care needs. AHPA believes that the next step in improving Medicare and tackling chronic disease is to make it easier for these patients to access the allied health services they need.

Currently a Medicare rebate is available for a maximum of five allied health consultations a year, for patients who are being managed by their GP under an Enhanced Primary Care (EPC) multidisciplinary care plan. However, the total five sessions with an Allied health professional per year is grossly inadequate.

For people with chronic conditions and complex care needs, health and quality of life would be improved by greater Medicare-funded access to appropriate allied health services. AHPA also considers that an independent review system is needed to assess and recommend evidence-based treatments which should be covered by Medicare.



Make GP Referrals to Allied Health Professionals Easier

AHPA believes that GPs should be free to approve allied health professional services for people with chronic conditions and complex care needs, on the basis of a GP Management Plan, without the requirement for Team Care arrangements. Some consumers do not need access to several different types of allied health services, but would benefit from access to one particular discipline, such as speech pathology, podiatry, dietetics or psychology.

The change needed is for GPs to be able to make an EPC Program referral for allied health services under Medicare by just using Medicare Item 721 (GP Management Plan), without also having to use Medicare Item 723 (Team Care Arrangement) or using items 720, 722, 730 or 731 (EPC multidisciplinary care plan).

AHPA also believes that allied health professionals as well as GPs should be able to claim under Medicare for case management and case conferences to improve collaboration and reporting arrangements.



Increase Allied Health Consultations Where Needed

The current limit of five Medicare-funded allied health visits a year needs to be replaced by a 6 + 6 + 6 formula, as in the COAG Mental Health Better access to psychiatrists, psychologists and general practitioners through the Medicare Benefits Scheme initiative. Under this initiative, the GP or other medical practitioner managing the patient can authorise up to six allied health services, followed (after a review) by a further six; and in exceptional circumstances can authorise an additional six, giving a total of up to 18 services per year.

AHPA contends that people with chronic and complex conditions may have as much need for allied health support as people with mental illness, and that therefore the 6 + 6 + 6 formula should be adopted for EPC chronic disease management under Medicare.

Increase the Range of Allied Health Services Covered

Medicare currently has a ‘one size fits all’ approach to allied health services provided under the EPC Program. Regardless of what service is provided and by whom, there is one single scheduled fee – currently $55.05 (for which the benefit payable is $46.80).

AHPA contends that the current single price-structure for allied health services should be replaced by a 3-tier structure providing different levels of payment for different types of service. These would be:


  • Initial consultation - 30 to 45 minutes (diagnostic assessment, preliminary treatment)

  • Standard service – up to 30 minutes (this equates with the current scheduled fee)

  • Extended service – 45 minutes and over.

  • An “out-of-room” loading for all consultations.

  • Consideration should also be given for limited access by patients to allied health service by telephone or internet in certain areas with limited transport and/or allied health professionals.

In addition, AHPA calls for the expansion of the number of allied health professions covered under the EPC Program to include prosthetics/orthotics and pharmacy. Both professions have unique and valuable contributions to the management of chronic conditions and complex care needs.

Furthermore, AHPA supports expanding the scope of allied health professional’s practice to include prescribing and referral rights for appropriately trained allied health professionals to prescribe a limited range of medication and refer patients/clients to other health care professionals. AHPA contends that this will reduce the number of visits to different service providers, and enable more timely and affordable treatment for patients.

These changes to the Medicare Allied Health items would provide greater flexibility in treatment options for patients, and more equitable returns to allied health professionals.

Introduce an Evidence-Based System for New Medicare Items

Allied Health Professions Australia contends that interventions by health professionals for which there is high-level evidence of effectiveness and cost efficiency should be directly funded by Medicare. It urges the Federal Government to set up an Advisory Committee, similar to the Pharmaceutical Benefits Advisory Committee, to assess current items, recommend possible new Medicare items, and review who is eligible to deliver items, based on the clinical evidence for their effectiveness; and to remove those items for which there is no evidence of effectiveness. This would enable a clear, independent process for acceptance/rejection of items for the MBS.



Rural and remote services

There is considerable evidence to show that people living outside Australia’s main urban areas tend to have poorer health. A key way to address this problem is to improve access to allied health services by identifying and addressing workforce shortages in rural and remote areas. Programs such as the More Allied Health Services (MAHS) will not succeed without an adequate supply of allied health professionals in targeted areas.

Geographically, culturally and socio-economically Australia is not a homogeneous county. There is the readily accepted difference between rural and metropolitan. However, diversity occurs beyond the urban-rural divide, with great variations between and across Australia’s rural and remote regions. A consequence is regional variation in the implementation and impact of health strategies. To ensure equity of access to the ‘right health service by the right health professional at the right time’ for rural and remote consumers there must be flexibility and consideration given to funding the most appropriate delivery mechanism. For example:


  1. An expansion of the specialist outreach program

  2. Funds pooling and ‘cashing out’ of programs such as Medicare

  3. MBS item numbers for services delivered by Telehealth

  4. Patient Transport Scheme

  5. Expanded scope of practice including prescribing and referral rights

  6. Increased number of ‘hub and spoke’ services linking small rural and remote communities with regional centres

Indigenous services

Like the Government, AHPA is particularly concerned about the plight of indigenous communities. Rural and remote areas have less allied health professionals per head of population than do urban areas, and indigenous communities in remote areas often have very little or no access to allied health services. Indigenous health services need to be strengthened by increasing the number of allied health professionals, in order to tackle chronic conditions such as diabetes and obesity.

Moreover, allied health professionals need to be appropriately trained in relevant cultural and practice issues. A greater emphasis on public health, including the social determinants of health as applicable in community development contexts, need to be taught as part of all health practitioners’ entry level qualifications.

Embrace and fast track an E- health solution.

AHPA strongly believes that an integrated and universally accessible electronic record system is imperative to team-based multidisciplinary patient centred care. This would allow for sharing of agreed information with other team members in real time, improving patient care and outcomes. To achieve this, AHPA recommends the following:



  • Greater engagement of allied health professions by agencies such as NeHTA. The engagement process to date has been dominated by the medical and acute health sectors, at the expense of primary health care and allied health.

  • Broaden the focus of software and hardware development to encompass all primary care practitioners and settings. To date there has been an uneven development of software and support for the purchase of hardware which has favoured certain groups – this needs to be redressed

  • It is accepted that there is unlikely to be one single national product but the Government needs to move toward requiring universal connectivity for any products under development and the modification of existing products to permit this.

  • Systems need to be designed which can incorporate monitoring and data collection functions for the range of professional groups using the system to allow for expanded clinical and quality audits and to contribute to research in the area of primary care.

  • Appropriate measures specific to allied health practice need to be developed, in consultation with practitioners, to ensure the uptake and sustainability of any e-health initiatives.

Conclusion

To improve health outcomes throughout the community, Australia’s primary health care system must offer an effective, coordinated and timely response to people’s total health needs, through affordable access to a range of health professionals, both as individual service providers and in multi-disciplinary teams. AHPA has identified a number of key issues in this paper which it believes to be the foundations of an enhanced primary health care system, including introducing direct access to allied health professionals under the MBS, instituting allied health prescribing and referral rights, supporting multi-disciplinary teamwork and coordination of services, and addressing workforce and skill shortages, particularly in rural and remote areas. AHPA believes that these changes will help address some of the current restrictions of our primary health care system and improve health outcomes for people throughout the community.





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