Dr Hambleton, Medical Board of Australia National Conference Speech, 18 April 2013

MELBOURNE

THURSDAY 18 APRIL 2013

AMA PRESIDENT DR STEVE HAMBLETON

***Check Against Delivery

The Medical Profession - The Next Ten Years

You have set me quite a formidable task - to speculate about the next ten years for the medical profession in just ten minutes.

This will be like an episode of The Time Tunnel.

I see two major shifts in areas that today are fundamental to medicine continuing to be a highly-sought-after profession rather than just a job.  

The first shift is how we structure the medical workforce, which will impact on how a medical practitioner chooses his or her specialty and practice location.

The second is constraints on health expenditure, which will impact on clinical autonomy in how we treat our patients.

So I will talk about the workforce first and then consider health expenditure – and, just before I finish, have a bit of a whinge.

Up to now, medical practitioners have chosen their specialities based on their personal interests and often go on to develop long careers in that field.

With significant medical workforce shortages in recent times, junior doctors have had a wide choice of specialty area.  They could generally pursue a career in one of the specialties that most appealed to them.

Our future medical graduates will face a very different set of career choices to those that exist now. 

The community’s health needs will begin to drive the mix of specialist services and will dictate the number of training places.  

Australian-trained medical graduates have also for the most part been able to work in the location of their choice.  This has led to both shortages and workforce maldistribution.

Successive Governments have been unwilling to sufficiently fund a comprehensive program of incentives to address these issues.  This has forced regional, rural and remote Australia to rely on the recruitment of international medical graduates (IMGs) in order to plug workforce gaps.

While IMGs are making an enormous contribution, this is an unsustainable situation.

At the same time, medical graduate numbers have grown dramatically.

By 2016, Australian medical schools will be graduating 3970 students a year, according to the Medical Training Review Panel.  This rapid growth now presents many challenges for the medical training pipeline. 

How will we be able to support sufficient prevocational and vocational training places to ensure that these graduates can achieve specialist qualification?

We have already seen Federal and State Governments clash over funding for intern places for 2013, while shortages of RMO positions have started to emerge in a number of States. 

Health Workforce Australia (HWA) is also predicting a shortage of vocational training positions from 2016. 

The National Medical Training Advisory Network (NMTAN) will provide advice to HWA on how the provision of sufficient training places might be better coordinated and better distributed.

We will need to encourage entry into those specialties where potential future shortages are predicted with a consequent reduction in choice. 

By 2025, HWA is predicting medical workforce shortages in the following areas:

• obstetrics and gynaecology;
• ophthalmology;
• anatomical pathology;
• psychiatry;
• diagnostic radiology; and
• radiation oncology.

Psychiatry and radiation oncology services are particularly at risk because of their existing workforce position of perceived shortage, with the projections indicating this will worsen further by 2025.

In contrast, the following specialties are perceived to currently be in adequate supply, and are projected to move towards oversupply by 2025 if recent trends in supply and demand continue:

• cardiology;
• gastroenterology and hepatology
• neurology, and
• surgical specialties.

Clearly, future medical graduates will no longer have the complete range of speciality choices that we have become accustomed to in the past.

Graduates will also need to look beyond the major cities and consider a career in regional and rural Australia. 

The AMA - in particular, the junior doctors in the AMA - agree that it is important that the medical workforce is meeting community need.

But it is also critical that Governments deliver well-thought-out policies that reward these career choices and ensure they are not seen as a last resort option. 

The expectations of our future graduates will need to be carefully managed as we move towards an environment where career choices are increasingly constrained.

If I were fixated on a particular specialty, but had to train in something else, or work in a particular location far from my choosing, how would that affect my enthusiasm and professionalism?

Would I respect my patients?

Would I be interested in continually improving my skills and knowledge in my scope of practice?

Would I be prepared to listen a little harder, stay a little longer, give up time to teach and train and inspire my future colleagues?

These are the sorts of questions that may confront the future medical workforce - and planners need to consider them.

The second major issue of health expenditure and its impact on clinical autonomy will also create greater stresses and pressures over the next ten years.

Australia’s health spending in 2009-10 was 9.4 per cent of GDP.  Ten years earlier, it was 7.9 per cent.  According to the Australian Institute of Health and Welfare (AIHW), it is projected to be 12.4 per cent in twenty years’ time. 

The medical profession is being asked to help control these spiralling costs.  We will be asked to identify and recommend the most cost-effective services.  

Funding arrangements will inevitably become more prescriptive about when in the patient clinical pathway a medical service will attract reimbursement.

I will use a very simple clinical scenario to illustrate what I mean.

A wrist ganglion is a small, harmless cyst, or sac of fluid, on the back of the wrist.

We don’t know exactly what causes them.  Most of them aren’t painful, don’t interfere with activity, and can often be left untreated without harm to the patient. 

In the old days, if treatment was needed, out came the family Bible to clobber them.

Sadly, most of them came back, which did not really matter because patients often did not front up for a second go with the Bible in any case.

Let’s get back to the modern day.  

Ganglions can be painful when they put pressure on the adjacent nerves, and the larger ones can impede movement and may need treatment.  

We now have two main treatment options – aspiration and surgical excision, which the Medical Services Advisory Committee (MSAC) is looking at.

