The president of the World Organization of Family Doctors shares his passion for healthcare and explains why there is a need for world-class governance to oversee publicly owned and not-for-profit health organisations. Tony Featherstone reports.

    Healthcare debates are usually framed around the challenge of funding rising health expenditure when governments worldwide are under budget pressure. Or they focus on the ageing population, obesity, mental health and other chronic diseases.

    These are critical issues. So too is another, less-considered aspect of healthcare: the need for world-class governance to oversee publicly owned and not-for-profit health organisations. Such governance will be vital to steward the sector through a period of immense change.

    There is pressure on all fronts. Annual healthcare expenditure is growing almost three times faster than the broader economy, and regulatory reform, such as the federal government’s proposed Medicare co-payment, has created uncertainty. Healthcare demand is rising at a time when fewer individuals and governments can afford it.

    As these risks grow, healthcare boards must ensure their organisation can cope with myriad threats, move quickly, and also take advantage of opportunities from an ageing population, technology and telemedicine, which is the use of telecommunication and information technologies in order to provide clinical healthcare at a distance. Experienced healthcare directors will be in greater demand as the sector’s share of the economy grows and as more healthcare companies list on the Australian Securities Exchange (ASX), as has happened this year.

    Professor Michael Kidd AM MAICD (Twitter @WONCApresident) understands these challenges better than most. As the recently appointed president of the World Organization of Family Doctors (effectively the chairman of the board) he is responsible for an organisation that has 131 country members in seven regions, represents half a million family doctors worldwide, and is seen as the voice of family medicine in the global healthcare system by the World Health Organization (WHO).

    “It’s a big role,” Kidd says. “It provides a tremendous opportunity to influence global healthcare policy, meet healthcare ministers and experts around the globe, and share ideas. Most of all, it is an opportunity to look at the role of general practitioners (GPs) in achieving universal healthcare, and helping more of the billion people who currently have no access to healthcare, get it.”

    Prioritising health

    In a distinguished career, Kidd has been on dozens of not-for-profit and government advisory boards. He is currently a non-executive director of beyondblue, Therapeutic Guidelines Limited, the Channel 7 Children’s Research Foundation, Flinders Fertility, and FCD Health, a primary care service provider in the Northern Territory. His day job is executive dean in the Faculty of Medicine, Nursing and Health Sciences at Flinders University in Adelaide (Twitter @Flinders).

    Kidd has a strong interest in indigenous health, having advised on Aboriginal and Torres Strait Islander health issues as a member of the advisory board of the Lowitja Institute (formerly the Cooperative Research Centre in Aboriginal and Torres Strait Islander Health).

    He also chairs the federal government’s Ministerial Advisory Committee on Blood Borne Viruses and Sexually Transmissible Infections, which is responsible for the development of Australia’s strategies for the prevention and treatment of HIV, hepatitis B, hepatitis C and sexually transmissible infections.

    During our interview, Kidd talks about the need for global thinking to solve health problems, especially in developing countries. In his various roles, he regularly travels overseas to meet experts and study other healthcare systems and issues. Kidd was in Cairo when this interview was arranged, and I spoke to him at length by phone in Dubai.

    He passionately believes in the role of GPs and the need to invest more in the health system’s “front-end” — awareness, prevention and the role of family doctors — to save on fast-growing costs in hospitalisation and surgical procedures. “I am deeply concerned that any additional co-payment might risk discouraging vulnerable people from not seeing their doctor,” Kidd says. “That is not what the community wants and it is not the best way to reduce overall health expenditure. If anything, it will add more cost over time because there is a risk of less focus on prevention and early detection.”

    Kidd’s empathy for the poor and vulnerable is balanced by a pragmatism that comes from 30 years working as a GP. The challenge, he says, is ensuring healthcare organisations are economically viable, while remaining true to their vision and values, the ethics of medicine, and the needs of patients.

    “Healthcare governance has a crucial role to play,” he says. “Australia will need more directors who can balance the organisation’s need to grow profits and remain viable, while ensuring profits do not come at the expense of those who most need care, or cannot afford it. Directors will have to think about the organisation’s corporate reputation, and move quickly when unexpected regulatory change has a sudden impact on the healthcare sector.”

