Dr Capolingua's National Press Club Address: "Advocating For Patients in Health Reform"

Last week, I stayed in Perth and spent every day except Tuesday in my General Practice as a GP.

Last Tuesday, though not at the surgery, I spent the day as a GP writing up a report for the State Coroner for a precious patient who came to an unfortunate death earlier this year.

Going through the case notes was like reliving every consultation, every conversation, every experience and memory she shared with me.

It was difficult.

I would see her for an hour every month, bulk bill her so that there was no financial barrier to her coming to see me.

The last note in the file is a reference to the conversation that I had with my patient's 19-year-old daughter the day after they found her dead.

The other days of the week I worked in the practice doing the work of a GP, along with my colleagues, staff and practice nurses.

We experience much responsibility and humility in that privileged role.

I can tell many stories about my patients.

But today, I stand at the National Press Club talking to you as one of more than 50,000 doctors around Australia who knows the reality of health care for patients.

What good timing it is for the AMA to be at the Press Club this particular week.

There is a lot to talk about.

The AMA exists to advocate for patients and ensure that they receive the best health system for their needs.

We have our differences with Government because we are worried about the health system and patients.

We have good reasons for our differences and if we do not speak out we fear that the community will be delivered a lesser health system.

Australian patients deserve a health system that continues to improve and go forwards.

Patients deserve high standards of care and improved access to doctors.

Patients deserve government health funding to be used as efficiently and effectively as possible.

Australians and their doctors are worried about our public hospitals' capacity and want improvements in indigenous health.

The AMA speaks on behalf of patients.

We measure ourselves on a better health system for the community.

Sometimes it is uncomfortable and inconvenient for government to hear it but we must say what we have to say.

It is a pity if government decides to ignore the AMA because we are the most informed health advocacy group in the country; doctors are hands on and connected to the people and their needs; whether it be in a General Practice, in a hospital, out in the bush, or in an Aboriginal Medical Service or an indigenous community.

The AMA is not in the way,... the AMA is the way.

The government talks the talk. Let's see them walk the walk.

The AMA is honouring general practitioners this week with National General Practice Week.

So let's turn our minds to areas of health delivery.

We have some $275 million in funding for government super clinics on the books.

The AMA has been vocal about the proposal because we want that money well invested so that patients do get better access to general practice and primary care.

The government paints a picture of a one-stop shop, a supermarket of health care that will help mums with toddlers and people with chronic disease, and every one over all.

This is the picture the government is selling; that to deliver best care, GPs need to be in big new buildings with lots of rooms, and lots of nurses and allied providers in those rooms.

Physiotherapists.

Psychologists.

Occupational therapists.

Pharmacists.

Dieticians, and the like, all working out of that same big new building.

Super Clinics, the Government says, are the way to go.

Come on down to the one-stop shop.

Elderly? Young mum? Chronically ill? Right this way! Have we got the clinic for you!

Just walk on through the door, and the world of medicine is at your fingertips!

It's a myth that's being propagated by the Department of Health.

It suggests that putting people in one building is going to solve all the woes of the health care system - including emergency department overload and access block.

It entices with its promise of ease and speed.

We are told, for example, that a mother with a couple of little kids would love to go to a one-stop-shop for all their health needs. So convenient!

Ok, Let's put that under a microscope.

Reality is, that when it comes to the vast majority of children, a GP can take care of all of their health needs.

GPs have alleviated some of the time pressures by employing our on-site practice nurses to conduct weigh-ins and administer immunisations. The routine things kids need.

But the majority of little children, thank God, have very little need to call on the services of a physiotherapist or a podiatrist or a speech therapist or a psychologist - the kinds of health services the government is talking about putting into a Super Clinic.

When your child is not seriously ill, when it's just the ordinary ailments and complaints of childhood, then you're not going to need to see anybody other than a GP.

And if they are seriously ill, you want a doctor to define that and direct how to make it better.

Of course, there are some children who need to see specialists.

There are children who are born with congenital or genetic abnormalities, children who have developmental disorders or severe allergies, children who contract serious diseases.

