Interview Dr Kerryn Phelps, AMA President, with Gareth McCrae, Radio 2SM 'Drive'. AMA's response to the Federal Government's Medicare reforms; mental health care; bulk billing

McCRAE: I tell you what, if you finally find the right doctor, you stick with that doctor, especially the GP because the GP, the family GP is never, ever going to go out of fashion. I have one of the best in the world and you grow up with your family doctor and another good doctor is Dr Kerryn Phelps, the President of the AMA, and she's on the line. Dr Phelps, good afternoon.

PHELPS: Hello, Gareth.

McCRAE: Are you better?

PHELPS: I am, thank you, all back to normal, thank goodness.

McCRAE: It's nice to hear your voice again, nice healthy and strong voice.

PHELPS: Thank you.

McCRAE: Have you been doing some exercises, have you, to get fit?

PHELPS: Yes, I have. I've been walking and swimming and making sure that I get plenty of rest, up until now, back to work this week so it's good to be back.

McCRAE: True to the adage, "Physician heal thyself."

PHELPS: Well, I had a bit of help.

McCRAE: Good help too, no doubt. Thank you very much for your time. I mean, obviously, with the Prime Minister having made some various announcements regarding the new Australian health care agreement, I see that just as an example, Victorian Premier - seeing we're not in Victoria I can safely quote him - Steve Bracks says that his state will seek to negotiate a better outcome under the proposed new health funding agreement. He says the proposed new agreement won't keep pace with hospital demand.

Well, sort of being pretty dumb, as far as all this is concerned, what's the AMA's position?

PHELPS: The AMA has cautiously welcomed the increase in funding. It looks like being about 5.4% a year. One per cent of that per annum is going to be population growth and the rest is going to be eaten up with ageing and increased costs. Now, obviously the rate of inflation will determine whether that increase is adequate or not but it seems to be in the right ballpark. So our point of view would be that there is a recognition that costs for public hospitals increase all the time.

There's also been the recognition by the Federal Government that public hospitals can't afford to have any less funding even though more people are in private insurance so where the Commonwealth could have clawed back funds because of the increased number of people in private health insurance, they haven't done that and so we will see at least increases in real funding going to the public hospitals via the states.

Now, the gauntlet has really been thrown down to the states to match that indexation and there is an incentive built into the government's announcement that will allow for that incentive. So what we're saying from the AMA point of view is for the states now to display their commitment to the public hospitals and say what they're going to do in terms of indexation.

McCRAE: Sure. There's always going to be antipathy between state governments and federal governments when their political persuasions are different. It's just the nature of the political beast, I would imagine.

PHELPS: It's a very unusual situation at the moment where you have a Coalition federal government and you have eight state and territory Labor governments. I don't think we've ever had that at any time before in history.

McCRAE: I think you're right, actually. In terms of the formula that exists at the moment, the AMA's position, I mean, would you like to see some sort of refinement between that partnership or that relationship, that reciprocity between the two different tiers of government?

PHELPS: The really important thing that needs to be discussed now is not just about level of funding, although that's critical for the future of our public hospitals, but also how that money is being spent. Now, we have long argued at the AMA that there needs to be more accountability for the financial outlay between the Commonwealth and the states and that we would like to see that the money that is earmarked for health is actually being spent on health and what it's being spent on and is it being spent in the most efficient possible way?

If we can get that information then I think that we'll be going a fair way down the track to knowing how perhaps money could be better spent, for example, where is there cost-shifting, where is there double spending, where is there the possibility of greater efficiencies? And, of course, if we can get greater spending in the public hospitals, if we can get greater efficiencies at the bureaucratic level, then everyone wins.

McCRAE: The other area that has always mystified me is the area of mental health. We have an enormous - I assume - an enormous problem as far as mental health is concerned in Australia and with the Richmond report and various other reports making certain recommendations, the recommendation was to do away with some of those institutionalised forms of dealing with the problem or dealing with the illness and that was taken up and all of those institutions, we see them being sold off and disappearing and money's coming in as a result of that and yet the proportionate amount of money hasn't gone back in to helping those people who are carers, etcetera, and you have days to focus on cancer and heart problems and all these other things but the mental health problem seems to get pushed aside. That's another area that perhaps really does need addressing to give assistance to the carers, not only the people who have the illness.

PHELPS: We really need a visionary approach to mental illness in this country and I think we need to acknowledge that while many people can be successfully managed within the community that there are times that people do need institutional care and that's very seriously lacking and that the carers, as you quite rightly point out, need a great deal of support, particularly where there are family members with serious mental illness.

McCRAE: Sure.

PHELPS: And it can make a family's life an absolute nightmare if they don't have the right levels of support in the community. And I don't think you could go to any state and say that there are sufficient levels of care in the community for people with serious mental illness.

General practitioners, of course, take a lot of the load of mental illness in the community and we have community-based services that do provide some support but it is definitely inadequate and in particular where people need more intensive kinds of treatment, it's very hard to come by.

McCRAE: I have nothing but the greatest respect for GPs. I think they do a marvellous job and I wish there were more of them all over Australia, especially the family GP. I mean, I grew up with one and, lucky enough, when we moved to a new area to find another one and the role that the GP plays in the family is just immeasurable.