    Kidd, for his part, rarely stops moving. He was made a professor of general practice at the University of Sydney in his mid-thirties and has an extensive medical research background. He has also written several books and textbooks and been awarded numerous fellowships of overseas medical colleges and academies. In 2009, he was made a Member of the Order of Australia for services to medicine and education. For good measure, he was “Medical Michael” on national youth radio station, Triple J, for several years.

    The 54-year-old laughs when asked how he manages to do so much work. “My friends joke that I am obsessively organised, and I do have a driven personality. But I enjoy all my roles; I have a great team around me, still manage to find time for family and friends and to stay physically and mentally fit. I have come to realise over the years that being a GP is an immense privilege. I am optimistic about the outlook for general practice and the healthcare sector, particularly in areas such as indigenous health, mental health, and helping older Australians stay as well as possible for as long as possible.”

    Here is an edited extract of Kidd’s interview with Company Director:

    Company Director: Why were you against the proposed $7 Medicare co-payment in its initial form?

    Michael Kidd: I accept that governments worldwide face rising healthcare costs. When I talk to ministers of health and health officials overseas, it is clear that governments face increasingly difficult choices on healthcare budget allocation. Like other countries, we face an ageing population, an increased burden of chronic diseases, greater incidence of mental health problems and continuing challenges with infectious diseases, of which Australia is not immune.

    At the same time, a well-informed population has higher expectations and demand for healthcare and remarkable advances in medical technology and medicines are coming at an increasing cost.

    But the answer is not making it harder for people, particularly the disadvantaged, to see their GP. There is clear evidence that growth in healthcare expenditure is highest in the hospital sector. We should encourage people to see their GP, focus more on prevention and early diagnosis and reduce demand for procedures and hospital stays. That is far more cost-effective.

    At a personal level, I was concerned that the co-payment, in its initial form, would have resulted in vulnerable people delaying seeing their GP. In my 30 years of medical practice, I recall only a few consultations that were not warranted. People go to their GP because they are concerned about their health or that of their family members.  The benefit for individuals and the community is better prevention, early diagnosis and treatment, and better management of chronic health problems and mental health concerns. The health of our nation depends on strong general practice.

    CD: How would a co-payment affect family doctors?

    MK: It is not clear how any co-payment would be implemented. I suspect there will be continued pressure on GPs to waive any out-of-pocket costs for those who are struggling and that will affect the financial viability of some practices more than others.

    A co-payment would also send an unfortunate message to GPs. It says our services are somehow less valued than other medical specialists, who do not face a co-payment, even though general practice is a speciality in its own right. It could also discourage our medical students from considering careers as GPs.

    In my travels overseas, many health experts comment on the strength of Australia’s healthcare system and other countries seek to replicate it. When governments try to change the core of that system — primary healthcare — you risk damaging a model that works well.

    CD: How will the healthcare system cope with sharply higher demand for services, while governments are under severe budget pressure?

    MK: Invest more in primary healthcare and prevention. Keep people as well as possible for as long as possible. Keep people out of hospitals and older people in their home as long as possible. Avoid any unnecessary, costly investigations, treatments and procedures. Ensure people are not over diagnosed or over treated. None of this is new. It all starts with investing more upfront, in general practice and prevention, and benefiting later on.

    CD: What other reforms could best help Australia’s healthcare system?

    MK: Federal and state governments should embed a focus on health and disease prevention into all aspects of policy, as South Australia has done and other state governments to a lesser extent. That is, policies on infrastructure, education, housing, industry or any area must also consider their potential impact on the health and wellbeing of the community.

    I am a great believer in embedding prevention into every aspect of the health system and more broadly in the community. There is great scope to use social media to help all Australians take greater responsibility for their health and that of their family.

    CD: Is the healthcare sector doing enough now to prepare for the coming demographic tsunami of an ageing population?

