Dr Haikerwal addresses the National Press Club July 2006

Good afternoon, ladies and gentlemen.

This is my second address to the National Press Club. I thank the Club for the opportunity to share the AMA's thoughts on what's happening in health…and what's not happening in health.

I remind you that it is AMA Family Doctor Week - our annual tribute to Australia's hardworking GPs.

Our theme this year is GPs - Keeping Australia Healthy.

It is a job they do very well. We are living in a time when our highly skilled GPs are needed most - with growing demands from:

• an ageing population
• more people with chronic and complex care needs in the community
• people with mental illness
• people being discharged early into the community from hospital
• and an increasing health burden on the community from obesity, heart disease and cancer.

GPs are the 'crossroads' for care and wellness for the patients of Australia.

Ninety per cent of people visit their GP at least once a year. GPs provide a central point of reference and collation of health information from a variety of sources.

They are uniquely placed to provide holistic care for patients throughout their lives. We must keep them working and protect them - not replace them.

Australia must maintain a system of health care that is based on a GP-led model that is:

• cost-effective
• comprehensive and
• patient-centred.

Now is the time when we as a nation must be looking at the health of our GPs - their health in numbers and their health in morale.

My focus in talking to you today is the medical workforce - with GPs the priority.

Sadly, a lot of the structural problems confronting the medical workforce are still with us.

And this comes after considerable policy activity from Federal and State governments - some of it good, some of it not so good.

The most recent initiatives came out of last Friday's COAG meeting - which, from all reports, was the COAG meeting of all COAG meetings. One big happy family.

There was a welcome health focus in the COAG communiqu , with mental health the big winner with $4 billion new funding over five years. This part of the COAG process shows how the process should work.

Indeed, the current COAG process has been a triumph of collaboration between State and Territory governments and the Federal Government…for the most part.

It sees not just an in-principle commitment from the 'First Ministers', but also dollar commitments and inter-departmental policy development - between multiple Federal departments, and between the Federal and State counterparts.

Other elements were less of a triumph - more of an 'umph', you might say.

There was quite a bit on medical workforce, with 205 new medical school places - on top of the 400 previously announced by the Prime Minister. You then add up to another 25 per cent as full fee paying places.

But rather than looking at these new places and saying how welcome they are - which they are - we need to look at medical workforce policy in its entirety.

We need to look at what the Commonwealth is doing, and we need to look at what the States and Territories are doing.

We need to look at what has been done over the last decade or so, not just the last twelve months.

You can't solve the medical workforce situation by simply lobbing students at the problem.

In other words, you cannot train a new medical workforce overnight.

We need to look at medical training. We need to look at the changing face of the medical workforce and medical students.

We need to look at how many students are entering general practice and each of the other specialties to see if we are getting them into the right stream in the right numbers.

And we need to make sure that doctors, especially GPs, are able to work in the areas they are needed the most - particularly country Australia.

We have to preserve the Aussie tradition of a 'fair go' for patients and communities - equal access to the highest possible quality medical care.

The title of my speech today is The Case of the Disappearing Doctors.

Despite all the catch-up medical workforce policy of recent times, we still have a shortage of doctors.

You could say we have a dearth of doctors. In parts of rural Australia, they have a drought of doctors. They need a deluge of doctors.

If you allow me to digress briefly, did you know that the proper collective name for doctors is a doctrine?

A doctrine of doctors!

I didn't know that, either, so I checked a few other medical groups in James Lipton's excellent book, An Exaltation of Larks.

The collective noun for GPs is a 'family' - a family of general practitioners.

How appropriate in Family Doctor Week.

Then there is a palpation of internists.

A fibrillation of cardiologists.

A stirrup of obstetricians.

A rash of dermatologists.

A void of urologists.

A pile of proctologists.

A cast of orthopaedic surgeons.

A hive of allergists.

A plague of epidemiologists.

A resect of surgeons.

A movement of gastroenterologists.

And on it goes…literally. And they are all in short supply, whatever their collective noun.

As we are in the National Press Club, I can tell you that the same source gives us:

• a scoop of reporters
• a click of photographers
• a mangle of copy editors
• and a feeding frenzy of paparazzi.

And that big building on the hill is full of an 'odium' of politicians. No further comment.

That ends the digression…back to business

Let's now look more closely at the medical workforce problems.

