AMA to promote core role of GPs in health reform

Australian Medicine, 3 August 2009

New Federal President promises inclusive but robust engagement with Government

The AMA – which has been invited at the highest levels of the Government to take an active part in implementing its health reforms – will promote the central role of the GP in patient care and how this central role must be reflected in any reform process, Dr Andrew Pesce told the National Press Club in his first major speech as Federal AMA President.

'The only health reforms we will support are those that make health service delivery better for people, and which recognise the importance of doctors as the foundation of quality health care teams.

Dr Pesce promised an inclusive but robust form of engagement when dealing openly and honestly with the Government on health issues.

'While I am committed to listening to what the Government has to say about health reform, I expect that the Government will listen to the AMA in the development and implementation of that reform.'

Dr Pesce also urged the Government to adopt a national long-term care scheme for people injured in accidents – including medical accidents – to replace the current adversarial court-based system.

It would 'fit in well' with the Government’s National Disability Strategy.

GP Week

'This week is GP Week,' he said, 'a week set aside by the AMA every year to pay tribute to Australia’s hardworking and dedicated general practitioners.' It was worth noting that two recent reports had endorsed the important role of GPs in primary care.

The OECD had confirmed that GP-led primary care was a cost-effective way to promote good health - a core message to governments from the AMA for many years.

It had also stressed the need to promote general practice as a career, as GP numbers were growing at a much slower rate than specialist numbers.

The Government had made a good start by supporting training for junior doctors to gain experience in general practice before they made a final decision on which career path they would choose, Dr Pesce said.

'We will need to continue to build on this.

'A fortnight ago, the Australian Institute of Health and Welfare reported that GPs are playing an increasingly important role in treating older patients and managing chronic medical conditions – and that they need to be supported in this role.

'With our rapidly ageing population and the increasing incidence of chronic illness in the community, this is a timely report from the Institute,' Dr Pesce said.

'Again, the AMA has lobbied strongly for greater support for GPs as the number of patients with chronic and complex conditions grows markedly.'

Health reform

Dr Pesce said that he wanted to point out in his speech about 'how I see the AMA working for its members, their patients and the community under my Presidency.

'It is an important time in health.

'We have a Government determined to instigate reforms.

'On any front, changes are needed because Australians do not receive equal opportunities to access health care,' he said.

'Access is determined by where you live, by your level of education and by your income.

'That is not the promise of Medicare.

'It is time to bring fairness into the system and to use scarce resources better - to make real improvements in areas of social disadvantage,' Dr Pesce said.

'We must remember that Medicare must first and foremost be about access to health services for all. Unfortunately, access is compromised by an over-emphasis on cost controls.'

He pointed out that Medicare was 25 years old, 'and starting to show its age.

Rumour has it that serious structural change may be put on the agenda.

'Not since the heady days of the introduction of Medibank, then Medicare, have we seen such bold plans for structural change in our health system being mooted. '

Today, as it did back then, the AMA would be actively promoting the key leadership role of doctors in the health system, and how this role must be reflected in any change process, Dr Pesce said.

'For the public, health care is about going to the doctor and getting diagnoses, advice and treatment.

'The patients of Australia trust us and expect us to do this for them.

Similarly, the Government needs to trust and seek our advice on health reform.

'Doctors are integral to the health system. Doctors must be consulted closely about changes in health care. The input of doctors is vital if the Government wants to make its health reform real: real for patients through better access to quality affordable health services, real for health professionals to use their skills and have rewarding careers and for the national interest through a healthier population and greater productivity. I could add another one here: real for governments who want to be re-elected.'

Dr Pesce said that it was his job to ensure that the AMA was engaged with government throughout the reform process.

'I intend to be a strong advocate for doctors and their patients and the communities they serve. 'Health reforms must be responsible and affordable.

'The only health reforms we will support are those that make health service delivery better for people, and which recognise the importance of doctors as the foundation of quality health care teams.

'A number of major reports were expected to be released soon: the report of the National Primary Health Care Strategy External Reference Group, the report of the Preventative Health Taskforce and the final report of the National Health and Hospitals Reform Commission.

Need for engagement

Individually and collectively, these reports would have a significant impact on how health care services will be delivered in this country, Dr Pesce said.

'They will have an impact on all the health professions. But it is likely they will have the greatest impact on the medical profession.

'Hence the need for AMA engagement with the Government.

'I was elected AMA President on a platform of engagement,' he said.

'Engagement does not mean rolling over. Nor does it mean going for the jugular at every opportunity.

