AMA President Dr Steve Hambleton, National Press Club, Q&A, 17 July 2013

Subjects:         Q&A

LAURIE WILSON:   Let's move to media questions now and the first one today is from Sue Dunlevy.

QUESTION:  Sue Dunlevy from News Corporation. Dr Hambleton, a few weeks ago when my microwave broke it cost me $90 to get it fixed. A few days later when I went to see my GP for a health problem, Medicare was only prepared to pay $35 - $36 for a service to fix a sick human. There are gaps to see GPs now amounting to $40 in out-of-pocket expenses for patients. We've seen some patients having to raid their superannuation to pay for out of pocket medical expenses when they have cancer. You've raised the issue of affordability. We've now got one in eight patients in some regions in Australia who can't afford to see a doctor. Neither side of politics is offering to do anything about the affordability issue in this election campaign. In fact, in the last Budget, the Government  raised the out of pocket expenses for some Australians by scrapping a tax break by making it harder to qualify for the safety, why is this issue not on the top of your agenda for the election? It rates as number two. And what needs to be done to fix the problem?

STEVE HAMBLETON:       Well, I think you've raised a very important issue and it's - affordability, particularly in - well, right across the health spectrum, but in particular in the primary healthcare area. If we don't do something about affordability, we're actually breaking the rule that the AMA just set for measuring is it a good policy or is it not? We do need to make sure that people can afford to see their family doctor in a longitudinal basis and get access to that early care at the cheaper end of the health spectrum, to do that health promotion, and make sure people stay out of those hospitals, which are expensive. Ignoring that comes at the Government's peril.

Governments have got to think not just about an election cycle, but about proper health reform and long-term healthcare costs in this country. We know there is an ageing population, we know there are increasing rates of chronic disease. If we prevent access or if access is not freed up at the beginning of the have process, it's going to cost a whole lot more down the track. We had seen these issues raised at the - with multiple reports warning us about the burgeoning rates of chronic disease that are coming our way. It is time for the real health reform to start to happen.

Many of these - some of these changes occurred in the last Budget and they were absolutely back to front in terms of providing people access to good care. Delaying the Medicare rebate rise by some months to next July is another nail in the coffin for that access and affordability, and that is something that we're very passionate about, that we do want to make sure that we actually continue to see access to quality doctors for people who particularly need it. Bulk-billing rates, some people say, is high and I've heard the minister say that. It's only part of the story and yes, we are getting good access currently for some of the population, but it's those that don't get access that are often the ones that miss out. We need to make sure the rebates reflect what it costs to provide quality care.

We heard also about our international comparisons. We are 20th in the OECD on our spend in Australia in terms of health. The population wants to make sure that they've got access to health. When I was in Canada, one of the comments they said to me is, ‘but we can afford it’. Actually, we can, too, so we need to spend money in the right place to make sure people can afford to see their doctor and get proper care.

LAURIE WILSON:   David Speers.

QUESTION:  David Speers from Sky News. At the risk of sounding like a shock jock, I want to look at what you said about asylum seekers today and your call for an independent medical panel to oversee the physical and mental health of those both onshore and offshore. I'm just wanting you to flesh that out a little, what role you see for the AMA here and what sort of access there is or isn't at the moment when it comes to look at these things? Are you worried that something is being hidden by the Government?

STEVE HAMBLETON:       Well, I guess the answer to the last part of the question is we actually don't know. We do know that there are inspections being allowed in various places and, as I mentioned, we had DHAG, the inspection group, but they were ham-strung in what they could say. That's been replaced by IHAG. Once again, they're reporting but they're not - they're reporting behind closed doors and we actually don't see that publicly. So what we actually need to do is shine the light on those places so we know what's going on, so we can understand the health problems that do exist. There's nothing like shining a light on something to get some action to get it fixed if there is a problem, and we do know from reports of people who have worked in those places that they are suffering some difficulties and hardships with providing appropriate medical care.

