Dr Haikerwal at The National Press Club Q&A: Medical workforce, Health checks, PBS, medical training, childhood obesity, Indigenous health

QUESTION: Good afternoon, Dr Haikerwal. The Federal Government has, or plans to, introduce a whole pile of Medicare rebates for GP services such as mid-life health checks and life scripts and what not. You know, given your assessment of the state of the GP workforce, does that mean that these programs are doomed to fail? Why or why not?

DR HAIKERWAL: Some of the programs like their 45-plus health check is something that's going to be introduced very shortly and something that all the general practices have been calling for, for some time. Before this particular measure was introduced to the Medicare schedule, you could do a lot of preventive work which is where all the action is nowadays, about keeping people well, preventing illness, early detection, and stopping people from getting ill early and maintaining their health. That was something that was, I suppose not properly in the schedule.

With the 45-plus check you can do that, and that's a very important step for Government to do. Now in order to achieve that, obviously you need a workforce to help do that, and the way in which these items will be structured hopefully will allow that to happen.

Alongside the 45-plus check we've seen enhanced primary care items or … which chronic illnesses can get other sorts of care. And all of these new items (have) introduced this team-based care element, where you're allowed to use the services of nurses working with a general practice to roll those services out.

So that's how we can leverage that doctor time - with other people working in that team - so we can actually benefit from these new items. If we didn't have that, (if) it was left just to doctors without increasing the size of the team, it would certainly be very difficult.

The new item numbers are a boon in one way, they recognise what needs to be done.

But unfortunately, in other ways it causes much more confusion in terms of which item do I use, what does this mean. What we'd like to see, I think, is a different way of approaching chronic health care, whilst maintaining the benefit we see of using other people in that GP team.

CHAIR: Next question's from Ben Packham.

QUESTION: Dr Haikerwal, given everything that you've said here today, do you think there'll ever be again a situation where it's the norm that Australians will all have a family doctor? Or has that simply faded into history?

DR HAIKERWAL: The hope is that people will continue to have a family doctor. The family doctor is really someone who can be - I always talk about the friend, philosopher and physician of a patient because they're the many, the main functions that we would actually be doing. It's important that if people get information off the internet or information from the friend down the road or from some alternative provider of health services, they can take that information back and have someone to help work their way through that in the context of their own health and the context of what's happened to them in the past.

And that's why it's important for that family doctor to be there… and what we are seeing very much is traditional general practice as we know it is under significant pressure as the complexity of running a practice is getting harder. Less and less young people that are graduating or graduating from general practice want to actually own their own practices or be part of an ownership program, because they think it's just too hard.

And when we mentioned this to the Health Minister yesterday, he said "well perhaps it's actually good, we need people to look for accountability". But unfortunately it's more than just the accountability - it's actually the avalanche of paper that's there upon us now and the red tape that's binding us up.

It's making it so much more difficult to attract people to own general practices. The method of delivery of health care this way, the method of having that guide through the health care maze, the method of having general practice at the crossroads, somewhere - a clearing house for all your information - is safe, is effective, it's cost effective.

CHAIR: John Breusch

QUESTION: Dr Haikerwal, you mentioned that the AMA should be involved in any reforms to improve the sustainability of the PBS. The Government has proposed among other things, that doctors should be required to prescribe a generic medicine where one is available, otherwise they'd have to give a clinical reason why they should go with a brand of medicine. … And the AMA as I understand it is not happy about that.

If a generic medicine is an exact replica of a brand of medicine then what could possibly be the problem with going for the cheaper generic?

DR HAIKERWAL: Okay. Thankyou. Generics are a very important part of the sustainability of the PBS. They are a cheap alternative of a molecule that was obviously part of … 20 years of research and introduction and then 20 years of production by a company under patent.

So if they come off patent they get cheaper medicines. The problem in Australia today is that when the generic medicines are produced, the saving (in) going (to) a no-name brand currently isn't seen by us as a taxpayer, and isn't seen by the patient in terms of what they pay … for that medication.

So if you take a medicine like Simvastatin, which is used for cholesterol lowering, you save 71 cents for the no-name brand. But the savings on that can be much more significant and should be retained in the system. We did a survey, and … in practice people tend to prescribe generically. There is a box on prescription forms that you tick which says "we would prefer you not to substitute it". That's hardly ever ticked. (In) maybe 20 per cent of cases that's ticked.

And so people are prescribing generically and yes, the molecules are the same, but sometimes the way they're bound and put together makes the way they get into the body and they get absorbed into the body and get used slightly different. One very good example is the medication call Warfarin, which we use for thinning the blood in many people. And there are only two brands out there. But the brands can be quite different and if you get it wrong it's a significant problem.

So there is a time when the doctor will tick "I want this brand, not that brand". So we've got no problems with generic prescribing. We think we should socialise the savings from generic prescribing into the system. Those savings should be retained within the PBS for the benefit of all Australians in the system and we've got to make sure that if somebody is ticking the box, it's there for a good reason.

