AMA President, Dr Andrew Pesce: Speech to National Press Club

Good afternoon, ladies and gentlemen.

I wish to first acknowledge the traditional owners of the land we are meeting on today – the Ngunnawal people.

In recognising the Ngunnawal people, let me add that the AMA, like others, was extremely disappointed in the findings of the recent Productivity Commission report – Overcoming Indigenous Disadvantage.

The report, which was considered by COAG, shows the lack of progress in improving the circumstances, the health and the prosperity of Indigenous Australians.

I know that we weren’t alone in feeling a sense of failure and even hopelessness.

Despite that, our challenge is not to wallow in despair and give in to a sense of futility.

Reconciliation is a word used a lot in the context of our relationship with Indigenous people.

As a doctor, I believe there is no more important reconciliation required than to reconcile our desire to improve the health of Indigenous Australians with our historical failure to achieve our ambition in this regard.

We need to believe in the creativity and passion of our community, which has successfully risen to other challenges.

We must work together to garner the resolve to meet this, our most fundamental challenge.

And I say this very mindful of the burden it will place on the medical profession.

Doctors have a clear role and responsibility to contribute to what must become a national plan to improve the health, living conditions, and life expectancy of Indigenous Australians.

We need a national plan with clear targets and benchmarks for concrete action.

It is a national tragedy that requires a coordinated national response.

It is our number one national priority. 

I call on others who rightly recognise the land on which we live, to do more than just tacitly recognise the gap that exists, but to make real the aspirations of Indigenous Australians.

GP Week 

I would also like to inform you that this week is GP Week – a week set aside by the AMA every year to pay tribute to Australia’s hardworking and dedicated general practitioners.

It is worth noting that two recent reports have endorsed the important role of GPs in primary care.

The OECD has confirmed that GP-led primary care is a cost-effective way to promote good health.

This has been a core message to governments from the AMA for many years.

The OECD also stresses the need to promote general practice as a career – as GP numbers are growing at a much slower rate than specialist numbers.

This Government has made a good start by supporting training for junior doctors to gain experience in general practice before they make a final decision on which career path they will choose.

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.

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

I will talk further about the role of GPs a little later.

AMA Advocacy

But first I would like to talk 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. 

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.

What doctors see every day is that:

• there is not equal opportunity to essential health care in Australia;
• there are too many scarce health dollars caught up in the games that governments play;
• the system is still confusing and uncoordinated for people coping with chronic conditions, severe disabilities and very tenuous social support;
• the safety nets for frail elderly Australians are frayed and, at times, elusive; and
• there is a lack of attention given to people with dual diagnoses - such as people, often young people, who experience mental illness and substance abuse.  This is increasingly becoming a national disgrace.

So, no wonder governments are looking at reform.

Medicare is 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 was back then, the AMA will be actively promoting the key leadership role of doctors in the health system, and how this role must be reflected in any change process.

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 real 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.

It is my job to ensure the AMA is engaged with Government throughout the reform process.

And 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.

We expect to see a number of major reports released in coming weeks.

One, the report of the National Primary Health Care Strategy External Reference Group.

Two, the report of the Preventative Health Taskforce.

And, three, the final report of the National Health and Hospitals Reform Commission.

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

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.

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 their 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.

And as AMA President I have already had several productive and cooperative meetings with the Health Minister, Nicola Roxon, and her staff.

I am confident we will work well together.

The health debate cannot be run by ideology – 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 Big Issues

The health reform agenda is huge, and I do not have the time today to comment on every item that is bound to emerge from the imminent reports.

I will speak briefly on some of the major issues.

But I would also 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 National Health and Hospitals Reform Commission (NHHRC) report is what they will recommend on who should run the health system, and how, and who pays.

Much has been made of the Prime Minister’s election pledge to take over public hospitals if the States don’t lift their game.

Whether or not the States have lifted their game, the States are 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.

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 our perspective – and the public’s perspective – the major governance issues are around 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.

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 see any of the reform options, is that we actually hear governments commit to act, and act with conviction.

Australians need governments to take responsibility, not merely to posture.

Inaction simply adds to the increasing levels of cynicism that unfortunately bedevil the cultures of many public hospitals, as decent people struggle to provide high quality health care to very needy people within a system that is grossly underfunded and manifestly over-managed.