There are complex medical needs of the people coming from various places around the world and some of those things, you might need, for example, you might need a CT scan. Getting a CT scan offshore is not easy. Providing appropriate services for people with complex diseases, things we don't normally see in this country - TB, sickle cell disease, all of these things can occur in the people coming offshore. They need proper treatment and we need to look after them properly, so shining a light on that by having an independent inspection body who can publicly report and report to Parliament so we all get to see it is almost guaranteed to fix the problem.

LAURIE WILSON:   And just specifically on the role of the AMA on that, I mean, do you see the AMA playing a key role? That was one of the questions that David raised.

STEVE HAMBLETON: Well, we're very happy to play a role. We actually have a representative that's been on both of those groups that I mentioned just a moment ago. Very keen - we've got a child psychiatrist who has been very generous with his time to make himself available, and we've also got other members quite happy to make themselves available on those sort of committees to provide that medical expertise. You know, this is a humanitarian issue. I mean, let's stay out of where they are from and why they're here and all the other stuff. Once we are in control or once we take responsibility for people, we should be providing them with first-rate health care.

LAURIE WILSON:   Question now from Joanna Heath.

QUESTION: Joanna Heath from The Australian Financial Review. Dr Hambleton, the medical community has expressed a lot of outrage over certain things that the current government has instituted, the budgetary measures you've mentioned. You've previously called them the four horsemen of the apocalypse, and arguably you were a bit more favourable to Tony Abbott's record on health rather than Kevin Rudd's, in your speech. Do you think those measures have been enough to influence the voting intentions of the medical community and other associated entities that are affected by things like the self-education cap at the upcoming election?

STEVE HAMBLETON: Look, I think there's been some disturbing things happening at the moment in health that really are running against what we need to do as a country to actually improve our health system, invest in the right areas to make sure we get a long-term sustainable system. It is clear that both of the men vying for - to be the next Prime Minister have got history in health. Both of them had a vision for health, both of them made significant changes that actually - some - well, a lot of which we agreed with, a lot of which we supported the thrust of.

But I think what we need to hear from now to when the election is called, what they're going to do from now on. The Australian population needs to understand and they know that health is an issue they very much care about. We actually want to see what are the policies that they're going to bring to the next election and do they fit that slide rule that we gave you? Is it going to make a comprehensive, coordinated primary healthcare workforce stronger? And yes, we need to invest in our hospitals, but we need to think about the long-term future as well. So we want to go back to both of those people, given their history in health, and ask - and challenge them to tell us what they're going to do next in their health policies.

In the last Budget we saw some backstepping, we saw decreasing access to primary healthcare that doesn't meet the rule. We don't want to see that happen. We want to turn that around. Even the policy of self-education expenses eventually feeds back to patients and it certainly is - potentially dumbs down the medical workforce and we don't want to see that either. We want to see a stronger, well-educated workforce, better access to patients, a stronger primary healthcare structure underpinned by a good communication system. If the policies are going in that direction, they'll get the tick from us and they should get the tick from us and should get the tick from the Australian population.

LAURIE WILSON:   Before I take the next question from the floor, if I could just ask a follow-up to Joanna's question. In the document you released today - in fact, in your foreword, you make the point that some research that was undertaken, I presume by you by essential media research, in June were found that the - ensuring the quality of Australia's health system ranked second only to management of the economy in terms of, you know, what would influence people's vote, but - and it ranked 45 per cent versus 47 per cent for the economy. But did you get any indication from that polling as to, you know, what - apart from health being a general issue of concern, how much are people alienated from one side of the politics or the other in terms of - or happy with in terms of the health programs that they've currently got? Does it give you any insight into what the actual impact on polling might be?

STEVE HAMBLETON:       In fact, it probably doesn't give us that differentiation that we're seeking. It certainly meant to us how highly important health is as a policy area in the next election, you know, and there has been so much press about health in the last few years. I mean, we know our hospitals are under pressure, we know that there's ambulance ramping, we don't have enough beds to - well, the reality is our number of beds per 100,000 population is below the OECD average. The number of beds for people over 65 is particularly telling, and of course our population is ageing, so that's accelerating very quickly.