GPs refer those children to the most appropriate high-end specialist, allied health, or paediatric services.

These specialists are not the people that will be sitting in your local Government Super Clinic. They will be in specialist centres or attached to the Paediatric Hospital.

You will want your child to access the best provider for their need, not just the one that is down the corridor helping to pay the overheads for the Clinic.

So the myth of the one-stop-shop for mums is busted.

I'll give you another example.

Super Clinics will make it easier for elderly people and the chronically ill to get to all the different medical practitioners and allied health services they need.

Maybe it's the physio, or the podiatrist, the dietician, the occupational therapist, the cardiologist or, in the end, the palliative care specialist.

In reality, the need for these services should be based on clinical requirements and they should be accessed on that basis.

If it is not based on clinical need, then there is something wrong.

GPs are the most-effective gatekeeper in primary health care.

Medical Practitioners have the comprehensive training to treat the patient holistically, not just as an ailment or disease.

Only doctors can take a history, examine and put together the whole person when making a diagnosis, initiating investigation, management and treatment.

Without GPs in the clinical coordination role, patients run the risk of being tossed back and forth without any coordination of their care.

Patients directly access allied health providers now and should be able to continue to do so.

You can go and see your podiatrist or dietician now whenever you need to.

But the government is trying to sell the idea that the allied provider can take care of all your diagnostic needs, and that should all be Medicare rebated, without the clinical coordination of the doctor.

This will lead to fragmentation of care. This is the exact opposite of the positive objectives of improving primary care.

It will not be cost effective and it will create duplication.

Systems overseas in which patients have been diverted from seeing the doctor cost more in the end, through other layers of services and increased referrals back to medical practitioners.

Patients may actually get sicker before they are directed to see their doctor.

I am in a mood to tell stories today, so let's tell a "Government Super Clinic story". A mythical tale.

We have a woman of about 40 - let's call her "Patience".

"Patience" - in the Government's myth - strolls down to the local Super Clinic to see her GP.

The large, bright building beckons with the promise of efficiency and good health.

It's a beautiful building - all that money.

Emblazoned above the double-glass sliding doors is a caduceus, the staff-and-serpent symbol that dates back to the physicians of ancient Greece.

"Patience" arrives, registers at the front desk, and then is seen by the doctor.

History and examination over, the GP develops an investigation and management plan and decides that referral to the in-house dietician and the resident psychologist are part of that management.

A delighted Patience returns to the clinic's reception area, where she swipes her Medicare card and asks for appointments with the dietician and psychologist.

She is able to see them straight away - as if!

So half an hour later, armed with some written material and an improved knowledge of what constitutes a healthy diet, she then crosses the corridor to see the psychologist.

An hour later and all in one morning, the one-stop-shop has catered for all her needs and "Patience" exits through the gleaming Super Clinic doors.

It is a simple nice story, isn't it? Great marketing.

How about what could be more likely to happen?

On the morning of her appointment, Patience gets up early.

She wants to make sure she has plenty of time to get to the Super Clinic.

Patience had always gone to her family GP, who'd been based at the local shops.

She'd been visiting her doctor there for 20 years. A doctor who knew her and her children well enough for a friendly chat when they ran into each other on weekends; a doctor and a practice who held records of her every injury and illness, every pregnancy, every referral for two decades.

But the Super Clinic changed all that.

It drove all the GPs in the surrounding areas out of business.

They were all forced to either retire early, or move away.

So now, Patience has to ride two different buses and walk for six blocks.

And when she gets to the Clinic, Patience will probably see a doctor she's never met before.

Every time she goes, she has seen a different GP, and last time she was there, she was told that in future she will first have to see a nurse who will decide for her if she should see a doctor.

The large concrete building beckons with all the charm of an accountancy firm.

Emblazoned above the double-glass sliding doors is a caduceus.

But instead of the traditional serpent, a twisted length of red tape is entwined about the staff, like a bureaucratic boa constrictor.

Patience walks in, tries to catch the attention of one the receptionists and registers her unique patient identifier.