'I plan to deal openly and honestly with the Government.

'I will highlight problems with its policy and bring solutions to the table. 

'It is my preference to have healthy dialogue with the Government over the issues that concern my members and my profession and our patients.

'I do not intend to engage in media skirmishes without having first made a genuine attempt to talk things through.

'My style will be inclusive, but robust.

'While I am committed to listening to what the Government has to say about health reform, I expect that the Government will listen to the AMA in the development and implementation of that reform.

'As AMA President, I have already had several productive and cooperative meetings with the Health Minister, Nicola Roxon, and her staff. I am confident that we will work well together.

'The health debate cannot be run by ideology,' Dr Pesce said.

'It must be about the best possible health outcomes for all Australians, no matter which political party is in power.

'Evidence must be the basis of sound health policy. The medical profession is very good at providing and using evidence to achieve positive health outcomes.

'So, my message to the Government is: 'Hi, I'm Andrew Pesce. I'm from the AMA, and I'm here to help.

'The health reform agenda is huge,' he said, 'and I do not have the time today to comment on every item that is bound to emerge from the imminent reports. But I would like to raise a couple of matters that I want the AMA to lead the debate on during my Presidency.'

Governance

Perhaps the most anticipated aspect of the NHHRC report was what it would recommend on who should run the health system, and how, and who paid, Dr Pesce said.

Much had been made of the Prime Minister’s election pledge to take over public hospitals if the States did not lift their game.

Whether or not they had, they were showing little enthusiasm for a Commonwealth takeover. “If the truth be known, I think the Prime Minister and the Health Minister are less enthusiastic about a takeover than the States,” Dr Pesce said.

'So the focus is very much on the Commission’s recommendations in this area.

'Not having access to a crystal ball, I will not try to guess at what the Commission has come up with. Instead, I will outline the AMA's preferred path.

'From the AMA’s and the public's perspective, Dr Pesce said, the major governance issues concerned public hospitals.

'The major problems in the public hospital system are the practical difficulties of better resourcing and better results for patients.

'For people like me who have been around public hospitals for many years, there is growing frustration with the levels and styles of bureaucracy that run the system.

'There is frustration at the litany of undelivered promises from governments of all persuasions.

'And there is frustration that the failure to deliver on promises is always blamed on the other arm of government.

'These undelivered promises transform into the problems – the deaths, the mistakes, the queues – that make their way on to the front pages of our newspapers every couple of months. 'We are all aware of the problems,' Dr Pesce said.

'Indeed, the Prime Minister himself was clearly aware back in 2007, when he said that he had a long term plan to fix our nation's hospitals. And we all remember 'the buck stops with me'.

'As the AMA President, my only plea, before we have seen any of the reform options, is that we actually hear governments commit to act, and act with conviction.

'Inaction simply added to the increasing levels of cynicism that unfortunately bedevilled the cultures of many public hospitals, as decent people struggled to provide high quality health care to very needy people within a system that was grossly under-funded and manifestly over-managed.

 Dr Pesce set out what the AMA would support in the NHHRC's reform recommendations:

'So, we will be looking at the Commission’s recommendations through this prism and responding accordingly.'Watch this space.'

Health workforce issues

Health workforce legislation tabled in Parliament allowing nurse practitioners and midwives to write PBS-funded prescriptions for patients and provide services which can be claimed under the MBS was risky, he said.

'At best, it may assist in meeting unmet need in some areas of our health system by introducing more flexibility into the workforce. At worst, it can fragment care, increase risk of poor outcomes and increase costs through lack of continuity and coordination.

'We have always been concerned about it.

'Our concerns are based on the hard evidence that is available about how good primary health care should be provided.

'Our medical duty of care obliges us to help mitigate the risks of these measures.

'That is why we are engaging with the Government to ensure that there is proper collaboration with the patient's usual doctor,' Dr Pesce said, 'and that there are always clear roles and lines of responsibility for that patient's care.

'Doctors have been working in teams with other health professionals for generations. It is not a new concept - and we have great respect for the skills of other health professionals.

'The AMA did not see this measure as a panacea to improve access to health care. There were only 370 nurse practitioners across the country, compared with 23,000 GPs. And we did not have enough nurses to meet existing nursing workloads. Ms Roxon had made it known that she had further plans for workforce reform, Dr Pesce said, 'and we know from its Interim Report that the NHHRC supports elements of these reforms in certain locations and situations.

'Clarification was needed about the implementation of these changes. Further discussion and debate were needed about the concepts of team care, as opposed to independent care, as opposed to autonomous care, as opposed to clinical leadership – 'all very different concepts but used interchangeably by the Government at different times to different audiences'.