So people know the system's under pressure and they want to see us do something about it. Now the thing - what we're saying is yes, we need more beds, yes, we need better cooperation between state and federal governments, but unless we do long-term planning with some key overriding principles and step back from perhaps some of the things that end up on the front page, we're not going to get a long-term health outcome that's going to work for this country and keep it affordable in the long-term. That's why looking at an election cycle and saying I'm going to get something off the front page is really not good enough anymore. We've got to think a decade out, we've got to think a few elections out. It's a big challenge for politicians but we've got to set the rules up as the AMA and as the people of Australia, and we've got to say if you fit within these rules it works for us now at this election and it will work for elections to come.

So specifically for those minor issues on which side we haven't got that answer, but I think it's important for all Australians.

LAURIE WILSON:   There is a latent potential there is the point you're making. Next question now from Andrew Tillett.

QUESTION:  Andrew Tillett from the West Australian. Dr Hambleton, with car insurance, you pay more if you're an under 25 or if you're a bad driver and cause accidents. With travel insurance, you're probably not going to be covered if you're going skydiving on your holidays. With home insurance, you pay more if you live in a high-crime area. But with health insurance, risk factors just do not get taken into account with premiums, such as if a smoker pays the same as a gym junkie. I wonder if you think we need to look at the financial incentives in the health system and also perhaps in Medicare and look at charging people who won't take responsibility for themselves, the smokers, couch potatoes, who engage in known risk factors for their health, and make them pay more to get that seismic change in lifestyle patterns that you mentioned in your speech?

STEVE HAMBLETON:       Well, it's an interesting theory and interesting commentary and it's something I think that certainly doesn't fit with the way Australia puts its system together currently. When you talk to the private health insurers about community rating which I guess is a parallel to what you are saying, it's very important that we embrace everyone in the community and bring them all into the health system because you'd simply price out people with those risk factors, and then you start to get to the point where, well, are we blaming someone because of something? Is there a genetic difference? Is there a choice difference? And really, the way we set ourselves up is to make sure everyone gets access.

Now, should we do something about it? I think the answer's yes, and I think we do need to start well before those problems start to exist. Tobacco is a great example and we've worked hard on tobacco in this country and that has been a bipartisan issue. We've got our smoking rates down to 16 per cent. When you think about places like China where it's sitting at 45 per cent with a huge problem looming, we're doing pretty well, but we need to keep that health literacy and health education and that stopping the recruitment of the next generation going.

Similarly, we need to think about health literacy and we talked in the early part of the speech about the environment we find ourselves in. The first thing we talked about wasn't access to doctors, it was actually preventing people needing a doctor in the first place, and that's a bit about what you're talking about. We need to know about diet, we need to know about exercise, need to know about the dangers of alcohol, we need to make sure we don't advertise and promote alcohol to our children and groom them to be drinkers when they reach the magic age of 18. As we've said before, we know the human brain doesn't stop developing until 25, so if we want to have a medical argument about alcohol, it's very different to that legal argument. We need to do all these things and make sure that we know that exercise is good for us. If you exercise half an hour three times a week, that's very good. If you exercise for an hour three times a week, it's better, and these are the sort of messages we need to get out. But we so need to make sure people get access to care and we need to make sure that we support the community rating so everyone gets access. There certainly can be finetuning of those insurance products, but penalising people who are already sick is probably something that we can not support.

LAURIE WILSON:   Dan Harrison.

QUESTION:  Gday Dr Hambleton, Dan Harrison from The Age and The Sydney Morning Herald. I want to follow up Sue's question about out-of-pocket costs - you spoke in your speech about the growing share of costs that are borne by patients and the Government points to historic high rates of bulk-billing which you acknowledge, but you said that's only part of the story. Can you expand on that?  What is the real picture that is perhaps being masked by those figures?

