TRANSCRIPT:

Question and Answer Session

National Press Club Address

AMA President Dr Andrew Pesce

Wednesday 21 July 2010

KEN RANDALL: As usual we have a period of questions, first one today is from Sue Dunlevy.

QUESTION: Dr Pesce, this was billed as the health election. We're five days into it and neither leader has yet mentioned the subject, and isn't that partly your organisation's fault?

In 2004, when you were facing spiralling medical fees - indemnity fees, you - doctors threatened to walk out of hospitals. You made that a political problem, the government had to cave in and provide hundreds of millions of dollars of subsidies for your medical insurance.

Have you lost your mojo since then? If you really think that health reform needs to be tackled in this country, why won't you use your industrial muscle in the same way on this issue, or is it just that you use it when your incomes are threatened rather than the health system?

ANDREW PESCE: Thanks very much Sue.

[Laughter]

I'm glad that you've drawn attention to probably the major positive health initiative that a government has ever instituted at our insistence. Where what had to that point in time been an insurmountable problem was basically dealt with, dealt with in a way which still stands today without any need for modification and gives people a secure sense that if they require compensation they'll get it. And it gives doctors, and now nurses and midwives - and they've got the same policies now for themselves structured in the same way - security that they can provide health care without being worried about being bankrupt or being bankrupted even after they retire. So thanks for drawing attention to that great success.

We didn't strike because it threatened our incomes. We went on strike because it threatened services for patients in key areas. Most doctors were going to be able to continue to work but in key areas such as obstetrics, neurosurgery and paediatrics, we were going to actually have a complete loss of workforce and loss of services and I think everyone agrees that would be untenable.

The problem with health reform now, of course, is that it's much broader, it's much harder to focus. If we said we're going to go out on strike before we get health reform right, we'd be out on strike every week.

So, look, I think there are ways to engage, there are times to be strident, there are times to be militant, but there are times to engage and there are times to be positive.

I think that we've put a lot of effort into trying to get that balance right, and I think that the reform agenda, it's not perfect, I've said to you that, you know, there are some disappointments for us.

But certainly there are some very, very important aspects which are now accepted and which are going to help move our system forward; a system of national standards so that the whole country works under the same standards, and we can really understand where things are going well, and if they're not going well, how we might be able to fix them.

We're going to be funding on a different basis in our hospital system so that we are encouraging funding to follow the community's health needs rather than the community's health need being determined by historical budgets which may have been decided 20 years ago and only been indexed according to political pressure or inflation.

There are a whole lot of really, really good things that are coming out of the health reform. But health reform is complex and, you know, I don't think anyone's ever going to get it all right all the time.

So we are here to advise, we're a sounding board, we're a canary in the coalmine sometimes and sometimes we're a roaring lion. So, you know, we pick our role judiciously to try and get the best outcomes for our patients.

KEN RANDALL: Thank you. Here's a question from Simon Grose.

QUESTION: Simon Grose from Science Media.

I've got a question about your research - medical research policy that you put out today.

You're calling for a new strategic direction from the National Health and Medical Research Council and saying that they should focus more on community, health issues, preventative health and on multi-disciplinary research. Now, I reckon that NHMRC would be a tad appalled because they would say that you haven't been watching that they've been doing that.

I know that they're very conscious these days about accelerating the passage of knowledge from the bench to the bedside, and putting out guidelines for clinical treatments, for preventative actions on - to meet emerging issues, and that they're very conscious for the need to fund multi-discipline research.

So could you just fill us out a bit on what you think the NHMRC are doing wrong and how wrong they are?

ANDREW PESCE: Okay. Well look, doctors are very well versed in evidence-based change. I guess, probably more than any other profession, for some time now we've committed to saying, look, we know we must have done things in a certain way for a long time but if we actually analyse what we're doing, look at the research evidence, you know, we're willing to change and move forward and provide evidence-based care.

Now, I guess that point that I'm going to make to answer your question is, I think it's high time that health administration used the same principles, and maybe the NHMRC should not involve itself only in researching clinical care, but models of health service delivery, models of funding, so that we don't get this political discussion about is the government's diabetes plan better than our chronic plan. We'd like to see an evidence base to inform the decision of governments as to how they can best provide health care through the funding mechanisms and the way they organise services.