Medical Workforce - Problems

We may now be putting more students into one end of the system, but it will take some considerable time before this batch comes out as fully trained independent medical practitioners.

There will be a lag.

In the meantime, we have doctors retiring much younger. We have more and more doctors working part time.

And the Medical Journal of Australia this week reports that fewer and fewer Australian medical graduates are choosing general practice.

However, an inflexible training scheme does not allow graduates who want to be GPs to take that path either.

The MJA study showed that between 1985 and 1995 the number of medical graduates from Monash University who went on to work in general practice dropped from 50 per cent to 33 per cent.

The reasons given include low morale, high workload, heavy administrative burden, and poor job satisfaction. But at a time when we should be making general practice more attractive, the opposite is happening.

Why?

Much of the system is run on the goodwill of the GPs and it is being exploited. While doctors are driven by care and concern for their patients, there is a limit to their capacity to function in a 'heads down, bums up, and blow the consequences' way.

The GP world is turning.

The red tape burden grows heavier.

One of the significant turn-offs to doctors working in general practice - or indeed anywhere in the system - is the avalanche of red tape, and the strangulation of effort by red tape.

Another turn-off is the authority prescription system.

The equivalent of 240 full-time doctors spend their whole year on the telephone waiting for Medicare Australia to approve authority prescriptions.

That's the equivalent of 1.3 million patient consultations lost each year. What a waste.

Unless we as a medical profession are intrinsically involved in solving the sustainability problems of the PBS, this waste of precious patient time will get worse.

And we have a surge in compulsion and bonding to force doctors to practise where they may not want to practise.

The States have been ranting and raving about more medical student places - and that's exactly what they've now got.

But still they seem hell-bent on role substitution - if they don't have enough doctors to do the work of doctors, then they'll get people who aren't doctors to do the work of doctors.

This is short-term policy madness of the worst kind.

It is an insult to patients.

It is a disincentive to doctors and potential doctors.

And most of the people that the governments expect to do this work do not want to do the work.

Most health professions have workforce shortage issues of their own.

So how do we solve The Case of the Disappearing Doctors?

Like all good investigations we have to look at the who?, what?, when?, where?, why?, and how?

The who?

The chief suspects are all Australian governments.

The what?

Poor or ill-directed medical workforce policies.

The when?

The last decade, at least.

The where?

Everywhere, but country Australia is suffering the most.

The why?

Short term political gain ahead of the long term national interest.

The how?

We fix it by providing quality training for the right number of doctors to serve the Australian people wherever they may live.

The two big challenges are:

• Making general practice an attractive career option for medical graduates, and
• Providing incentives for doctors to live and work in country Australia for the long haul.

I said at the AMA National Conference in May that I wanted my second year as AMA President to be the Year of the GP - and I meant it.

With a Federal Election due next year, I'd like the Government and the Opposition to make it their year of the GP, too.

I can think of no bigger vote winner than making sure that all Australians have equal access to a GP.

Governments may think that the COAG Communiqu is the end of the story.

Wrong. It's just the beginning.

So, where to from here?

We believe we have to get back to the basics and get medical training right.

Medical Workforce - The AMA View

You are well aware by now that the AMA is good at being critical of what others have been doing or not doing to solve the medical workforce crisis.

Well, we are not always negative.

We like to accentuate the positive.

We have been putting out our ideas and policies and solutions, as well, for quite a while.

As a number of our governments are heading to elections in the next couple of years, we suggest they take on board some of our suggestions - especially on medical training.

The difference between our policies and many of theirs is that ours come from the coalface - the places where medical services are delivered every day.

They come direct from:

• the hospital wards and emergency departments
• the general practices
• the specialists' rooms
• the aged care homes
• the maternity wards
• the outreach services
• the Aboriginal medical services
• the medical schools
• and the teaching hospitals.

They come from every State and Territory - urban, rural and remote.

I have had the privilege as AMA President over the last 14 months to visit doctors in all of these settings in all the States and Territories.

I have heard their stories and they all have similar themes.

They are hanging in there, though, providing services - with excellence and compassion.

They are coping. But as the critical mass of colleagues and support around them is eroded, they will not be able to continue.

As I said earlier, it is not just about more medical places.

The big picture is getting the medical training right.

Medical training is a magical mystery tour.