STEVE HAMBLETON:       Well, I guess the issue of out-of-pocket costs is important because that is real access and we do need to understand that a little bit more. The out-of-pocket costs that Australians are paying compared to internationally is about the middle of the range, but when you analyse it, it's actually not the medical out-of-pocket costs. It's actually often these discretionary costs at the pharmacy that - where we're spending a lot that are counted in that OECD calculation. But there are certainly pockets where the rebates that are paid for medical services, where there are large gaps. Now, if we're talking about most of the time most people get good access. We can all find areas where some people get very bad access, and they - it costs a lot of money, so we do need to look at those specific areas to make sure that the rebates match the cost of providing quality service.

If there is a gap there, we should look at that and we should do something about it. I think it's very important, because people are spending large out-of-pocket costs and that's not why - how the Medicare system was set up. Some of the Medicare rebates are historical. We do need to actually improve it, make sure it works for our population. Primary healthcare is such an important area that broadly the gaps are minimised because that's the investment which is at the cheap end of the spectrum which will save us money in the long term.

So I think there are pockets that need to be checked. We need to make sure we don't decrease access to that good quality, doctor-led, team-based care and primary healthcare and general practice that we need to underpin for change in our health system.

LAURIE WILSON:   Question now from John Millard.

QUESTION:  Thank you, Laurie. John Millard, freelance. Dr Hambleton, you've mentioned the increase in undergraduate places for medical students in Australia, some 50 per cent increase in the last five years and most people would agree that that's a good thing. This in turn, though, puts pressure on internships, particularly the first year internships which medical graduates must perform before they go into clinical practice, and some states are have - they made preference for undergraduates from their own medical schools in that state. The ACT, in fact, not only gives preference to graduates of the ANU, but discriminates against those who are applying interstate for an internship. Now, this has attracted a lot of criticism, particularly from the community, including the Australian Medical Students Association. Some have even claimed that this is against - contrary to section 117 of the Australian Constitution. Does the AMA agree with these criticisms? Does it have its own view about them? And if it's in line with these criticisms, what does it intend to do about it?

STEVE HAMBLETON:       Look, I'm glad you raised that area. It's really important that we actually begin to start to train enough doctors in this country to satisfy our own needs. There is just no doubt that - well, we've been - it is an unhealthy reliance in this country on international graduates to prop up our health system, and so we were under-training doctors for a long time. In fact, it was probably a decade after I graduated that there were any increase in the numbers of training anywhere.

Thankfully back in the days of Tony Abbott, and it has been continued by the current Government, we actually are increasing the number of student places, but it appears to me it's almost a surprise to the state governments that these students are coming out of university and they need training. As a nation, we need to solve this problem. It's - we've got to remember that we're part of a nation, that, you know, the states need to think about the impact of their own decisions on what the nation's doing. We need to make sure that we are - well, if we are targeting self-sufficiency, and I haven't heard that said by a politician - are we actually targeting self-sufficiency? And I think we should. Or even indeed being net exporters, we've got to make some decisions that are nationally consistent.

So at the moment, we've got international graduates who are getting preference over Australian doctors in some states. We've got to think about what the implications of that are. Yes, we - and that may actually have further implications on funding medical schools. Now, we know - we actually supported a doubling of the funding of government-funded medical school places, so medical schools don't have to rely on international students to pay their way.

So there are distortions in what happens because of the funding coming in internationally, and we've got to remove those distortions. We've actually got to stop the unhealthy reliance on international colleagues, we've got to actually train our own to make sure that we have got enough. So we do want states to be consistent, we do want them to talk to each other and we don't want to have an argument in November this year about where the interns are - places are going to be found. So we are calling the Federal Government - showed some good leadership last year. We still want the Federal Government to show leadership this year, but we are also calling on state governments to remember you're part of Australia, you're part of a target. Health Workforce Australia tells - is framing that target for us. How - let's all work together to try and get it done.

LAURIE WILSON:   Mark Metherell.