She sits and waits for her appointment with the dietician.

She had initially called the clinic to make an appointment with the GP to discuss her weight concerns and aching joints but the receptionist had decided that the dietician might be a better first port of call.

In the consultation after being weighed and measured and from the information obtained from Patience, the dietician makes an assessment that the back ache Patience has been experiencing is most likely due to the strain her increasing weight is placing on her spine.

He gives her some written material, talks her through a new, healthier diet, and then advises she also sees the Clinic's psychologist.

Patience returns to the reception area, where she's forced to line up for 20 minutes to pay for the consultation and arrange her next appointment.

She swipes her Medicare card.

The appointment with the psychologist is next Tuesday.

During her appointment the following week, the psychologist carefully assesses Patience's psychological history and attributes her weight problem to emotional eating as a result of traumas she suffered in her childhood.

She recommends Patience continue weekly appointments with both herself and the dietician.

She swipes her Medicare card.

Patience is diligent in following her new diet and keeping her regular appointments, but she just can't budge the extra weight she's carrying.

On top of that, her backache is getting worse, and every minor scrape and cut seems to get infected.

She is struggling to care for the kids, her husband seems intolerant of her, and she can barely function in her part time job. She feels awful.

Despite the sessions with the psychologist, Patience is becoming depressed.

But her dietician and psychologist assure her that she is complying and doing the right thing.

One morning, after struggling through a rotten headache, Patience passes out.

She wakes to find herself in an ambulance, being rushed to the Emergency Department of the local hospital.

After careful examination and investigation the doctors make a diagnosis of Cushing's Syndrome, caused by a corticotrophic pituitary adenoma; a small tumour in her brain.

Left untreated, it would eventually have killed her.

(excess production of Adrenocorticotrophic Hormone leads to adrenal hyper secretion of cortisol, Cushing's Syndrome)

This has been a costly exercise for the patient and for the government and the community.

I'm not saying that GPs are beyond error, but they are the medical experts, and they are best able to assess a patient in a broad holistic manner.

Each allied health provider is appropriately specialised in their field and delivers care on that basis; this is not the same basis as the doctor.

GPs are the pivotal gatekeepers; the people who select the services that each patient requires to get the best health outcome possible, in the most efficient and cost-effective way.

Without appropriate medical diagnoses and supervision, patients' problems won't be dealt with properly in the first instance.

Missed diagnosis, false reassurance, misdiagnosis, delay in care, all cost dollars and time and human expense.

The Prime Minister and his front bench have entered government with a ravenous appetite for reform.

They have to be careful that their zeal for alleviating the system's pressures doesn't leave patients worse off.

As the story of "Patience" illustrates, there are some key problems with the GP Super Clinic model.

They'll disrupt continuity of care as patients will lose their existing GPs and local practices, and be directed to rostered GP's, or worse still for patients, not see a doctor but another provider for a diagnosis, when these people are not trained to be able to do so.

In this era of workforce shortage, Super Clinics are going to be difficult to staff.

Inherent in the government Super Clinic plan is to leave GPs and patients with little choice of specialist or allied health service.

The referrals will have to be directed to the providers in the Super Clinic for the one stop convenience concept and the viability of the government clinic to work.

GPs must be free to refer patients to the best person for the job - not just the person who happens to be down the corridor.

Government Super Clinics will take the control of your clinical care from the GP - and that's something every patient should be concerned about.

Australia has a very fine health system.

Doctors agree with the government - it can be better.

We want to work to improve primary care.

At the moment, it's not unusual to have to wait a few days to get in to see your local GP. We're that busy.

But we will also see you straight away if it is urgent, and we do use our practice nurses to help.

So instead of throwing cash at new Super Clinics, which we fear will not work to the patient's advantage, why not use some of the money to enhance existing general practices?

We need to keep local surgeries open, they enable continuity of care.

Local surgeries are part of the fabric, the social infrastructure, of local communities

When it comes to a new primary health care strategy and better ways to spend the $275.2 million Super Clinic dollars, the AMA has a shopping list for Government of valuable items that will make it better for patients.