In my day, the emphasis was on the magical.

Today, it is all a mystery.

After years of inaction and neglect, the Federal Government has now decided to turn on the medical student tap.

As we saw again last week, each COAG meeting seems to herald another announcement to increase medical student numbers.

By 2012, the combined effect of increased HECS funded and full fee paying places will see the total annual intake into medical schools increase to around three-thousand-two-hundred students - compared to just thirteen-hundred in 2000.

This represents a 150 per cent increase.

Clearly, the Commonwealth is now making a big investment in the future medical workforce.

I believe we will need every single one of these new places - but we have to be strategic in their ultimate deployment.

More than ever, younger doctors are keen to pursue a greater balance between their work and personal lives.

These doctors remain deeply committed to patient care.

However, they will simply not be prepared to work the stupid hours that doctors of previous generations, including me, did without question.

Nor should they.

It is said we have to take into account the growing participation of women in the workforce, which has significant workforce implications.

Sure - but the boys rightly expect and want a family life, too.

We also know that the medical workforce is ageing. Australia faces substantial workforce losses as the baby boomers retire.

Retaining this expertise - these experienced doctors - in our community is essential.

Essential for service delivery.

Essential to teach the next generation.

Both these factors are reflected in the latest studies in the MJA to which I alluded earlier.

They just don't get it. We need definitive measures to support general practice.

Doctor demand has also risen, spurred by an ageing population and rising incomes.

As the population has more discretionary income, they demand higher quality complex services and more of them - more often.

More is possible, more is expected, and more is being done.

The critical issue now is to make sure that Governments meet their obligations.

They have to provide the resources needed to ensure that students receive:

• a complete medical education
• a guarantee of clinical experience in their first year, post-graduation, to allow them to become registered doctors, and
• access to post-registration clinical experience and supervision to support their studies towards general practice or other specialist practice.

Training a doctor is about a lot more than classroom theory, simulations and performing procedures on dummies.

Virtual reality is for virtual patents in virtual beds in virtual hospitals. For treating human beings, it is virtually useless.

We've got to get back to basics.

Seeing and treating real patients with real conditions is fundamental to producing a comprehensively trained and highly skilled medical practitioner.

Medical students, interns and vocational trainees need to spend time in hospitals with hands-on experience in properly supervised roles.

For this, we need more bed capacity, beds that are occupied with patients being treated, and with doctors free to teach around those beds.

The AMA receives regular reports from medical students and doctors that the myopic focus on service delivery in public hospitals is making it harder for them to provide a quality training experience.

Health departments have forgotten the importance of investing in training for the future.

Teaching hospitals are supposed to teach.

Indeed, most hospitals in Australia today will need to teach.

To teach has been a very central concept of medicine since the time of Hippocrates.

A recent survey of 561 medical students in Western Australia, where there has been a dramatic increase in student numbers, found that:

• 80 per cent believed increased numbers was having a negative impact on the quality of their education
• while 77 per cent were concerned about the quality and availability of future training positions.

There was also dissatisfaction with the high rates of student to teacher ratios and the increasing reliance on junior doctors as teachers instead of more experienced clinicians.

These are worrying trends, particularly when we are only part way through ramping up student numbers.

They just don't get it. The States and universities need the students. The students need clinical teaching and training opportunities.

But the problems don't end there.

Looking ahead, by 2012 Australia will need three-thousand-four-hundred intern positions to meet the demand for places.

This takes into account overseas full fee paying students and Australian Medical Council exam graduates.

To illustrate the challenge, in 2005 there were one-thousand-five-hundred-and-fifty-three intern places available.

The AMA has warned that more increases would simply compete for the resources available to existing students, interns and vocational trainees.

There are currently not the facilities or the human resources to provide a complete medical training.

There are not the facilities or the human resources necessary to retain the high standards and quality that are intrinsic to such an education.

We are not saying that there should be a stop to the increasing number of medical places.

On the contrary, keep them coming.

What we are saying is that there must be a matching commitment to the funding and resources to provide for the clinical training of students and doctors in training throughout their entire education.

As things stand, there is an inevitable bottleneck in the system.

The number of students and doctors in training will far outweigh the available quality teachers and teaching facilities and resources.

We must avoid this bottleneck.

These future doctors need continuity in their education.