What we do have an objection to is there will be a generic that may be the preferred generic. There's a problem there because there are about a dozen generics on many different things, and some of them won't exist in a few years time, and if you get somebody that's given one prescription for one generic from the doctor and another one from the hospital, another one from the specialist, they don't realise they're three different tablets and they can overdose or take too many.

So there are very real safety issues. But there can also be some real issues around (this) notion that a drug from the same type is exactly the same as another drug in the same type even though they are a different molecule, but they're from the same family and that just ain't so. And especially when you're dealing with the brain and drugs in psychiatry or drugs to do with other things to do with the brain. It's very delicate, you've got to be very careful how you do it.

CHAIR: And the next question's from David Spiers.

QUESTION: David Spiers from Sky News Dr Haikerwal. You have called for extra pay incentives to keep GPs over the age of fifty-five and GPs in rural areas in the workforce for longer. Can I ask you what sort of dollars are you talking about specifically, and do you think there will be political support for that? And secondly, … to make (general practice) an attractive option for medical students, are you also suggesting there needs to be a pay incentive and if so, how much?

DR HAIKERWAL: Okay. Obviously dollar amounts are things that are difficult but the sorts of money that Government talks about, for instance if you look at the outer metropolitan retention scheme and how they attract people into outer metropolitan areas, they look at around $30,000 over that sort of money. I suppose people feel an incentive.

And there are other things in terms of maintaining them. In rural areas for instance there's a $15,000 grant to retain (GPs' skills in) rural areas and to simply go off and do continuing education and keep their skills up to date away from the area that they're working, and it's that sort of incentive that really is required. And I suppose a recognition of what's been done, a recognition of the difficulty and so on. In terms of retaining people in general practice, there has been talk - and I've been around four States and Territories in the last three days - and in all the places I've met doctors, they all say the same sort of thing. … We've talked about rural retention, we've talked about incentive payments.

We're actually having difficulty retaining in general practice altogether. Is there a need to look at HECS or partial HECS reimbursement in general practice? That may well be part of that as part of going into … a GP training program. That's the sort of thing we're going to have to look at if we can't get people in with other sorts of incentives.

CHAIR: Tony Melville.

QUESTION: Tony Melville, Director of the National Press Club. A couple of questions. The first, when you look at programs like 'Honey I'm Killing The Kids', you can see that there's a disaster, a health disaster out there and that in a sense the medical system, you could argue, has failed a generation of kids. When you walk round some of the malls in Canberra for example, you can see that quite clearly.

You can certainly see it in those programs. What more can be done at a general practice level on this? It's something that's got people's attention. How can we use that and move on from that?

The other is Indigenous health. You talk about rural doctors. How can we change the situation where Indigenous people dying in their 50s and 60s and non-Indigenous people are dying in their 70s and 80s on average. What more can be done in those rural areas and how can we get more Indigenous doctors and medical workers?

DR HAIKERWAL: Can I congratulate you on those two questions. I think they're the two most important questions. One is the health catastrophe that's on our doorstep and the other is the nightmare that already exists that we've got to deal with because it's the biggest blight on our healthcare system.

As far as obesity is concerned, I suppose the into that. I think it needs to be a fully independent survey. We don't know what we're eating.

We don't know what we're exercising because the last survey's about 10 years old. So a nutrition survey is important. We need to get kids up and about and exercising more - and adults.

And we called on government on Sunday to look at the $250 million that's out there for … elite athletes. … The same amount should be available to the community to get access to safe exercising facilities, bike tracks, walking tracks and so on.

Then there are other things around … school tuckshops. The red, yellow, green in Queensland or the banning of fizzy drinks in New South Wales and Victoria. They're all moves in the right direction. The one that everybody doesn't like to talk about in Government, we think, is the banning of advertising during kids' viewing time. Kids will see one-and-a-half movie lengths' worth of junk food advertising during a school holiday period. So it's significant and that has to go.

Aboriginal and Islander health. The figures are appalling. Certainly an area of great passion for me. I took on this job and the first thing I did was take on the chairing of our Indigenous task force and I've learned every single day. I've been to a different AMS when I was here, one other in Canberra, when I was in far North Queensland, we're off to Cape York on Monday of next week. We went to Wadeye in the Northern Territory.

I went up to Broome and to Derby and communities out there and each place has got a little twist to the Aboriginal health story. If you look at the bigger picture stuff, there is a lot of catching up to do and it can happen but it will take some time for the first figures to happen. But the situation where only 20 to 30 percent of Aboriginal people will reach 65 years of age has got to stop. The provision of health services for Aboriginal medical services are great progress. The Government does a great job in supporting these things.

The way in which they fund medical service in these areas is a bit of a problem. The problem is that you have lots and lots of funding buckets that one Aboriginal service will feed from.