PHELPS: I think that one of the things that's underestimated in our community is that the money that we spend, that the government spends, on health is not money that goes into a black hole. It is a great investment in the future of the nation.

McCRAE: Yes.

PHELPS: And if we can spend money appropriately on community-based care and that most of that's done in general practice and we keep people well, we keep them out of hospital, we minimise the amount of medication that they need, we minimise the amount of hi-tech treatment that they might need, if they have to go to hospital, by keeping people well for as long as possible in the community.

Now, if we can really concentrate on making general practice a priority in this country, then I think that the whole nation, into the future, will bear the benefits.

McCRAE: Sure and there's also a responsibility on the part of federal governments to, at the university level, make it more accessible for people who want to do medicine, given that it's a seven to nine year investment of time, the difficulty of getting in sometimes can be a problem as well.

PHELPS: I think we do need to guard against medical training being only for the wealthy or the people who can afford it. I think it's very important that it remains accessible.

McCRAE: Sure, sure. The other thing I'd like to ask, if you don't mind, and it has to do with bulk billing, obviously, with the Medicare situation people who are in a situation where maybe they have a doctor who bulk bills. Use me as a practical example. If I go to the GP, as I did the other day, the GP - and I have no problem with it - the GP or the receptionist said at the end, "That will be $40, sir." I paid the $40. By then, some other day, went along to a Medicare office with a green Medicare card, handed the card over, they gave me back $25 and five cents, I think, whatever it is.

PHELPS: Yes, that's right.

McCRAE: Can you explain, to someone like me that - it's become so complex, with all the discussions and all the overlays of what's likely to happen, what's not likely to happen. What is the basic tenets of bulk billing that are likely to be affected negatively?

PHELPS: The reason that it's called bulk billing is that you, as a GP, if you agree to take the patient's rebate as your full fee for providing a service, then you gather up all of the vouchers, if you like, and you send them in bulk to the government and the government pays you in bulk for those consultations.

Unfortunately, Medicare has not kept pace with the cost of providing services in general practice so whereas in the beginning a fee of about $20 might have seemed reasonable, 20 or 30 years down the track it doesn't look particularly reasonable at all and so we're now looking at a situation where the real fee ought to be around that $50 mark and so GPs who are bulk billing are really, in effect, subsidising Medicare by about $25 a consultation or by 50% of the real fee.

Now, what we need to do, I think, in any review of Medicare - and it's desperately in need of review at the moment and I believe we are on the threshold of some of the biggest reforms we have ever seen in the history of Medicare in the next few weeks - what we need to do is to say are the people who need treatment and who are having difficulty affording it able to access, number one, a doctor and, number two, treatment that is affordable for them?

And we need to have something in the system that ensures that people who don't have health care cards don't fall between the cracks, don't have to think, "Can I afford to go and see a GP?" Because ultimately the cost will be greater if those people are sick, they don't get the care they need and they have to go to hospital. It's a false economy to have people not going to the doctor because they think they can't afford it.

McCRAE: OK, so- -

PHELPS: But GPs can't afford- -

McCRAE: No.

PHELPS: - -to keep propping up Medicare.

McCRAE: Of course not.

PHELPS: So it has to come from one of two places. It has to come from the government through taxation or it has to come from individuals who visit the doctor. The problem with it coming substantially from individuals who visit the doctor is that you're going to have the sickest people in the community having to pay the most and there's a social injustice in that.

McCRAE: Most definitely. So we need some - obviously yet to be announced in the future - but we need some sort of admixture between those two systems, government paying as opposed to individuals paying, that is fair to those at the bottom end of the income bracket. Is that a fair enough comment?

PHELPS: It's absolutely fair. I think that people who are definably disadvantaged, who have a health care card, who are on social security, who are unemployed, who are pensioners, who have severe chronic illness that prohibits them from having a full-time job, those people are not so difficult to identify.

It's the people who are working, who have a number of kids, some of whom might have, for example, asthma, chronic illness of some sort, who need to visit the doctor on a fairly frequent basis, these are the people that I think that there needs to be very particular consideration of because those are the ones who could fall between the cracks of any system that sought to just be a safety net for the people who are definably disadvantaged, if you like.

McCRAE: Sure. Well, when it's all out, I'd love the opportunity to talk to you again.

PHELPS: I think that will be early next week.

McCRAE: You should be the President of the AMA, I think. You make is sound so easy.

PHELPS: I've got another month in the job so I'll see what I can do.

McCRAE: Stand again, all right?

PHELPS: I can't. I'm not allowed.

McCRAE: Aren't you?

PHELPS: No.

McCRAE: That's part of the rules, is it?

PHELPS: Yes, yes, it's a three year maximum.

McCRAE: Oh. Have you been there three years?

PHELPS: I have.

McCRAE: Congratulations.

PHELPS: Doesn't time fly when you're having fun?

McCRAE: Look, it's always a pleasure to talk to you and I'm glad you're well and after that month is up I look forward perhaps to seeing you back on television.

PHELPS: Yes, for sure. Thanks, Gareth.

McCRAE: Thanks, nice talking to you. Dr Kerryn Phelps and she does make it sound so much easier when you talk like that so thanks very much for her time.

Ends