To make this happen, the Commonwealth needs to hold the States and Territories to account to provide the resources to firstly support the increases that have already been put in place.

Empty reassurances from the State and Territory Governments are not acceptable.

Australia must not and cannot repeat the mistakes of the UK where several thousand junior doctors are now unable to find training positions.

What we need is an agreement - a pre-nuptial agreement, if you like - whereby the Federal Government releases medical school places only upon the States delivering on their training obligations for students, interns and post-graduate trainees.

The medical profession must be part of any reference and validation scheme to assess appropriate training posts.

The AMA is not alone in these views.

During the recent AMA National Conference, Commissioner Mike Woods - who chaired the Productivity Commission Report on Health Workforce - acknowledged that increased medical student numbers would overwhelm currently available resources for clinical teaching during undergraduate and subsequent years.

The Productivity Commission was unable to identify a solution to this problem in the timeframe available to complete its report.

Ramping up medical school numbers is a politically attractive strategy.

Without the support for training, however, the potential legacy will be a generation of new doctors who, through no fault of their own, will have significant gaps in their skills and knowledge - and no opportunity to further their vocational training in Australia.

Regrettably, many of these doctors may look overseas to fill these gaps.

In a very competitive global marketplace, attracting these doctors back to Australia will prove to be extraordinarily difficult.

The Commonwealth must take a long-term view of this issue and give priority to the resources available to ensure that the quality of medical training is maintained during undergraduate, prevocational and vocational training.

While public hospitals are the responsibility of the States and Territories, it is time for the Commonwealth to take a much stronger position on the resources committed by State and Territory Governments to support the training of the future medical workforce.

The Commonwealth must demand answers that include concrete strategies, backed by funding allocations.

If necessary, the Commonwealth should consider another system.

They should explicitly outline what funding is provided for medical training in future Australian Health Care Agreements

And they should link these monies to performance benchmarks.

This needs to start now.

The Federal Government has a role, too, with more training in general practice and private consulting rooms and private hospitals.

The willing teachers must not be disadvantaged for teaching. This important role must be recognised.

Governments will often stand by and wait for something to break before trying to fix it.

This cannot be allowed to happen when it comes to medical education.

Full fee paying places

Another element of the Government's efforts to increase student numbers that the AMA opposes is the reliance on full fee paying places.

The previous decision to increase the cap from 10 per cent to 25 per cent of enrolments was wrong.

If we need these places to meet community demand, why aren't they HECS funded?

HECS funded places allow everyone a fair shot at medical school based on commitment and ability rather than their financial circumstances.

Full fee paying places deliver the wrong message that medicine is only for the rich, and they will compete with HECS funded places for increasingly scarce clinical training opportunities.

These students face a dismal future if State Governments fail to deliver the resources necessary to support their intern training.

The COAG communiqu specifically affirms that States and Territories have guaranteed to provide clinical placements and intern training for Commonwealth funded medical students.

Full fee paying places are not Commonwealth funded.

And the States and Territories are not guaranteeing to provide these full fee paying students an intern position.

There is a very real potential that parents and students will borrow, scrimp and save in order to fund a two-hundred-thousand-dollar-plus medical degree.

If these students find that on graduation there are no intern positions available, it will be one of the greatest scandals in medical education.

The intern year is essential if a doctor is to be granted general medical registration.

It is the basic 'ticket to work', indeed, to start the next part of training.

A medical degree is not something you can return to the store for a refund if the system fails you in this way.

Private clinical training

We also need to expand specialist training into private clinical settings.

Trainees are not getting a broad enough experience and many are missing out on seeing many common conditions or complaints.

This is again a safety and quality issue.

There has been a fundamental shift in the management and delivery of health care in this country, which makes exposure to private practice and private hospitals a vital component of medical education.

There is now greater management of health care within the community settings.

People are staying in hospital for shorter periods.

There is an increased role for private hospitals, with 56 per cent of surgery now undertaken there.

There are new and changing technologies and medical techniques.

Teaching hospitals are dealing with an increasingly narrow range of conditions.

They are not providing many trainees with the training or broad clinical exposure they need.

Our public hospitals are largely focused on acute care, whereas chronic care is now much more prevalent in the community.

This issue has been examined by a number of reports, all of which have endorsed the principle that training should take place in both the public and private health care systems.

There are a number of small pilot programs operating in areas like dermatology, physician and surgical training that are yielding positive training results.