We at the AMA have grappled with this issue for many years as well.

In 2005, the AMA told the House of Representatives Standing Committee on Health and Ageing Inquiry into Health Funding:

“Commonwealth-State arrangements in health care are difficult to unravel because the cost and blame shifting potential of that system is appealing to politicians.

The inertia against change is immense.

While that remains the case, improvements in accountability by government will remain elusive.

Were it possible to resolve some of the areas of shared responsibility so that one level of government was fully accountable for outcomes, this would be a significant step forward.

However, we are not holding our collective breath.”

That was the AMA view in May 2005.

In July 2009, as we await the NHHRC report, let me set out the sorts of things we would support in their reform recommendations.

Any proposal would need to genuinely and clearly improve access to health and hospital services.

There must be good integration across all related health services.

Changes must result in high quality health services and health care.

There must be minimum levels of bureaucracy.

Administration, performance reporting and accountability requirements must not take precedence – in terms of time or funding – over the delivery of patient care.

Services must be organised and administered as close as possible to the actual delivery of the service (to the bedside).

Reform must enable more decision-making by health professionals at the local and institutional levels.

Reform must encourage a move to national standards.

There must be clear political accountability and responsibility for performance.

The reforms must be clearly understood by and accepted by the public.

Reform must maximise individual choice as to the quantity and location of desired health services.

The reform package must be affordable, both for the nation and for Australian families.

And our bottom line, as outlined by my predecessor in our response to the NHHRC’s Interim Report earlier this year, is how to improve patient care at the bedside, not which level of government does what.

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

Watch this space.

Workforce

Another area of reform being pursued by the Government is the health workforce.

We have already seen legislation tabled in Parliament that allows nurse practitioners and midwives to write PBS-funded prescriptions for patients and provide services which can be claimed under the MBS.

This legislation is risky.

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, 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.

And we don’t see this measure as a panacea to improve access to health care - there are only 370 nurse practitioners across the country, compared with 23,000 GPs.

And we don’t have enough nurses to meet existing nursing workloads.

The Minister has made it known that she has further plans for workforce reform.

And we know from its Interim Report that the NHHRC supports elements of these reforms in certain locations and situations.

There may be more in the Commission’s final report.  We will know soon.

Much of the work in this area is in its early stages.

Clarification is needed around the implementation of these changes.

Further debate is needed around the concepts of team care as opposed to independent care as opposed to autonomous care as opposed to clinical leadership.

These are all very different concepts but they are used interchangeably by the Government at different times to different audiences.

More information is needed on how the proposed collaborative care models, that are supposed to be in place soon, will work. 

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

And 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. 

And 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

I want to seriously engage the Government on rural health as well.

Australians who live in country areas deserve and are entitled to access to quality affordable health services – just like city people – but they don’t always get it.

Patients do it tougher out there.  And the doctors and other health professionals who work in rural areas do it tough, too.

Recruitment of Australian-trained GPs to rural Australia has almost come to a stop.

Country general practice is relying almost totally on overseas trained doctors.

Of all the OECD countries, Australia now has the second highest reliance on overseas trained doctors.

Such that, today more than 40 per cent of rural GPs are overseas trained doctors – and they are there because they are required to spend 10 years working in country areas.

At the same time, we are losing our rural proceduralists at an alarming rate.

These are our rural GPs who maintain their skills and training in areas such as obstetrics, anaesthesia, emergency care, and surgery.

And more than 130 rural maternity units have been shut down in recent times.

We need to revamp the incentive system to lure GPs, 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.

Getting more doctors into the country will undoubtedly help patients and communities.

The government made a downpayment on rural health incentives in the last Federal Budget.  While we welcome this, a lot more is needed.

In the meantime, we must do more to help the patients get to quality health care if it is not locally available.

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

While all Australians will benefit from e-health initiatives, rural Australia is where new and innovative technology and information systems will pay off big time.

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.

Electronic health records will 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.

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.

There is a lot happening in the ehealth sector at the moment – through COAG, NEHTA, and the NHHRC.

But fundamentally this is an issue on which governments must show leadership to ensure progress. 

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

I’d like to turn now to a couple of important areas where the AMA intends to lead community and political debate.