So that's one thing that I think I'd like to see a concerted effort in evidence-based research which hasn't been happening in this country in - enough, forever.

KEN RANDALL: Steve Lewis.

QUESTION: Doctor Pesce, Steve Lewis from News Limited.

Two questions if I may. Firstly, the Coalition's policy to privatise Medibank Private if it's elected, can I ask you does the AMA support that particular proposal?

Second question, six years ago, two elections ago, the current Prime Minister, then shadow health minister put up a far-reaching proposal called Medicare Gold; I might add with the assistance of at least one person in this room. That…

[Laughter]

Indeed at this table. That particular policy of course was rejected by - [indistinct] by the Australian people. If Julia Gillard is elected, do you see merit in a scheme like Medicare Gold re-emerging with the AMA's support, that sort of scheme re-emerging as part of the health reform that you've outlined today?

ANDREW PESCE: Okay, look, Medicare Gold related to providing treatment for older Australians. I think the debate has moved substantially beyond that and I think we need to see a unified approach for, you know, reform for all Australians' health care. The principle which that question raises is the principle of using alternative insurers and payers to provide access for patients who otherwise wouldn't be purchasing private health insurance, i.e. I suppose privatising it, the public health system, make it open to different funders organising different types of care. It's obviously something which people give thought to, and I think it also plays in with the question about privatising of Medibank Private.

I think that one of the strengths of the Australian health system is that, to a large extent, the third party payers have not been for profit themselves. And I think that focuses resources at the - you know, to provide clinical care rather than seeing how many can be shifted around and provide profits for insurers.

Now, obviously, we don't use that approach in a whole lot of sectors of our economy but in the medical and health field it probably makes sense to focus your resources on clinical care.

In terms of the Medicare Gold question, I think the - I guess the modern version is the Medicare Select proposal which was raised by the National Health and Hospitals Reform Commission. This was to provide choice for patients, to open up the market, to provide alternative sites of clinical care.

I mean, if you think about it, at the moment the public hospital system has more or less a monopoly on public patient care. Has this contributed to its sort of diminishing performance over the years because it's not exposed to competitive pressures? Possibly yes.

So you can see the attraction of saying, let's try and open this up. On the other hand, we need to recognise that our public hospitals are, at the end of the day, the - I guess the treatment centre of last resort.

We want to make sure that whatever proposals get put forward don't diminish the standards in our hospitals, don't cherrypick the easier and more profitable areas of health care, and leave the public system inevitably to focus on the harder to treat sicker patients who can't afford to pay for even that standard of care.

So I think that these are still debates which probably are very much in their infancy.

The AMA welcomes the debate. The AMA will have input and we apply the principles that we have here, that it should be focused on the quality of patient care, provide patient choice, be affordable, and be equitable. And so that's the basis upon which we should analyse those questions.

KEN RANDALL: A question from Sophie Morris.

QUESTION: Sophie Morris from the Australian Financial Review.

Many of the items on your wish list involve structural or administrative change, however some of them will inevitably involve big increases in funding. Yet we're in a political environment where both of the major parties are seeking to make a virtue of fiscal rectitude.

You've also - you've been critical of the Coalition for seeking to fund its mental health strategy through axing spending on proposed government programs. I'm wondering, are there any items in the health portfolio where you think it's possible to make savings?

ANDREW PESCE: I think that the main saving, time and again, and overwhelmingly, will be if we can get our health care models right.

Simple, simple, simple example; I'm a doctor, I see a patient in my rooms who discharged from a hospital two weeks ago, had an operation. Probably had a thousand dollars worth of public funds spent on investigations, X-rays, blood tests, et cetera. She comes to my rooms. There's no way I can access those results. In fact, I often can't even find out what operation she had. And now she's coming to me for health care. Often doctors will just repeat tests.

You know, there's a lot of increased expenditure, because of the inefficiency of our health system, so e-health is one major investment which isn't a cost, it's a cost saver if we invest it wisely. Similarly in our models of health care.