Last week's COAG meeting endorsed this move.

But all the groundbreaking work in medical training - and all the evolutionary trends - are geared to specialties other than general practice.

If we are to get the right mix in our future medical workforce, we need to see a revolution in general practice training to steer graduates down this path.

If we don't dramatically increase the number of medical graduates who choose general practice and stay with it throughout their careers, we will still have a medical workforce crisis in a decade's time.

At the same time, we need the systems and the incentives - not bonding - to get young doctors to practise in country Australia.

If you look at the profile of our already depleted rural medical workforce, you will see the urgency.

Rural Medical Workforce Profile

Many of our hardworking rural GPs are nearing retirement - voluntary or enforced - through being overworked, dare I say burnt out.

They rightly state that there is inadequate reward for their efforts.

We need to improve funding for rural retention payments to doctors, including an increased payment for doctors who are already 55 or older.

We need to keep them in practice as long as we can until the new wave of reinforcements arrives in sufficient numbers.

The situation is already critical.

Australia wide, nearly 30 per cent of the GP workforce is 55 or older.

In rural areas, the proportion is much higher.

The majority of these doctors are males who work in practice on average around 13 hours per week more than female GPs.

This means that close to 30 per cent of the current GP workforce is likely to retire in the next five to 10 years.

And many of them are of the old school who tend to work much longer hours than the generation of doctors coming through the system now.

The Government needs to give these doctors more incentives to delay their retirement.

They are not just vital for patient care in our neediest communities, their unique skills and experience make them an important part of the medical education of the next generation of rural GPs.

Just as the rural workforce is getting older, the closure and downgrading of rural hospitals is de-skilling the rural medical workforce.

Doctors can no longer practise key procedural skills such as obstetrics.

Rural people are being forced to travel much further distances to access safe care.

The AMA is today calling for the State Governments to adopt a new public interest test to be applied before closing rural hospitals.

This public interest test needs to look at issues such as:

• the impact on the maintenance of skills of the local medical workforce
• the impact on the health needs of the local community
• the social and employment impacts on the local community
• and the availability and proximity of alternative resources.

The AMA also believes it is time to reward one of the backbones of the rural medical workforce - overseas trained doctors.

In a modern society, it is not good enough that we bring them here and then abandon them without access to free health care and education for themselves and their families.

For less than $10 million over four years, we can give overseas trained doctors access to decent health care and make them part of the community that needs them so much.

Until we get our own home grown GPs through the system and working in country areas, we must rely on foreign doctors to fill the gaps.

It is a job they have done and will continue to do with distinction.

Unfunded Bonded Medical Places

What we don't need is unfunded bonding of medical school places.

We certainly don't need an increase in the number of unfunded bonded medical school places - which is on the cards.

We urge the Government not to go down this path.

Their own programs show that it is not necessary.

The Government has in place training initiatives that will support long term sustainable increases in the rural medical workforce:

Recruiting medical students from a rural background is the best way of getting more doctors into the bush.

The AMA supports current targets that mean that 20 per cent of students in our medical schools have strong links to rural areas.

The Government has put in place an extensive program to develop rural clinical schools throughout the country.

There are 11 rural clinical schools linked to existing medical schools.

Early this year, Katherine in the Northern Territory celebrated the opening of its rural clinical school.

This month the Government announced an extra $16 million in funding for the rural clinical school linked to the University of Notre Dame and the University of Western Australia.

This program means that 25 per cent of all medical students now spend at least 12 months studying in rural areas.

With an exposure to the rural environment by a greater number of students who will see the benefits of working in these areas - with more support - they are more likely to do further training in the bush.

So why persist with bonding?

All the available evidence internationally says that bonding programs will not lead to long-term improvements in the rural workforce.

Few bonded students remain in rural or deprived urban areas after their required period of service has ended.

Overseas retention rates of bonded doctors in workforce shortage areas are around half that of doctors who practised in these areas voluntarily.

The AMA believes that rural communities are best served by doctors who want to practise in these areas and are not forced to do so by conscription.

Students should not be forced to sign up to a bonded place in order to gain entry to medical school.

At 17 or 18 years of age, they are ill-equipped to make such a decision.

By bonding them at this stage and in this manner, their goodwill and their enthusiasm are being exploited by Government and will ultimately be demolished.