So take Wununga for instance - 80 to 100 different bits of paper to acquit every year. … They've got to take bits of money from different places because there's no easy or clear or straightforward way of getting funding. So that's the medical side of things, but that's not all of it. But then nor is the violence, nor is the abuse.

That's all the big picture that people have been worried about up until Mal Brough's recent summit. It's important. You've got to have a safe environment and you've got to make sure the people are comfortable and can get to work, get to school, get to the doctor. But you've got to drill beneath that. What's the cause for petrol sniffing? What's the cause for drug abuse? What's the cause for alcoholism? What's the cause for the violence? And that's around social deprivation.

And if you go to these places you can't believe you're in Australia in 2006. And I think that's the real tragedy and therefore there has to be a COAG process and we've seen COAG work very well in mental health.

There's no reason why COAG can't pull together in just the same way in Aboriginal health because you don't just need health, you need education, you need housing, you need employment, you need infrastructure, water supply, food and you need some community ownership of this process. You can't do it and impose it. You've got to deal with communities and work with them and make those things happen with community buy-in.

CHAIR: Dr Haikerwal, can I take you back to the central point of your main address and that's the medical workforce. You painted a picture of GPs under stress, a profession which is less and less attractive to new entrants, widening responsibilities, new technology, all sorts of extra responsibilities that are imposed on doctors in the community.

Given all that, why is the AMA still so fiercely defending turf in terms of giving people below the status of doctors the ability to perform what these days are clearly called lesser procedures?

DR HAIKERWAL: At the end of the day, when we work, … we are quite comfortable with the thought of people (we work with) doing parts of that work. This business of task delegation. So you can take immunisations in a practice or you can take dressings in the practice or whatever the task is, in fact there are only two (tasks) that currently get a Medicare rebate for nurses to deal with in a practice. We would actually like to see that go.

We would like to see any task that a nurse is capable of doing within a general practice to be available to nurses to do. They need to be comfortable from their professional point of view that they're adequately trained to do that. We need to be comfortable that in a practice that we're happy for that to happen. But once that happens we're very keen for that to happen.

The only thing that we have about that, is that we believe the overall responsibility has to rest with one group of people. That responsibility tends to be the doctor, not just from a legal point of view, not just from a continuity point of view, but I suppose from a, a very much a comprehensive care point of view.

So it's not necessarily that people shouldn't do other bits of that work, but the way in which that work gets delegated. Task substitution is not about … a complete substitution of one group of people for another, because each group … has unique professional training, and is not substitutable for another.

CHAIR: The next question again from Danielle Cronin.

QUESTION: The Medical Observer is reporting results of a survey, saying that more than 80 percent of GPs believe that patients aren't having optimal treatment because they can't afford prescription drugs without a taxpayer subsidy. Do you think that the Government has gone too far in their bid to rein in the cost of the PBS and what have been the consequences for ordinary Australians?

DR HAIKERWAL: Thank you. The PBS is certainly under pressure. A year or two ago the clamourings were really huge - you know the growth was so large, 22 percent. What we've seen is that the growth has actually diminished.

So, maybe some of the Government programs have worked in doing that. There are many drivers to prescription and the cost of that.

…I believe that people don't like prescribing, people don't like taking medications unless they really have to. The co-payment increase that came through before the last election - and obviously both parties went to the election supporting that - was probably a big driver in the increased costs and therefore the reduced affordability and therefore a potential danger (of) people not getting the medications.

And it's not so much the people that pay $4.60, $4.70 for a co-payment who are in trouble - there is a group of them that can't afford even that. Nor is it those people that have so many that after three or four months they get into the free totally free-listed.

The real people that are suffering there are at work that have got an illness - say blood pressure or whatever. They all tend to have between two and three tablets. That's $100 a month, nearly. So for most people, if you suddenly say you've got to pay a hundred bucks a month for your health which you previously didn't pay, that's a big amount. And if you've got two in the family, that's even more. If you've got other conditions, it's even more.

So, the safety net has become I would say looser and the holes in the net are getting bigger and that is a concern. That, I think, is what the Medical Observer's survey is talking about. The consequences of not receiving medication are increased health costs in the future because although we talk about prevention, although we talk about maintaining good health, about good exercise, diet and all this sort of thing, you still need medications. You need to keep blood pressure down, you need to keep the cholesterol under control and if you don't do that the cost down the line is much more intervention, much earlier heart attacks which are much more dangerous and much earlier strokes which are also much bigger and therefore increased health consequences and loss of productivity, not to mention the personal cost to people whose family has suffered these tragedies.

CHAIR: Dr Haikerwal, time's caught up with us. Thank you very much. We'd like you to have two mementos of today. One is a year's membership. This is your second year as President - National President of the AMA and your second appearance here, so maybe you can fit in another one and here's the Press Club's gold tie. Thank you very much.