For years, the AMA has been calling for Government to support practices to increase the utilisation of general practice nurses and help GPs to expand access to care.

Practice Incentive Payments should be expanded to all GP practices to employ practice nurses, and increased funding provided for rural and remote areas.

Nurses working in a team with a GP enable doctors to increase service provision to patients without compromising patient care.

The AMA has been lobbying for expansion of the 'for and on behalf of' Medicare patient rebate for GP practice nurses.

This works.

This is the best way to expand primary health care in Australia.

Super Clinic money should be used in assisting practices to provide student, pre-vocational and GP training places, and reward the trainers.

It should be spent on retaining older GPs and enabling those with small children, to remain in the workforce.

Money should be invested in GPs providing after-hours care.

And providing medical care in rural communities.

The Super Clinic money could go towards assisting with the integration of local health services - supporting evidenced-based models of care.

Investing in IT infrastructure for better transfer of information.

IT will assist in coordinating care and improve continuity of care when patients move through hospitals, aged care facilities, or hospices.

We recognise there is a big challenge - how to distribute the medical and allied health workforce to best service all of Australia.

We are told that there are not enough nurses and not enough medical practitioners, although there are more Australian-trained doctors on the way.

We need to take on that challenge in a way that does not sacrifice safety or quality of care.

Let's tell one more story - let's visit Patience one more time.

This time, the Government has taken on the AMA's suggestions and shored up the already excellent services provided by local GPs.

Because we have more GPs trained, recruited and retained, and they can see more patients because they are supported by their practice nurses, Patience gets an appointment quickly.

A nice walk or a short drive down to her local GP clinic and Patience sees a doctor in the practice she has been attending for 20 years.

He greets her by name and inquires after her children.

After taking a careful history about her weight concerns and aching back, he examines her and in his mind works out a differential diagnosis and management plan.

He discusses with Patience some of the possibilities and reassures her that he will work out what is troubling her and they will deal with it together.

He refers Patience to the nearby pathology lab collection centre for some blood and urine tests.

The pathology results drop into the doctor's inbox a few hours later, and the GP's suspected diagnosis is confirmed.

The GP calls Patience and advises her that he has arranged for her to see a medical specialist nearby for further assessment and treatment.

By the time Patience arrives for her specialist appointment, the GP has transmitted the referral and all the test results and other relevant information electronically.

This is not a fake story, it's a real story. It happens in my surgery and many surgeries throughout Australia.

The diagnosis of Cushing's Syndrome is reached quickly and a plan for management and treatment begins immediately - with the specialist and hospital care coordinated by the GP.

The next time she sees her family doctor, there's no need for Patience to update him on her treatment. He already knows exactly what's going on.

A dietician is then engaged to assist Patience to return to her normal weight, and a psychologist will help her cope with any psychological problems that have emerged during her illness.

A true story.

Unfortunately though, under other reforms proposed by the Rudd Government, average Australians are going to find quality health care more and more difficult to access.

Reforms to the Medicare levy surcharge are going to make it more and more difficult for ordinary people to access all kinds of health care.

Here's the problem: The Government has confused tax relief with health system reform.

The Rudd Government is making health care more expensive and less accessible for families and low-income earners.

People earning $50,000 or 60,000 a year are going to struggle. Private health insurance will cost more.

Self-funded retirees who have saved to have the security and confidence of private health insurance may find it unaffordable.

They are at an age where they have an increasing need for health care.

If they don't buy health insurance, they're going to face a much more crowded public system. We have never seen waiting lists like we are going to see!

The Government's changes will end up overwhelming the public system with more potential patients in the immediate future.

It's hard to put a number on it, but it will be substantial. Up to one million people may drop their cover.

Health Minister Roxon says it doesn't matter.

She doesn't seem to take into account the fall out in private health insurance rates that will occur due to increased premiums because the young and healthy have dropped out.

She only sees the young and healthy, and suggests that they will not call on the hospital system "very much".

But the young and the healthy have accidents, especially sporting ones!

They have babies. They have young children.

They suffer unexpected illness, too.