Long Term Care (LTC) Scheme

The first is re-establishing the case for the Government to introduce a national long term care scheme for people catastrophically injured in accidents, including medical accidents.

For those of you who remember me from the AMA’s campaign throughout the medical indemnity crisis a few years ago, you will know that this is an issue close to my heart.

The AMA has a policy on the establishment of a long term care scheme.  It reads:

The AMA supports the establishment of a long term care scheme for the 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.

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 abandoned plans – or at least ceased discussions – for a national long term care scheme in 2005.

They put it off for another day – Prime Minister, that day has arrived.

I make one thing perfectly clear – the doctors got their package in 2005. Now it is the time to look after disabled Australians and their families.

Currently, about 50 per cent of catastrophically injured Australians are already covered by statutory schemes.

I believe that the cost of expanding the current scheme is affordable. The social benefit would far outweigh the cost to government in any case.

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.

The scheme 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.

A national scheme would provide justice, fairness and compassion for those who need it most – and, over time, provide greater affordability for governments and the community.

It would also underpin the medical indemnity system.

The AMA will put together a compelling case and seek community support for a long term care scheme.

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

Minister Roxon is showing interest in significant structural reform of the health system.

For our severely disabled Australians, no reform is more important than a scheme which provides assistance based on need, not a legal lottery.

The Government is consulting widely on disability services and we are sure they are hearing that the current system is not too flash – and that is the AMA’s view, too.

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.

You would be surprised to realise how many Australian families are left to their own devices to support children with a disability, even into adulthood, and what it costs them, both financially and emotionally.

It brings me to tears when I see elderly parents accompanying their disabled child with the love and patience that only a parent can give - but with uncertainty in their eyes that ask the question:  “Who will look after my child when I am gone?”

Our support to them as a community shouldn’t be about patching up the gaps when families can’t cope, so that people with a disability and their families can just get by.

We need to introduce an entitlement scheme that goes beyond a mere safety net to ensure that they can have sustainable and productive lives.

Doctors care about this issue for many reasons, including:

• Social justice and equity – people with disability (and their families) have a right to participate in our community and be supported;
• Doctors see the downstream impact of inadequate early support and assistance because they treat people with disability; and
• Doctors are frustrated at their inability to get assistance, care coordination and support services in the community for their patients who have a disability;

The AMA will work closely with the Government and with groups such as the National Disability and Carer Alliance in this important area.

Professional responsibility

I’d like to now speak briefly about the issue of professional responsibility within the medical profession.

It is an important matter – especially in this era of comprehensive health reform.

The medical profession, in consultation with the community, is best placed to lead on the development and monitoring of 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.

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

Being a professional to me means accepting the standards of my colleagues, and placing our obligations to our patients above our own individual legal rights.

The medical profession recognises its limitations and sets very high standards and codes and guidelines on what is and what is not suitable behaviour or practice.

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.

And, 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.

In saying that, it is important to be reminded that doctors already contribute many voluntary hours to the development of their profession and the assessment of their peers.

For example, they:

• Sit on medical boards,
• Sit on ethics and research committees,
• Sit on professional development and standards panels; and
• Are actively engaged in the activities of their Learned Colleges in the pursuit of professional excellence.

They do this because they believe it is important to contribute to the growth and development of the profession in all its areas of responsibility.

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.

Without going into all the details, I will provide you with a very practical and personal example of this responsibility.

I am currently working with the NSW Police as the expert adviser in the investigation of complaints and allegations made against Dr Graham Reeves.

As a senior obstetrician and gynaecologist, I am well placed to provide professional advice on the specifics of the complaints made against Dr Reeves.

But, more importantly, I made a deliberate and carefully considered decision to take on a significant extra workload.

I believed it was necessary for a recognised senior specialist - I was, at the time, President of our National Specialist Organisation - to take on the task of assisting in an investigation of serious complaints against one of my colleagues.

I am not at liberty to discuss further the details of the case – but I present my involvement as an example of professional responsibility, which I and my colleagues take very seriously.

I can take questions on professional responsibility, but not on the Reeves case.

Conclusion

In closing, I return to my theme of engagement – the importance of being at the table to put your arguments to Government at a time of unprecedented health reform.

I will refer to a major speech in another place just a month ago.