More information was needed on how the proposed collaborative care models that were supposed to be in place soon will work, he said.

'But I will make one point very clear: the AMA will continue to promote the central role of the GP in patient care.

'I am pleased that, as recently as a fortnight ago, Minister Roxon acknowledged the central role of the GP in patient care.

'The GP-led system works.

'When people are sick, they want to and have a right to see a doctor.

'That is why the AMA must be involved in developing and implementing any changes to ensure that any new arrangements result in safe, quality outcomes and that patient care is not fragmented.

'So, I am pleased to report that the Prime Minister’s Office has invited the AMA to be part of the implementation process.

We will be involved in consultation and providing advice in developing the regulations that will underpin the new legislation on nurse practitioners and midwives.

'We certainly have strong views about the safeguards that are required to protect the quality and safety of health care,' Dr Pesce said.

'We will be making sure that these views are put clearly to the Government.

'Looking ahead, the Government must factor in that there are a lot of new doctors in the medical schools at the moment who will soon find themselves ready to work in the health system, including in general practice. This influx of new graduates – in greater numbers – is a result of earlier dialogue between the AMA and Government.

'Engagement delivers results.'

Rural health

Dr Pesce said that he also wanted to engage the Government seriously on rural health. Recruitment of Australian-trained GPs to rural Australia had almost come to a stop. Communities seeking a new GP were relying almost totally on overseas trained doctors.

Of all the OECD countries, Australia now had the second highest reliance on overseas trained doctors. More than 40% of rural GPs were overseas trained doctors, and they were in country areas because they were required to spend 10 years working there.

More than 130 rural maternity units had recently been shut down.

'We need to revamp the incentive system to attract GPs,” Dr Pesce said, “especially some of the big batch of new graduates soon to emerge, to work in rural and remote Australia.

'Just as we must promote general practice as a rewarding career, we must promote rural general practice as a rewarding career experience.

'The Government had made a down-payment on rural health incentives in the last Federal Budget, he said.

'While we welcome this, a lot more is needed. 'A good start would be to overhaul the Patient Assisted Travel Schemes (PATS ) to make the financial assistance properly reflect the costs of travel and accommodation.'

 e-Health

Rural Australia was where new and innovative technology and information systems 'will pay off big time', Dr Pesce said.

'Until we see dramatic improvements in rural health workforce attraction and retention, patients' access to health services can be improved through telemedicine.

'E-health infrastructure in rural Australia must be a priority for all governments.

'More generally on e-health, the AMA strongly supports moves to making electronic health records a reality.

'They would bring wide-ranging benefits to the Australian community, particularly for patient safety and quality health outcomes.

'We are looking at the proposals for a person-controlled electronic health record very closely,' Dr Pesce said.

'I believe that patients should have control over who has access to their information. We must ensure, however, that this control does not inadvertently cause limitations to access – especially in the case of emergency physicians, for instance.

'Rigorous privacy safeguards must be in place.

'The AMA will be an active commentator and adviser on developments in e-health.'

Long-term care

Dr Pesce said that the AMA intended to lead community and political debate in seeking to re-establish the case for the Government to introduce a national long term care scheme for people catastrophically injured in accidents, including medical accidents.

AMA policy supported a long-term care scheme which included provision of benefits and services on a no-fault basis to all children with permanent disability diagnosed before 18 years of age requiring at least two hours of personal care per day for their lifetime, and all adults catastrophically injured through an accident or from a serious and rare outcome arising from medical treatment requiring at least two hours of personal care per day for their lifetime.

The AMA considered that these long-term care services should include support for accommodation appropriate to age, needs and circumstances, case management and coordination, attendant care needs, domestic support and home maintenance and counselling and social support.

The previous Government had abandoned plans – or at least ceased discussions – for a national long-term care scheme in 2005, Dr Pesce said.

'It put it off for another day.

'Prime Minister, that day has arrived. Now is the time to look after disabled Australians and their families.

'A properly-structured long-term care scheme would make more effective use of taxpayer money and, more importantly, provide better lives and quality of life for the disabled.

'It would take the place of the existing adversarial court-based system that results in one-off compensation payments, which are not structured for lifetime care and are only available to some people who need assistance.

'It would provide justice, fairness and compassion for those who need it most. 'It would also underpin the medical indemnity system.'

Dr Pesce said that the AMA would put together a compelling case and seek community support for a long-term care scheme.