    MK: It is doing a lot, but more can always be done. The starting point is avoiding unnecessary removal of elderly people from their home and putting them into hospital or aged-care facilities, wherever possible. We also need to use telemedicine to its fullest potential to give people access to advice and support at home and reduce costs. Longer term, better integration of healthcare and aged-care services would make a huge difference. In some aged-care facilities, residents get fantastic ongoing healthcare treatment. In others, appropriate healthcare support can sometimes be neglected.

    CD: How will technology transform healthcare in the next 10 years?

    MK: Technology is already helping in so many ways. Access to healthcare information is improving public awareness in ways we have never experienced before. Yes, there is a significant risk of healthcare misinformation on the internet, but better access to trusted, high-quality online information is a good thing.

    Development of electronic medical records, now well entrenched, provides scope for data mining that can better understand the collective healthcare needs of Australians as well as any trends. It must be managed carefully to retain patient confidentiality at all times, but the benefits of analysing large amounts of healthcare information in real time is compelling.

    The next decade will also see new ways of interaction between healthcare professionals and patients. Telemedicine has great potential to bring treatment to people, especially those in remote areas or those with mobility issues. For example, we have an initiative under way at Flinders University and SA Health that uses telemedicine to help terminally ill people receive palliative care and remain at home.

    Flinders University is also doing work on restorative care to help the elderly who have had heart attacks, strokes or significant falls, get back into their home. Again, technology will play a greater role in keeping these people connected to their healthcare professionals.

    CD: How will the GP industry evolve in the next decade?

    MK: A significant trend over the past two decades has been the consolidation of GPs into large practices. This will continue at pace in the next decade. Bigger practices will allow more dieticians, psychologists, podiatrists, mental health workers and other healthcare professionals to work alongside the family doctors, either in a full-time or part-time capacity. There will be a dramatic rise in the number of nurses working in primary care across Australia and providing excellent care.

    New technology will help GPs do more of the work in-house, for example, basic pathology, or procedures that previously would have been done elsewhere or required day-surgery. Again, this should make it cheaper and easier for patients who will not spend as much time waiting for care or going from one healthcare professional to the next.

    I also believe social media will change aspects of the general practice industry. We are yet to find a model that will allow doctors to use social media to communicate safely with patients. But digital technology, generally, is taken up very quickly by healthcare services providers when they can see a compelling benefit. One need only look at the vast array of healthcare applications and evolving iPhone attachments that are helping doctors capture digital images of eye or ear examinations, or even do some pathology, for example. Doctors will be surprised at just how much technology helps them in coming years.

    CD: Is there enough focus on healthcare governance in Australia?

    MK: Company Directors has done some excellent work on healthcare governance. The governance training and education available to healthcare professionals has expanded greatly in the past decade and it is remarkable how much governance support there is for this industry.

    We see the benefits of that work with very capable non-executive directors joining the boards of healthcare organisations. That said, while there are a lot of healthcare directors who are very knowledgeable on content, we must ensure there are enough directors who can match those skills with strong governance expertise.

    CD: There has been a sharp rise in the number of healthcare and aged-care companies listing on the ASX this year. Is it hard to govern a healthcare organisation that has the sharemarket on its back for higher profits, while remaining true to patient needs?

    MK: It is a challenge, although getting the balance right between profits and people is not unique to healthcare organisations. Being altruistic means little if the organisation is not economically viable. The board must ensure there is sustainable growth and that the organisation remains true to its values including helping patients and showing compassion to them. Directors must pay special attention to the healthcare organisation’s reputation and ensure it is maintained and enhanced.

    Regulatory volatility is another governance challenge. The latest federal Budget shows how quickly things can change and have great impact on healthcare organisations. Directors need to be able to govern in a rapidly changing regulatory landscape in some areas. Great healthcare boards are nimble, on top of potential risks, and able to adapt quickly. Like all good boards, they support the CEO and understand the nuances of their organisation and its industry.

    CD: You have a special interest in the care of people with HIV. Why have previous safer-sex messages failed to alter the behaviour of high-risk groups, given HIV rates are at a 20-year high?

    MK: It is a complex question. HIV rates in Australia are high compared to the average of the past decade, but still low compared to the rest of the world. A lot of good work came out of the World AIDS conference in Melbourne this year and this will lead efforts towards reducing and perhaps even eradicating HIV over this coming decade, which is not as impossible as it sounds.