I work in the public hospital and I'm keen that we don't rundown the public hospitals in order to fund another sector of the economy. But if you think about it, if we can effectively and efficiently treat people in the community without having to come in to hospital, that's always going to be cheaper, and so if we can generate savings and it's a real efficiency equation, not necessarily chopping and changing, increasing funding here and taking it away from somewhere else. If we do it right, the savings should follow.

KEN RANDALL: Doctor, let me ask you a question about red tape and bureaucracy following up from Sophie's question.

Given the enormous proportion of the annual budget that now goes to health and will keep on growing, I suspect, over the next couple of decades, where do you think accountability measures could be pared back to relieve the paperwork burden on doctors?

And do you think that there is an over-bureaucratisation of the workforce arrangements under the latest health and hospital reform measures?

ANDREW PESCE: Look, I think that the move towards a national registration scheme and the ability for work that used to be preserved in certain areas to be considered in others is, you know, one of those ways that can address the sort of rusted on, sort of workforce patterns. And I think that, you know, doctors, even though are often accused of turf protection, we understand that we can work better with our colleagues so that we can focus on the things that we do best and evolve other work to other people, but it's important to make sure that's always coordinated and collaborative.

In terms of efficiency, there's a lot of - in the same ways, doctors for a long time stuck to we doing things because we always do it, the same thing can happen administratively. For example, the Pharmaceutical Benefits Scheme Authority process, which I refer to - you know, for a long time we were told, you needed to go through… you know what you have to do? You have to decide your patient needs a necessary treatment. If it's not on the PBS list, you have to ring up a number. You have to ring a 1800 number, you have to hang on, you have to talk to someone and say, I want to provide such and such a drug. What's the Medicare number? What's the patient's name? What's it for? What's the indication, what's the approved indication?

Now, if you only do that once a day - I'm lucky, I'm a specialist; I only have to do that maybe once in a day. If you're a GP, you may have to do it 20 times a day. This was done because it was necessary to save money and stop inappropriate use of medications. Surprise, surprise, when we looked at it, it doesn't do that at all. So there are a whole lot of things which we need to look at and this is where I'm getting to - we need to really look at the evidence of what it is that's being achieved through our administrative requirements.

Often I think there's sort of a bit of a knee-jerk reaction. The moral hazard equation, you know, but if you actually look at it, you actually find that a lot of the times they're just completely unnecessary and just increase costs rather than decrease them.

KEN RANDALL: Here's Tony Melville.

QUESTION: Tony Melville, a Director of the National Press Club.

A couple of questions. I'm interested in the disability insurance scheme. Just wonder if you could elaborate a bit on that, and the need for that. Perhaps some examples of cases where it would really help.

And, secondly, just - it's argued that… hospital overcrowding is in the media all the time but it's argued that there is often over-treatment of people on terminal illnesses, and doctors are very reluctant to move from hospital care to other sorts of care. Just wonder how doctors can be educated to sort of change their positions and perhaps free up some of those problems.

ANDREW PESCE: Okay. Well, the first answer is the national disability insurance scheme; this is an idea that has been pregnant for a long, long time. You may or may not know I'm on the independent advisory panel to the Productivity Commission investigation into the feasibility and the likelihood of, you know, having - and making recommendations on such a scheme.

I guess I'm bound by the confidentiality of that process but I will say some things. You never cease to learn the importance of this. As an obstetrician I had a very sort of pretty narrow focus, I suppose - you know, the brain damaged baby; knowing the high care needs for a whole lifetime; seeing the distress and the pain that was already caused by the condition being made even worse by the failure of some sort of compassionate response of our society.

But there's a whole lot of disability services which are required at a much lower level than that. And one thing that has been made quite clear to me and, you know, you have these moments sometimes and say, how come I didn't see that before, that the autonomy of a person is obviously compromised by the disability that they have in certain ways. And we should be doing everything we can to try and wind that back as much as we can.

Now, we can't fix the disability because it's permanent but if we can think of ways to give them the same choices that you and I take for granted because we don't have a disability, recognising it can't be everything, but to the extent that we can increase their autonomy to regain their ability to make the choices, the self-determination that we all take for granted. It's just a huge issue. In itself it's therapeutic just the thought that you can do that has an impact on the level of disability in your life.