The speaker on that occasion said:

“My view is that health care reform should be guided by a simple principle: fix what’s broken and build on what works.”

He also said:

“There’s already widespread agreement on the steps necessary to make our health care system work better.

“First, we need to upgrade our medical records from a paper to an electronic system of record keeping …

“…The second step that we can all agree on is to invest more in preventive care so we can avoid illness and disease in the first place …

“… And we need to rethink the cost of a medical education, and do more to reward medical students who choose a career as a primary care physician … who choose to work in underserved areas instead of the more lucrative paths.”

Sound familiar?

The speaker was President Barack Obama.

He was speaking at the Annual Conference of the American Medical Association.

He received warm applause.

At the opening of his speech, the President said:

“And we also know that one essential step on our journey is to control the spiralling cost of health care in America.  And in order to do that, we’re going to need the help of the AMA.”

Several times during his speech, President Obama called on the AMA for help in his health reform agenda.

And several times he paid tribute to AMA policy, which he had turned into law.

This was a speech about engagement in the political process.

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.

Thank you.

 

An edited transcript of the question and answers session at the end of Dr Pesce’s Address

Question: You mentioned that the state of Indigenous health is a national tragedy. How would you rate Government efforts to close the gap and can you nominate three practical steps that could be done right now to improve the situation?

Dr Pesce: Look, I think governments have been, like a lot of us, noble in their intention; the difficulty has always been translating and reconciling that intention with the outcomes. I think they all mean well, but I think we need to look at what works and we need to assess what works, and what we see in terms of practical steps.
The three steps are: consultation with local communities.  No matter what you do, if the local community isn't engaged, they don't turn up. Secondly, we need to really assess the effectiveness of the various programs out there. There have been a myriad of programs. We need to assess what's worked, we need to see what hasn't worked and we need to focus on the strategies that do appear to work.
And, finally, we need to really find ways to deliver services out to the remote areas, because some of it is tied up, not only with the Indigenous question but also the remote question. And that really comes down to finding options for incentives to attract workforce to the areas of need.

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, which says that Kevin Rudd's threat to take over the hospitals was an election stunt before the 2007 election?

Dr Pesce: Now, 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, very correctly identified a major concern in the community and everybody is acutely aware of the deterioration of public hospital services in this country.
I think that was a very insightful thing that was picked up. Of course, the big difficulty is translating the acknowledgement of the problem with the solution in what's been a very complex area. And one of the complexities is, of course, the fact 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 the hospitals, the public hospitals are under-funded 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: I think 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 Hospital Reform Commission.
It's just too difficult to say whether one thing on its own is going to solve a problem. And it may solve a problem in one area and shift it to another area, and that's been the big problem in health all the time; that by dividing it up into little pockets and silos, there's been temptation to just solve a small problem here which doesn't solve the big 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: I am asking about hospitals again. In your principles 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: Well, I think you have to measure and decide what decisions are best made at the coalface, under a template of overarching funding responsibility.

I graduated from medical school in 1984, so 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 is it that is done best at that high level and what's done best at a local level.

I can tell you that 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 solve the problems: because there aren't funds, it's got to be approved by this body, it's got to go to that Minister. And so we need our administrations to help us, not be obstacles to what we can do.

Question: On Indigenous health, has enough been done to recognise the problems that the swine flu, or H1N1, poses to Indigenous communities in particular. And, more broadly, has the issue of swine flu been overtly sensationalised or has the level of response to it been appropriate?

Dr Pesce: Swine flu has probably been the best documented reported epidemic in our time and that's raised a lot of issues.

I honestly think that the Government has done a great job at recognising the potential threat of the swine flu pandemic.  It had to make decisions at a time when it was unclear whether it was going to be a very virulent virus that had up to 40% mortality rates like the SARS virus, or whether it was just going to be another flu.

It wasn't going to get presents for over-reacting or under-reacting if it got it wrong, so I think it made the right call. It was very cautious. It however didn't want to over-react until there was evidence of where the problems were.

Now, we now have good evidence that swine flu, in the general population of healthy people, tends not to be any worse than the seasonal flu that has afflicted us every year. We do however now see that at-risk patients may be more at risk of developing life-threatening complications and they need to be aggressively identified and aggressively treated. And pregnant women are one of those at-risk groups, even though they're generally healthy otherwise.