The impact on public paediatric, and maternity hospitals cannot be denied.

These extra public patients are going to be calling on a system that is already groaning under its own weight.

Our public hospitals are beset by: tight resource constraints; high levels of demand; medical and nursing workforce shortages; equipment issues, and intermittent political crises. They do not need this as well!

Morale is low.

There's a strong sense that the system is being managed in the interests of government and bureaucracy - but not in the interests of patients, or the people who provide their care.

Both state and federal governments find it convenient to attribute this strain to general practice.

We keep being battered about "inappropriate admissions to Emergency Departments and hospitals."

In fact, genuine GP-type patients only make up about 10 per cent of the people who show up at hospital emergency departments and they consume only about ONE per cent of emergency department resources.

Removing such patients from the hospital system would make only a small difference.

The fact is, with increasing population, longevity and the ageing population, obesity and chronic disease, there is only ever going to be more demand on the system - not less.

Acknowledging the inherent increase in demand and now the additional demand created by the Medicare levy surcharge change fall out; there MUST be a much bigger financial contribution from the federal government to the public hospitals.

Significant extra resources must be pumped into the public system - most urgently, MORE beds. Many of Australia's public hospitals are operating at 100 per cent occupancy or more.

Australia must set itself a target of no more than 85 per cent hospital bed occupancy. Safe occupancy.

The AMA has previously said that, to achieve this, Australia will need at least 3,750 more public hospital beds at a cost of an additional $3 billion from the Commonwealth in the first year of the agreements, and significant annual indexation after that.

And that was BEFORE the extra pressures on our public hospitals that the changes to the Medicare levy surcharge will create.

Here's another fact.

The public hospital system in Australia can only keep going because of the private health system.

Private hospitals handle 40 per cent of all hospital admissions, and more than half of all surgery.

People with private health insurance have elective surgery in the private system.

Half the population chooses to go private, and that enables the rest to access elective public surgery... and even with that ratio, we know how long waiting lists are.

The Government must support the important role of the private hospital sector with a stable policy environment and incentives for strong participation.

Raising the Medicare levy surcharge income levels undermines this.

Instead of supporting the private system - and through it, the public system - the Government has taken away an incentive to keep private health insurance.

Labor has a history of removing supports for private health insurance.

If this is the Government's first decision in relation to private health insurance, what will be the second?

There are three pillars holding up the delicate balance between public and private health care - and each is necessary to the survival of the others.

The first pillar is the Medicare levy surcharge.

It's about distributing responsibility for the public health system based on people's means and the level to which they're prepared to pay for their own medical care.

It's a social equity measure that is now being undermined in the guise of tax relief.

The second pillar is lifetime community rating: A measure put in place to encourage people to buy insurance when they're young because it's cheaper to the system than if they buy it when they're older.

Basically the rating means, if you hold your insurance for a long while, you get rewarded.

If you have private health insurance, as well as the assurance of access to the care that you need, when you need it, you are rewarded financially with the private health insurance rebate - the third pillar.

That discount on insurance is about the government making it affordable for everyday people to take financial responsibility for their own health care.

Like the three legs of a stool, cut one short and the stool topples over.

Clearly, Senators Fielding and Xenaphon will need to address this issue for low income and average income Australians.

The AMA believes they should put the following to the Government:

If the government is serious about trying to give people relief - whether through tax or insurance - it should keep the private health insurance rebate for everyone and perhaps offer additional incentives for low and average income earners.

And if the Medicare levy Surcharge changes do go ahead, the AMA is calling on the government to include in the next Australian Health Care Agreements an explicit provision to provide additional funding to the states for each half-a-per cent decrease in private health insurance participation rates over the life of the next agreements.

Let us talk about the Northern Territory Indigenous Initiative; pretty topical over the weekend wasn't it?

The AMA is proudly on the record as a long-term advocate for more resourcing to bridge the 17-year gap in life expectancy between Indigenous and non-Indigenous Australians.

Even before the former government announced the Northern Territory intervention, the doctors of the AMA were petitioning all governments to help close this gap.