'The Government should support the AMA’s work on a long-term care scheme because it fits in well with the National Disability Strategy.

'It was consulting widely on disability services

'We are sure that they are hearing that the current system is not too flash – and that is the AMA's view too,' Dr Pesce said.

'It is a system that kicks in when there is a crisis and is based on a welfare mentality. But it doesn't provide adequate ongoing support and the assistance that is needed over the lifetime of a person with a disability.'

Professional responsibility

Dr Pesce said that professional responsibility was an important matter – 'especially in this era of comprehensive health reform'.

The medical profession, in consultation with the community, was best placed to lead on developing and monitoring its own standards and ethics, rather than have them imposed from governments or outside regulators.

'Profession-led regulation and monitoring will always ensure that patients' needs come first. This is central to our professional sense of duty to society. 'Doctors have high expectations of themselves and their colleagues,' Dr Pesce said.

'But it is necessary for the public to have confidence in our high standards.

'The AMA has been actively involved in writing what could become the first national code of medical practice in Australia.

'For those of you who doubt the strength of our own standards, I should tell you that the planned introduction of a national code of conduct has been substantially strengthened by input from the AMA,' he said.

'As AMA President, I commit us to helping implement and educate the doctors of Australia about the fundamentals of the code, and how it should be applied in daily practice.

'My profession has on occasions been accused of being an old boys' club, looking after its own. If this has happened in the past, I believe it is an exception.

'But I remind my colleagues to take seriously the obligations placed on us by our profession. 'If we don't lead in this, governments will do the job much less satisfactorily.'

Finally, Dr Pesce pointed out that, several times in his recent speech to the American Medical Association, President Obama had called on the association for help in his health reform agenda.

'This was a speech about engagement in the political process,' he said.

'Today, I formally invite Prime Minister Rudd to address the 2010 AMA National Conference to discuss his health reform agenda with our members.

'Prime Minister: my name is Andrew Pesce. I'm from the AMA, and I'm here to help.'

Question: You said in your speech that you thought the Prime Minister and the Health Minister were less enthusiastic about a Federal takeover than the States were. Does that mean that you'd agree with the Opposition that Kevin Rudd’s threat to take over the hospitals was an election stunt before the 2007 election?

Dr Pesce: I don't think things are done as stunts. I think it just shows that it's a lot easier to make a promise than to actually work on the response to that promise. I think Kevin Rudd at the time very correctly identified a major concern in the community and everybody is acutely aware of the deterioration of public hospital services in this country. That was a very insightful thing that was picked up. The big difficulty is translating the acknowledgement of the problem with the solution in what's been a very complex area. One of the complexities is, of course, that the responsibilities are divided. So, it becomes a very difficult political issue and I am not here to teach the Prime Minister how to solve political issues.

Question: You say that public hospitals are underfunded and over-managed. Would you prefer to see a Federal takeover of the public hospitals or a Federal takeover of non-hospital operations and health?

Dr Pesce: We need to look at the whole package of reforms that's going to come from the Government's response to the National Health and Hospitals Reform Commission. It's just too difficult to say whether one thing on its own is going to solve a problem. The AMA will look at any proposals which deliver funding which is locally responsive and allows doctors and nurses to look after the patients, at the bedside, in the clinic, in the rooms. That's what we need. We need to see the plan and then we'll be able to comment on it.

Question: You said you want more administration and more decision-making as close to the bedside as possible. At the same time, you want clearer political accountability. How do you do those two things at once?

Dr Pesce: You have to measure and decide what decisions are best made at the coalface, under a template of overarching funding responsibility. I've been in the hospital system for 25 years. In that time I've seen six or seven generations of expansion of hospitals, expansion of area health services, contraction of area health services, re-amalgamation of area health services, and the problem is that people haven't focussed on what's done best at that high level and what’s done best at a local level. Doctors and nurses know how to solve problems for their individual patients. The problem has been, for the last few years, our administrators are not helping us solve those problems. They're giving us all the reasons we can't: 'because there aren't funds', 'it's got to be approved by this body', 'it's got to go to that Minister'. We need our administrations to help us, not be obstacles to what we can do.

Question: You're the first President of the AMA in recent years to have direct hospital experience as a specialist. Do you think that the Federal Government should take over the hospital system? A poll yesterday of 800 residents in Sydney found 67% of them wanted the Federal Government to take over the NSW health system. Do you agree with them?