So, in answer to your question, going through this process, noticing the positive response of the Productivity Commissioners who really are going to great lengths to accumulate the testimony and experience of the people affected, I'm really hopeful that we're really going to move forward on this.

The second part of your question you'll have to repeat because I got a bit carried away.

KEN RANDALL: The treatment of terminally ill patients.

ANDREW PESCE: Yeah. Look, I think - I've faced this question many times. I'm the clinical director at a public hospital, a women's health unit. We sometimes see that we - practises have crept in or evolved or are there that, really, you just know aren't quite right. And how do you change the fact that, you know, doctors have done this forever and they say, well, we've always done this, we're not going to change.

I've talked about this to my international colleagues as well. I say, how do you do that? I mean, one of the big advances, for example, in the American health system - they don't have a lot to be proud of but one of the things they do well is analyse and manage risk, and their safety and quality systems are probably amongst the best in the world because they're such an economic imperative, health care is so expensive there. I say, how do you do it? And they say, look, it's actually not that hard. What you do is you talk to doctors, and they're always reluctant to change. But if you commission the work - and this gets back to the evidence base - if you commission the work that shows that patient outcomes are improved by there being a system which can tweak the doctors' usual individual clinical judgement, then doctors respond to that.

Doctors will always do what they know is best for their patients. If there's doubt about it, then they'll sometimes stick to their old ways. But if you go to the trouble and demonstrate improved outcomes by applying changes, doctors will always come on board.

KEN RANDALL: Let's go back to Sue Dunlevy.

QUESTION: Sue Dunlevy from The Daily Telegraph.

Dr Pesce, when the Medicare system was introduced under the Hawke government, the rebates used to cover 85 per cent of a doctor's visit. Today they cover around 50 per cent of a GP's visit, and patients whose doctors don't bulk bill are paying up to $30 out of their own pocket when they see a doctor, then they've got to pay $33 for their medicine.

There's been a lot of talk about cost of living pressures in this election campaign. If politicians are serious about addressing rising cost of living pressures, isn't it time that they increased the Medicare rebate by $20 to $54 and brought it back to 85 per cent of a doctor's fee?

ANDREW PESCE: I couldn't have put it better myself, Sue. Thank you very much for that question.

[Laughter]

Yeah look, you were here last year and we sort of have the same discussion. When the Medicare rebate was introduced, it was a great social policy decision which focused on giving access to the public and gave them access to medical care, and basically covered the cost of that care.

Because of the failure to adequately index that rebate - it's not that it's happened overnight, it's just been gradually happening, we've been gradually talking about it and consistently talking about it over many years - the value of that rebate has fallen so far away that now the largest growing single part of the health economy is patient out-of-pocket expenses. That's a fact.

Now, this is a political question that our politicians have to think about and they have to make a decision. Do you want the Medicare system to, once again, be a vehicle for universal access to quality health care, or do you want it to be a vehicle to restrict the Government's exposure to medical costs and transfer the costs to - at patients' out of pocket expenses? It's a pretty simple question, it's a very complex deliberation, but that's something that I'd like to hear answers during the election campaign.

KEN RANDALL: Simon Grose.

QUESTION: Simon Grose. I met you just four months ago but - then Prime Minister Kevin Rudd introduced the health reforms that are currently the political agenda. And he said it's going to end the blame game.

Now, you've had a few goes at the bureaucracy today and we're moving from a system where we had two sources of funding and two layers of administration, to a system where we're going to have two sources of funding and three layers of administration. So what hope do you see that the health blame game is going to end?

ANDREW PESCE: One of those layers of administration is purely a financial vehicle to deliver money so, you know, I don't think you need to over-emphasise that layer.

But we've talked about doctors and their reluctance to change. Well, I tell you what, get in between a state department of health and devolution of its powers, and you're in for a torrid time.

Look, I've been on public record and - I don't hammer the bureaucrats. They are doing their job that they're asked to do by the governments of the day.

The governments have to realise that the pendulum which led them to say, if we're taking the political responsibility for health outcomes, well, bloody hell, we're going to keep control of all the decision-making because we're not going to be vulnerable based on the unpredictable idiosyncrasies of decisions being made at the local hospital network.