    In the 1980s and 1990s, there was much fear about HIV and AIDS and the education campaigns were very effective. Now, there is a new generation that has never known anybody who has died of AIDS. The messages that were so effective a few decades ago need to be different for young people today. We have to embed HIV awareness into school curriculums and help young people understand the importance of prevention and early diagnosis and treatment. We have to recognise that HIV campaigns are not one-off events, but a continuing investment to raise awareness and reduce the gap, four years on average, between infection and being diagnosed.

    CD: Are we seeing enough progress on indigenous health?

    MK: The health of Aboriginal and Torres Strait Islander people is Australia’s greatest healthcare challenge. It is not unsolvable. There have been gains in recent years and much of it is because of the good work of Aboriginal community-controlled and governed health organisations that target primary healthcare to the needs of their local population. This model needs to be respected and supported, because it has great promise. I was heartened to see the Prime Minister, Tony Abbott, in Arnhem Land recently, getting a first-hand view of the success of these programs.

    So much has been done, and continues to be done, on Aboriginal health. The Reconciliation Movement and the Close The Gap campaign on indigenous health have achieved a great deal. Flinders University established the Northern Territory medical school in 2010 and we are graduating our first territory-trained doctors this year. Thanks to the great philanthropic work of the Poche Centre Network (funded by the successful entrepreneur and philanthropist, Greg Poche and his wife Kay) Flinders University has established new centres in the Northern Territory and South Australia that are supporting more Aboriginal people to train to be healthcare workers and training all our students to provide better-quality, culturally appropriate care.

    CD: You have also worked overseas, notably as an adviser for the World Health Organization on primary care management of mental health for Western Pacific islands. How big an issue is depression in the Pacific islands?

    MK: Depression is a serious cause of disease burden worldwide and the incidence is rising. For the past eight years I have been involved in a WHO project that seeks to integrate mental healthcare with primary healthcare in the island nations of the Western Pacific.

    In Australia, your GP can treat mental health issues, such as depression, as part of their primary healthcare service. That is not true of many poorer countries, where mental health issues are treated separately and where there are insufficient numbers of mental health workers. Accessing a secure supply of medicines for mental health issues in some low and middle-income countries can also be problematic.

    The WHO program is also focusing on the human rights issues of those with mental health problems in the Western Pacific. The program is working hard to reduce the stigma that comes with mental health problems across the region. As a director of beyondblue, I have seen the positive benefit from raising awareness and understanding of depression as a serious health problem and tackling stigma and discrimination.

    CD: You are the current president of the World Organization of Family Doctors (WONCA) and will serve until November 2016. What do you hope to achieve?

    MK: As chairman of the board, I have to make sure the organisation fulfils its responsibilities, responds to our members in 131 countries, and is a strong global advocate for the role of general practice in strengthening health systems.

    Our mission is ensuring there is high-quality primary healthcare available to people worldwide, delivered by well-trained family doctors. Currently, a billion people do not have access to any doctor or nurse, and about 70 countries are not represented in WONCA, so we still have a lot of important work to do.

    CD: Will we see you on private sector boards in coming years?

    MK: My board work has mostly been in the not-for-profit and government sectors. I would welcome the opportunity to expand my governance work to private companies in coming years.

    CD: Where did your love of medicine come from?

    MK: As a kid I was always fascinated with how the body works, and as I got older, with how the mind works. I wanted to use what skills I have to make a difference in the world and realised that a career in medicine was a way to combine these passions. Over time, I came to appreciate what a great privilege it is to be a doctor. Medicine can be arduous and challenging, yet it is incredibly fulfilling and rewarding to be able to support the people who trust you for their health care treatment and advice.

    CD: How do you relax away from work?

    MK: I make sure that I do not neglect family or friends, or neglect my own physical or mental health. Being organised helps me get through a lot of work and still have plenty of enjoyable downtime with my partner, family and friends. I enjoy reading, listening to music, and swimming. Thankfully, nobody can reach you yet on your mobile phone when you are in the water.

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