It was always recognised that Indigenous communities were probably going to be at risk because they do have a higher level of underlying chronic conditions. And the problem of course is always once again translating the decision to say yes, Indigenous communities are an at-risk population, but then getting the resources to those communities to deliver what we would see as optimal health responses to the outbreak.

Often that's failed. And I think one of the things we have to acknowledge is we need to learn the lessons that have come out of our response to the swine flu pandemic.

As I said, I am not being critical - we've done a lot of good things - but we've made some mistakes.

We need to learn from those mistakes so that in future, if the big one does come, if there is a SARS-like infection that comes in the next few years, we're better placed to respond to that effectively.

Question:  You're the first president of the AMA in recent years to have direct hospital experience as a specialist. You're at the coalface in the hospital system. 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 New South Wales health system. Do you agree with them?

Dr Pesce: They've obviously identified that there's a big problem. And, you're right, I've been working in the health system for a long time and 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 in Australia 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 hard-working and dedicated GP or your consultant position 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, then 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 the 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.  And what did it show?  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.

So I think 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: Dr Pesce, 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.  And the second is, doctors do have a major influence on out-of-pocket costs for patients.  Where do you see the bulk-billing figures heading? Are they going to stay at the comparatively high level they're at now? Which direction basically: up or down?

Dr Pesce: Well, 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-of-pocket expenses, and those who might be able to afford it.

So, that's how they determine their charges.  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 …?, and just expect it to be implemented down there (lowers hand). And the end result is that continuous tension between the service providers and the service payers.

Now, it's inevitable there is going to be some tension, but I think 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 the budgetary constraints all the time.

Question: At the end with something of a personal question about doctors I guess.

You've just been elected President after what's often a hotly contested political process in the AMA and I'm just interested in what drives doctors. I've seen a lot of them get into politics and they want to do political things. I'm not talking about just people like Brendan Nelson, but just the whole political … what drives a doctor to give up so much of their time and often their salaries to get into this sort of thing?

Dr Pesce: Well, I think it's because we see that it's too important not to do that. And if you ask me why am I president of the AMA, I think it's because I just couldn't say no.

When I see that there's some need out there and people ask me to do something, I've always asked, what is it that I can do? There are lots of reasons why I wouldn't do it.

I mean, my only regret about this job is that my poor patients, suffering patients, who booked with me nine months ago before this was even on the template - I'm away for two days and that's a real struggle for me, and it's probably the major tension after the tension of not being with my family.

So I look very much, when all this is over, to returning to care for both of those sets of people.

Question: I’m just wondering what sort of revamp you'd like to see to the incentives you referred to, or the need to revamp incentives in terms of attracting younger doctors into rural areas. I'd say that trickle's almost turned to nothing …

Dr Pesce: Yep.

Question:     … in terms of young doctors who are prepared to go there. And I'm wondering, does it really need to be more than financial, because even here in the ACT for instance, we struggle to attract doctors: a very high standard of living, a very low level of bulk-billing, which presumably provides some commercial incentive. But, if that doesn't attract doctors, then how do you do it to those, if you like, much more remote areas than the national capital?

Dr Pesce: Look, if I had the answer to that I'd be the Health Minister, I suppose.     But my honest answer to that is I don't know that anyone knows what's going to work. And what I would say is it is necessary for governments to try a few things.

Instead of trying to come up with a new policy which is going to fix the problem, let's come out with several options. Let's see what works at a local community. And what might work in Brewarrina may be completely different to what might work in Cape York and what might work in Alice Springs and what may work in Bega.

So, instead of trying to hit the silver bullet and say, this is it, this is what's going to solve the problem - which isn't going to solve everyone's problems - let 100 flowers bloom. Let's just say, these are the options. Let the local communities, the local workforce, the local doctors, the local nurses say this is how we can use the various funding options which are available and help us look after our patients.

So I'm not going to give you a single prescription, because it's not going to work everywhere in Australia. What I would encourage the Government, and governments to do, is to say we don't know what's going to work either.

The last thing we need to do is have an ideologically-driven one. Let's just say, let's have a few models of funding available, and let the local workforce and the local communities decide which works.

ENDS