It's very intuitive; it makes sense. But the problem is those decisions end up not improving the picture, especially when you need to make change, for two reasons. You're too far removed from the point of care, so you don't really understand. Unless you've got a very, very good information system, you don't really understand what's needed and the impact of your decisions.

And the second thing is that if the doctors and the nurses and the allied health professionals who have to implement those changes don't have some sense of ownership over the decisions to make those changes, surprise, surprise, we complain rather than make the change.

So it ends up becoming a dysfunctional system and you just cannot run a system where those decisions are being made centrally rather than locally.

Now, overall resource allocation, sure; that's a central decision. State governments have to decide how many hospitals they're going to have, how many are going to treat cancer because not every hospital can do everything all the time. They have a decision to say here is - in consultation with the doctors and nurses who understand, here is where we're going to have the services.

Activity-based funding is a formula which is going to, in a very rough sense, deliver funding to the volume of work that's being provided there. But then get out of the way. Let the doctors and nurses manage it. They need help. They're going to need people - I don't want to sit at my desk, you know, filling in accounting books. But ask my opinion then implement the decisions to say, you know, this is the money you've got to spend, these are the patients you've got to look after, how do you think you can look after them. That's the way we're going to get forward progress and we're going to get engagement of the clinical workforce that will have ownership of the decisions and work hard to implement them, rather than complain about perceived or real inadequacies.

KEN RANDALL: Let's go back to Sue for her last question today.

QUESTION: Sue Dunlevy, Daily Telegraph.

The maternity reforms introduced by the Federal Government require collaboration between obstetricians and midwives. A study in Queensland this year found that doctors thought they should have the final say in the care of pregnant women, and midwives thought they were capable of doing that.

In such an environment, how can collaboration work? And is there a danger that under these reforms some midwives could be shut out of caring for pregnant women because doctors won't collaborate with them?

You're an obstetrician, a leader of your profession. What are you going to do to make sure that doesn't happen?

ANDREW PESCE: Well, the first thing I did was involve myself in the process to set up the framework. And this was done with a very open and honest and objective intent to improve the access of our women to maternity services, and to provide continuity of care by the people that they want to look after them. Been through a whole lot of effort and work to translate that intention into the structures that are being implemented with the Maternity Services Review.

And I'll tell you right now that if it doesn't result in an improvement in the access to services, then the Government is going to revisit its decision-making.

So I'm very, very happy with what's happened. I think that the framework has been set up for very, very good and constructive collaboration. Probably the only part that's missing at the moment, and which I would encourage the organisations involved to finalise, is a consensus guide between the obstetricians and - the College of Obstetricians and Gynaecologists, and the College of Midwives, in saying, this is a consensus statement on evidence-based collaborative framework, consultation referral guidelines.

So when a midwife approaches me saying, Andrew, I'd like you to collaborate with me in provision of care, my patient has actually said she'd like you to be the obstetrician if there's a problem, I'll say, that's good, you know the document, don't you. Yes. You're going to work according to that document. I therefore know what to expect from you and you know what to expect from me. Fantastic. We can go ahead and do that.

If we can get that going I think this is a great step forward.

I referred to it in my speech and I'll say it even more clearly now, I will be telling my colleagues that I believe they have a very strong obligation to make this work. We are, I think, setting the gold standard for collaborative maternity care in this country if we get this right. It will be better than any other country in the world by far, and this is something which you should be proud of and work towards.

So I'll be giving a very clear message to my colleagues and I've already started doing it. I've addressed the graduating class, if you like, of this year's obstetric registrars saying they really should be very happy about this, work very, very strongly to support it. And I'll be giving that message very, very clearly.

And if they seem to be grudging and not wanting to do it, I'll say, well, if you don't like this, if you don't make this work, I'm sure that this will be revisited and whatever comes up you'll be even less happy with. So let's make it work.

We work with midwives all the time. In a sense, this is a bit of a sad discussion to have because 99 per cent of my working life, I've worked with midwives and we've worked really, really well together. So there should be no reason that we can't do that.

KEN RANDALL: Thank you very much.

21 July 2010

CONTACT:            John Flannery                       02 6270 5477 / 0419 494 761