Dr Pesce: They've obviously identified that there’s a big problem. I know, and my patients know, and my colleagues who have the misfortune of coming into the hospital system as patients know, that things are getting worse. We need things to get better. Should the Federal Government take over the hospitals? We need to see a proposal for me to say is that going to help. The AMA will not comment on a policy before it's released. I have no doubt that serious change is needed, and we need to see what proposals there are.

Question: The cost of medicine is increasing due to the ageing population, the increased cost of medical science and technology and to some extent (some people are suggesting) to the cost of paying doctors. I don't now talk about the hardworking and dedicated GP or your consultant physician, but some of the fees that are demanded and received by some medical specialists, procedural specialists, have been criticised even by members of your own profession. Do you think the cost of providing medical services could be reduced significantly if some of these surgeons and others could reduce their incomes to perhaps three or four times the Prime Minister’s salary?

Dr Pesce: If you're suggesting that the problems with the health system are due to overpaid doctors, there’s no evidence of that at all. If you compare the incomes of doctors in Australia to comparable countries, I think you will find that we’re not doing badly. I fully support improving payment to our underpaid GPs and non-procedural specialists. There was a very significant process that the AMA agreed to and was involved with - the Relative Value Study - a number of years ago, where the AMA undertook to implement the findings. It was overseen by an arms-length actuarial firm. It was all done according to the rules. It showed that, yes, we needed to pay the non-procedural doctors, the consulting doctors and the problem-solving doctors who didn’t do procedures much better. And - surprise, surprise - this meant it was going to increase the cost to the government. And it got dropped like a hot potato. The AMA still would support the principle of a relative value result for payment of doctors, but that’s not the major issue facing our health system.

Question: What's your view on pathology companies approaching doctors to ask them to reduce their bulk-billing of requests to labs for patients? That’s my first question. The second is, doctors do have a major influence on out-of-pocket costs for patients. Where do you see the bulkbilling figures heading?

Dr Pesce: The answer to the first question is that doctors make a decision because they know the patients who need to be bulk-billed because they can't afford out-ofpocket expenses, and those who might be able to afford it. When they order a pathology test, they can request the pathology provider to make the same concession to the patient, but they don’t direct the pathology provider to do that. I would think that most pathology providers would usually follow that recommendation. So it's not possible for a doctor to determine whether a patient is bulk-billed for a service by another provider. But I think that the GP or the doctor who’s organising the test is probably best placed to make that call. And I would support that the doctor is the one who continues to make that call. The second question on the bulk-billing - sorry, can you repeat it please?

Question: Yes, which way are bulk-billing rates going …? [Indistinct]

Dr Pesce: The principle of Medicare is that there is access to medical services. When Medicare was introduced, the fee structure supported pretty universal access with minimal out-of-pocket expenses for medical services. Since the introduction of Medicare, the decision to save costs and decrease in real terms the rebates for services has meant that it’s been impossible to deliver services at that rebate. When I graduated, I came from a non-medical family. I didn’t know whether Medicare … was a good remuneration or not. I bulkbilled all my patients for two years. After two years, my practice was still not making money. So, for those who think that the rebate can provide a realistic income level and cover practice costs as well, it just doesn't work. If the Government is serious about the rebate funding medical care, it has to be serious about setting that rebate at an appropriate level. You can't have it both ways. You either want to save government money and then increase costs to patients. Or you say, no, we're going to have to invest in this because we believe it’s in the public interest that the Medicare rebate pays for care.

Question: You said earlier that the system is manifestly over-managed and you'd like to see one where there were minimal levels of bureaucracy. And you've acknowledged that the costs of medicine, if we use all the tools that are available, will go up. And that scares politicians out of their pants. Does the profession have a concept of the best management model that's possible?

Dr Pesce: I think that the costs relate to efficiency of delivery, but also the expectation in the community. In a sense, we're also caught up in the bind between community expectations of improving access, improving health care services and the cost of delivering that. And we understand that it's not sustainable to have several percentage points growth every year ad infinitum. So, to a certain extent I think we need to consult the communities about where they see a reasonable investment because it's their taxpayer dollars. But, answering your question as directly as I can, I think doctors and nurses who look after patients can clearly articulate the priorities. It's a question of the funders to come in and say, these are our priorities, and then they have to get together and work out how the dollars are spent. The problem is that it’s easier to make a decision at the level here [raises hand] and just expect it to be implemented down there [lowers hand]. The end result is that continuous tension between the service providers and the service payers. It's inevitable there is going to be some tension, but we have to pick those decisions which must be made at that upper level and then have those bureaucrats understand that local decision-making - local prioritisation - has to be listened to and a priority as well, rather than fitting local decision-making into budgetary constraints all the time.