QUESTION:  Mark Metherell from the Consumers Health Forum of Australia, Doctor. Thanks very much for your speech. You spoke about the continued need for reform. What about a rethinking of the way doctors are paid in Australia? You mentioned the fact that Medicare, as it's currently constructed, is - takes us back to much more acute care entrenched system, whereas these days, of course, it's chronic disease, aged care which require a much more continuing set of arrangements between doctor and patient. Would the AMA ever consider rethinking its love of fee-for-service and look at, say, a greater degree of salaried medical professional? We think of what's happening with aged care patients who often can't get a doctor to come to the nursing home for months at a time, and also with chronic care, the proposals for the diabetes scheme that are still under consideration, is this something the AMA would ever seriously consider, a move to more salaried basis for medicine?

STEVE HAMBLETON:       I think we've got to look at the principles that we just talked about, about what is going to lead us to a better outcome in our health system and we do need to think about chronic disease, ageing population, access to care for people exactly as you said, in aged care facilities, in their own home, and the Medicare rebates for that are simply insufficient. In terms of complete - of different payment systems, I guess I had a bit of an opportunity to look at those different payment systems and the AMA does look at them periodically over a time to see if there are advantages, are there benefits?

If you do a Cochrane Collaboration review of different payment systems internationally, there is isn't a clear recommendation from that very rigorous review of payment systems to say one is so much better than the other. And when you do travel around the country and you look at countries like the UK, where there's a capitation system where you see the similar problems on the ground, where you see difficulties getting access to general practice, patients tell me they get eight minutes, one problem, and if you've got a second problem come back tomorrow. Very different payment system. The average in Australia is 14 minutes and it's actually growing and the BEACH data tells us that, so our system is not that bad.

When we start looking at payment for performance, which is one of the other systems, the UK brought that in and remember when I said Australia's is 8.9 per cent of GDP, UK is now 9.4. They are paying a lot more and we're getting better bang for buck. So the payment system, while it's got some flaws and needs fixing, isn't the only answer. Certainly focusing on chronic disease is really important, and we've moved in that direction with the structured approach to chronic disease that we've got in our Medicare schedule.

The DVA and the CVC program is actually extending that to a longitudinal proactive interactive approach to chronic disease, which is really being embraced by doctors and showing some early promising results. The area that you focus - that you asked the question about, though, is really important and that's something we need the Government and future government to do something about and that is increase access of doctors to people in their own homes and in nursing homes, because they are an area where we can save a lot of money.

Now, can we afford it? Well, three days in an acute care bed would pay for a lot of care in a nursing home and a lot of home visits, so we've got to think about where are we spending the money and we're looking for policies and we're proposing policies that we bolster that spending, because that's a good spend and it'll save money in the long run. Entirely different payment systems - we look at it as AMA and we haven't concluded that any are much better than fixing the one we've got.

LAURIE WILSON:   We'll take a final, quick question - we are close to time - from Peter Phillips.

QUESTION:   Dr Hambleton, Peter Phillips, one of the directors of the National Press Club. Thank you for your third annual presidential address to the club which, if I might say, seemed to be rather more genial and benign in quality and character and approach than some of your previous addresses and certainly addresses by some of your predecessors. Does this bespeak a new approach to the issue of engaging government by the AMA, or is it because we've got now - we're facing an erstwhile unforseen close-run thing in the new election, you want to be nice to both sides? Or are we looking at a new era in the AMA's approach to government, being more engaging and more genial and generally more positive?

STEVE HAMBLETON:       No, I don't think the AMA's going to be more genial. We're going to call it how it is. If we don't like it, we'll say so, and we want to scrap the cap, we've had problems with Medicare Locals, we think that the super-clinic program has got to go. So there are things that we just plain don't agree with, and I guess today was an opportunity to say to the Australian population here is a way of measuring the promises that you'll hear, here's some - a way of testing things. If you want to differentiate between a good promise and a short-term promise, it might get something off the front page and here's how to do it.

So we've got an election coming up. It's a different environment. We're actually going to - we're calling on both sides of politics to tell us what they're going to do, and we want to know - we want to tell them how we're going to measure it and we want to help the Australian population with those decisions so I can say yes that's a good policy, that takes us closer to health reform and makes it better for me, for my parents and my kids. If we can do that, I think we're doing a good thing.

LAURIE WILSON:   Let's conclude on that note.

17 July 2013

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