Into the 21st Century: Winning Some, Losing Some
When Dr Andrew Pesce succeeded Dr Capolingua as President in mid-2009, it was clear that he wanted to exchange hostilities for consultation, telling the AMA journal Australian Medicine that he thought that the profession was not comfortable with the notion that the AMA was always at war with the Government. In his first Presidential Message in the 2009 Annual Report, he pointed out that the organisation that Dr Capolingua, had handed over had become “the most powerful and respected lobby group in the country” and he acknowledged her work that had “significantly improved” NRAS. But he had campaigned for the leadership of the AMA on a platform of engagement, he said, “engagement with our members, engagement with the broader medical profession and the other health professions, engagement with patients and the community and engagement with the government of the day”. This did not mean being captive to the Government, he said. “It means having a strong relationship of trust and respect in which you can argue your case openly and forthrightly in public and behind closed doors. It means that you will win some and you will lose some, but you are always part of the conversation.”
The AMA had won some and lost some over the years immediately preceding Dr Pesce’s Presidency. It had been a tough time. It and its members had grappled with arguably the most disruptive of the four attempts at system reform in its history and it is fair to say that they became truculent as their exasperation grew over what they had been asked to do.
To understand the reason for this hardening of attitudes, to understand the AMA’s judgment on the Rudd reforms, it is necessary to move beyond reliance on the familiar complaint that the AMA is congenitally anti-ALP or reactionary. It is necessary to see the world as the world appears to many of its members. The Rudd-Gillard reform was but another in a long list over the AMA’s 50 years of politicians coming up with beaut ideas for their view of a better health system, a great many of these ideas having as their basis an ambition for greater central control over the system and its workforce. Apart from anything else, whatever the reasons for these reforms, whether they work or not, they inevitably mean disruption in the workplaces of its members. The AMA and its members would not have this problem of reform on their own, of course. But they would see elements in the sixth and latest reforms as worse than merely inconvenient or disruptive.
General practice has been made more complicated in previous reforms, its operation altered, the incomes it generates often monitored and sometimes limited. But the actual role and position in the system of the GP have never really been threatened. As the AMA has often pointed out, the GP is always the gate-keeper, the central figure in primary care provision. The Rudd proposals for the public hospital system – the area that often attracts the most attention – do not seriously change the role of the doctors practising in it. On the other hand, in primary healthcare, where 28,000 to 29,000 general practitioners work, they propose a quite serious challenge to the role of the doctor.
One immediate difficulty with the GP Super Clinics and Medicare Locals proposed in the latest reforms, as the AMA would see it, is that the detail of where they fit in the primary healthcare system is not clear, or at least inadequately explained. A longer-term, more important issue is the competition and change that they threaten to GPs’ interests. But there is a potential problem with these schemes with even more significance, at least to the AMA’s GP members. The Primary Healthcare Strategy was a central element in the Rudd reforms, and a central element of that strategy was the notion of the multi-disciplinary team of health workers, with the doctor as one member. The AMA has insisted, successfully, that the primacy of the GP in the multi-disciplinary primary care team is acknowledged. It has even been formally included in enabling legislation. But GPs have a special place in the AMA story. The AMA has gone to battle many times to protect their interests. GPs have watched with growing trepidation as governments have toyed with ideas about increasing the role in the health system of health workers other than doctors, such as pharmacists, nurses and opticians. There will be members of the AMA, and doctors generally, who will react in the same way to what they will see as role substitution, activities in the primary healthcare team that used to be reserved for doctors. The multi-disciplinary primary healthcare team may yet be the most contentious of all the elements in the sixth system reform that the AMA has had to deal with.
For most of its 50 years, and especially as its influence on the national health system has increased, the AMA has had notoriously difficult relationships with various governments, especially when they have sought to reform of the system. There have been periods when it has opposed governments, especially when in its view they have tried to control the operations and incomes of its members. There have even been periods when it is fair to say that it has fought government not just because they have seen it as hostile to private practice (where most of its members earn their living) but simply because it is government per se.
When it was born in 1962, the AMA faced a difficult dual challenge: getting out from under the aegis and, to some extent, the control (however benign) of the BMA, while also evolving from a grouping of distinct branches into one truly national organisation. Fifty years later, its status as an influential national body is assured. It is demonstrated by the range and scope of the information and advice that over the years it has put into the mix that goes into policy-making: aged care, new diagnostic technology, climate change, e-Health, dietary standards, hospital funding, Indigenous health, medical standards and best practice, patient privacy and doctor-patient confidentiality, collaborative care, medical education, taxation, the health and safety of the medical workforce, smoking, substance abuse, immigration, advertising, cyber-bullying, genetic testing. The range of the AMA’s interests and influence can also be seen in the scores of position statements it has drawn up over recent years: boxing and health, for example; child abuse; physical activity; reproductive technology; complementary medicine; equal opportunity in the workplace; domestic violence; healthcare of people in detention, rural and remote health. Whether its views on these issues are acceptable or not, or comfortable or not, that they are held and advocated by the AMA and its members makes it impossible for governments to ignore them, impossible for health policies proceeding without heed taken of them.
Michael Wooldridge, Minister for Health in the first Howard Government, may have himself been a doctor, but he was one of many health ministers on both sides of politics who have found the mettlesome AMA a trial and a tribulation. His mark on the health system was relatively insignificant but he may well be remembered for having sought to dismiss the AMA as “just a doctors’ union”. But the story of the AMA, especially since its reorganisation 23 years ago, demonstrates how mistaken this attitude can be, how government can underestimate to its disadvantage the strength of the AMA’s involvement and influence in health – and wider, but related social issues.