From the start the AMA put its hand up to help the government.

The former Prime Minister specifically highlighted our longstanding concerns and offers of support in his original announcement on the intervention in June last year and requested the AMA's assistance.

Clearly, at this point it was only the AMA who could help get the right doctors into the Northern Territory quickly.

The AMA supported the initiative because we wanted it to be real, and to deliver the right services and outcomes.

We did not want it to be just "window dressing" for the Coalition government leading into the election last year.

This has been a big administrative task.

AMA(WA) and AMA(QLD), who have existing locum agencies, understood the work required and responded to the Government's needs, often at short notice.

The AMA had to identify doctors with the appropriate clinical skills for the needs in the Territory and that matched the rest of the health team, verify their medical registration, police checks etc, and then deliver the list of these doctors to the government for the government then to contact them for deployment.

These doctors were not only GPs, but also paediatricians, hospital doctors and other specialists.

The AMA began this process in late June 2007.

Eventually the Commonwealth Government and the AMA formalised the process in a contract to meet costs.

To date, the AMA has not received any payments for its services, despite providing three quarters of all doctors deployed in 2007 ahead of the Federal Election.

In 2008, the Government has chosen not to use the AMA as a source for more new doctors but it may be well using doctors provided to the Government by the AMA as I know many of my colleagues have been contacted for deployment.

To suggest it was for "profiteering" just does not fit with reality.

Our involvement was formalised with a contract in October last year.

The AMA will receive payment only for the doctors that were deployed, even though many more were vetted and delivered to government as part of this process.

And we continue to honour that contract.

It is deeply regrettable that this important work by the AMA has been misrepresented.

The intention of the AMA all along was to get doctors into the Territory as quickly as possible.

The AMA's involvement ensured that the child health checks happened.

The AMA has been consistent in its message to the Government that this program needed to be sufficient to improve indigenous health in the long term, and needed to be sustainable for the size of the intervention.

Recognising this, the Government is now embarking on the next phase that will see the establishment and operation of the "Remote Area Health Corps Agency".

The Commonwealth Government has already superseded the contract that it has with the AMA by putting out to tender a contract for the establishment and operation of this agency in May. Tenders closed on the 10^th of June.

The contract they are offering is to establish this service for up to $10 million over two years to "mostly recruit on behalf of the NT health service provider." It is for doctors, nurses and other health workers.

This $10 million is for recruitment only and clearly recognises that there are true administrative overheads and costs involved in this type of activity, as experienced to date by the AMA.

Given the ongoing nature of this Agency and the breadth of services that it will cover, the AMA has declined to tender for this activity.

In reality it would almost have to be the Northern Territory Government that could do that work, and hopefully do it effectively.

This most recent attack on the AMA is unjustified and is not helpful in progressing the delivery of long-term sustainable health services to indigenous Australians.

Doctors continue to stand ready to provide medical care for indigenous communities in the Northern Territory and we continue to advocate for the expansion of health services for all indigenous Australians.

But at the same time, we as Australians must take ownership of the health of our indigenous people and provide truly sustainable and planned interventions that will make a difference, and which are properly and fully funded.

We do not treat health services for non-indigenous Australians as a charity.

The AMA is part of the origins of the "Close the Gap" concept.

We stand on our track record in this area and will continue to voice our concerns; support or disagree with government; ensuring that they deliver culturally appropriate and sensitive health services that will engage indigenous people and improve their outcomes.

We make no apologies for this and we will continue to make the government accountable.

Politicians and bureaucrats make health policy.

Doctors and patients deal with the fall-out of that policy.

Doctors are close to patients every day.

Governments aren't.

Communities need hospital beds. It appears that Governments don't.

Communities want to keep their GPs local.

Super Clinics don't.

When you're chronically ill, when you're elderly, when you're battling a serious illness, the last thing you need or want is to have to do battle with bureaucracy.

When you're sick and tired and overwhelmed, we - your doctors - will speak up for you.

The AMA is a voice for patients.

Our position is an expression of their experience.

Our policies are a plea on their behalf.

Thankyou.