This bonding scheme is inequitable, short-sighted, poorly targeted and it erodes the basic human rights and civil liberties of our young people.

No other sector of our community is subject to such a ludicrous and unfair scheme.

By the time it comes to fulfilling the terms of their bond, these students' personal circumstances will have changed significantly.

The AMA is determined to get more doctors into rural areas, but in a way that is geared for success.

We recently unveiled an alternative plan that would encourage young doctors into rural areas much earlier than current unfunded bonded arrangements allow.

Medical students could commit to a period of service in a rural area towards the end of their studies or on graduation from medical school.

In return, a student or graduate would be given relief from HECS debts along with an annual incentive based payment.

Participants in this scheme - which provides proper support - would have greater life experience and would be in a much better position to make an informed decision about their future.

Funding would be scaled so that it properly targeted areas of workforce shortage - so that rural areas would attract higher incentives than other areas.

The incentives would be flexible to allow a doctor to move from a rural area to an outer metro area if personal circumstances dictated.

Unlike the unfunded bonded places, this scheme would deliver benefits in a much shorter time frame.

Graduates could be working in workforce shortage areas in as little as two years, and the rural placement would not be an affront to the civil liberties and goodwill of potential students.

In contrast, it will be six or seven years before the current cohort of unfunded bonded students will be required to start their bonded service.

It is a system that would work. As I keep saying to the Health Minister, "You know it makes sense".

Meanwhile, as our next generation of medical students make their way through their years of training, our State governments continue with policies and strategies that will make the careers of our new doctors anything but brilliant.

As I said earlier, they continue to pursue role substitution plans.

The Medical Quality Story - Why Go For Doctor Substitutes?

The first question that must be answered is why any government would contemplate doctor substitutes at this time.

Medical practice is at its highest level of evolution.

Medical research in Australia is lauded and applauded all around the world.

We have international medical heroes up there with the Socceroos and our cricketers.

It is a major achievement for a sports-mad country like Australia to finally have medical pioneers and achievers who are household names.

We have Nobel Prize winners, Barry Marshall and Robin Warren.

And we have our Australians of the Year:

• Fiona Stanley
• Fiona Wood
• Ian Frazer, and
• Gus Nossal.

Quality of medicine is at an all time high.

Safety is at an all time high.

We continue to push the bounds of what can be achieved in medicine, public health, saving lives, and improving quality of life.

But all of a sudden, governments want to draw a line in the sand and say 'that's enough for now'.

Rather than go the hard yards and build on centuries of achievement, they want to replace doctors with non-doctors.

They want to take functions traditionally and best performed by doctors and give them to other professions.

They want some communities to have medical tasks performed by nurses and other allied health professionals - without medical supervision.

They want some Australians to have access to one level of medical care and other Australians to have access to another, lesser level of medical care.

It is not just policy laziness.

It is not just penny pinching.

It is backward looking and a body blow to the quality of medicine in this country.

Role substitution is not a medical workforce solution. It is a medical workforce catastrophe waiting to happen.

The AMA and others are pushing the team-based care model, whereby a doctor is always the team leader with overall responsibility for the care of the patient.

This model not only addresses the workforce shortage issue, it maintains the quality and safety of patient care.

But team-based care is another speech for another time.

Conclusion

I want to leave you today with one simple message - a doctor is a doctor is a doctor.

Australians want and deserve the highest possible medical care and they can only get that from a doctor.

This care must be accessible and it must be affordable.

There are no substitutes for doctors in a modern sophisticated health system like ours.

There is a place for nurses and all the other allied health professionals in the system.

They have the right skills and experience to do the important jobs that they do.

They work with doctors and doctors work with them - cooperatively and productively as a team.

And this is how the great majority of us want to work.

And this is how our patients want us to work and need us to work.

If we get the medical workforce right, we are better equipped to address the issues confronting our community in the 21^st century.

If we get the medical workforce right, we can take care of:

• Indigenous health
• Aged care
• Obesity
• Cancer
• Chronic diseases, and
• Mental health.

Our governments must build on and improve their policies and initiatives to supply a highly skilled medical workforce to all Australians - no matter where they live and no matter their circumstances.

They need a simple doctrine - protect Australia's doctrine of doctors.

I'd vote for that. I'm sure you would, too.

Thank you.