The recurrence rate for aspiration is around 60 per cent and the recurrence rate for surgery is around 40 per cent.  

Also, studies show that, if left alone for six years, 30 to 40 per cent of wrist ganglions will resolve spontaneously anyway.

If left alone for 10 years, that rate goes up to 50 to 60 per cent.

So now MSAC is having a look at whether non-surgical treatment and allowing time for spontaneous resolution or surgical excision is more cost-effective.

If they find the former, then it is quite likely we will see the withdrawal of Medicare rebates for the surgical treatment options.

Or, at the very least, we will see a very prescriptive set of clinical circumstances at the end of a long pathway when benefits are payable.

Thus the prescribed funding arrangements will impact on clinical autonomy.  

I would effectively be constrained to provide only those treatments that attract funding, not the treatments that I might consider are clinically appropriate, which is how the Medicare Benefits Schedule works today.

If the financial constraints are not introduced in an appropriate way, a number of questions arise.

How would this affect my professionalism?

How would this affect my patient’s perception of my professionalism and conduct?

Patients have come to expect that doctors will do everything in their power to ensure all the tests and all the treatments that can be done are done, even when they are not necessarily essential.  

The AMA heard from Professor Andrew Wilson last year that it’s not the ageing population or the prevalence of chronic disease that is driving increased health expenditure.  It’s the volume of treatment provided in each episode of care.

So it will be very important for us to be having a good look at what we can do to ensure every health dollar is spent wisely but still maintain first class outcomes. 

But there are implications for the doctor-patient relationship.

If the funding arrangements constrain the treatment, the doctor will have to work with what’s available.

Patients’ expectations may not be able to be met and they would be more likely to be dissatisfied with their healthcare experience.

They might blame their doctor, not the funding scheme - which could mean more complaints to the Board.

In that context, the challenge for the medical profession is to accept that we do have a role in the stewardship of the health system.  That means evaluation and change will need to be part of the medical practitioner DNA.

In terms of our clinical practice – I will borrow a phrase from Lord Darzi who spoke at our National Conference last year - we would have to more closely translate what we know into what we do.  And it would have to be done in a structured way.

The AMA is ready to help and is already involved in reviews of services on the MBS, and a Government forum on the sustainability of the MBS.

Another way that governments are looking to reduce the costs of care is to expand the role of other health practitioners.  

Some of this will impact on longstanding working arrangements where the scope of practice and the roles and responsibilities in providing care to patients are clear to every practitioner involved in that care.  

Obviously, the concern for the medical profession is that if role expansion isn’t managed properly and sensibly, there is potential for harm to patients and, ultimately, increased exposure to medico-legal risks for doctors.

The reality is that the buck does stop with the doctor. 

And now the whinge - but it is a constructive one.

The AMA would like to see the Medical Board having a much more active role in the way the other health practitioner Boards are setting standards and guidelines for their registrants.  

The AMA was a supporter of the concept of national registration, if it was done the right way, but was very cautious about accreditation and the collection of multiple Boards under the AHPRA structure.

But we did see that it provided a better opportunity for registration Boards to work together to coordinate the standards for each of the health professions, and to ensure that scopes of practice were appropriate and relevant to their education and training.

Let’s go to a specific example …

Next week there is a meeting between the Chief Medical Officer and the Optometry Board.

They will discuss the guidelines that the Optometry Board recently put out in which they gave the green light to optometrists to prescribe anti-glaucoma medications independently.

Optometrists and ophthalmologists have for a long time worked together in ‘shared care’ arrangements.

The AMA is concerned about the clinical implications of this, where the Optometry Board is quite clearly endorsing independent practice for a serious sight-threatening clinical condition where it is more safely offered in a collaborative environment. 

We are very concerned that the Optometry Board deliberately chose the guideline approach rather than making standards that would require endorsement of the Health Ministers.  

We accept that health professions will have changing roles over time and may want to expand their scopes of practice.

We accept that politicians can see the financial merits of allowing health professionals to change and sometimes expand their scopes of practice.

But we cannot accept that this can be done by stealth, by a Board whose primary role is to protect the public without mandatory reference to our own Medical Board - that is, all of you sitting before me - on a public safety issue as grave as this.

For the patients’ sake, the Boards must work together so that registered health practitioners in this instance are required to collaborate on patient care - particularly where the expanded scope of practice is not part of the core training and education for the health profession, and where the new training is not a patch on the training of the ophthalmologists that they seek to replace.

It is not just the Optometry Board.  Don’t get me started on the Chiropractor Board and the treatment of infants and children.

And, before we move off this topic, beware the Psychology Board who will have a guideline for prescribing anti-depressants before the ink is dry on the Optometry arrangement.

The AMA stands ready to engage in discussions about medical practitioner professionalism in the context of future workforce requirements. 

We recognise our role in the constraints of finite health funding and we want to be part of the build of a better more sustainable health system delivering better outcomes for our patients. 

Let’s work together to manage the changes that we need to make to assist the profession to move more deeply into the 21st Century to deliver first class outcomes to the community while building the trust and confidence of our patients.

18 April 2013

CONTACT:         John Flannery                       02 6270 5477 / 0419 494 761

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