Dr Mukesh Haikerwal, President AMA Victoria with Geraldine Doogue, Radio National 'Life Matters'

Doctor Bob Birrell, the Director of Monash University's Centre for Population and Urban Research, has been analysing the distribution of GPs and says the cities simply don't have the shortages that rural areas do, worse, that the government's timing is wrong. Just as the market forces are starting to work in the way they're designed to. Dr Mukesh Haikerwal, the President of AMA Victoria disagrees. His practice incorporates western Melbourne suburbs and he says, the people there are not being well served, or served by enough doctors. Welcome to you both. And first to you, Mukesh Haikerwal, could you describe the problem as you see it?

HAIKERWAL: Sure. We've always known, as you said in your introduction, that rural and remote Australia has a major problem in terms of numbers of doctors and recruiting and retaining doctors. But we've identified, for some time now, that the problem of obtaining a general practitioner service is not confined to those areas, but also is increasingly so in some inner city areas, but much more so in the outer suburban fringe areas. The reason for this is, that the population is increasing as the metropolitan sprawl increases.

DOOGUE: But what is the problem? What are they having? They can't get to a GP, they have to wait too long or they don't get enough time with them - what is it?

HAIKERWAL: All of the above. I mean, a colleague of mine in Sunbury, for instance says, you have to wait six weeks to see him, to fit in for an appointment, which is, you know, a crazy situation. There aren't enough GPs around, you have to wait a long time for the appointments and you know, the access to other services around them, also is a problem.

DOOGUE: So what are you saying? That more money would mean that there would be more GPs attracted to those areas?

HAIKERWAL: Money is only part of the solution, but it's an important part. The problem is, that the size of the population is increasing and therefore the demand is increasing, and people aren't attracted to work in the areas, in the outer suburban areas, cause they're deemed to be areas that don't sustain a reasonable practice.

DOOGUE: Well, what do you mean by that?

HAIKERWAL: Well, the practice costs have increased dramatically as time's gone by and general practice has basically been cut to the bare bone in terms of what's provided and the cost of what it's provided for. And the reason for that is that doctors have been, you know, dedicated and ethical practitioners with a high moral obligation, have been trying to do right by their patients, and not charge them out of pocket and basically try and bulk-bill.

DOOGUE: 'Cause I think there's about a 96 per cent bulk-billing in these areas, is there not?

HAIKERWAL: That's right. It's a high, very high percentage of bulk-billings for general practitioners services. And the reason for that is that the patients are often from low-income families or no income families, and the doctors try to do right by their patients and not charge them out-of-pocket. But that's a situation which used to be sustainable, when the rates of rebate that patients would get for those services, were reasonable, have gone completely out the window. And doctors are really giving a huge subsidy now that they bulk-bill and they cannot sustain that sort of practice.

DOOGUE: And what average income do you say the doctors in these areas are taking home?

HAIKERWAL: Well, that's a good question. It's not a case of the gross which we always hear about, what people that maybe taking $100,000 -$200,000 from Medicare. Once you take out the practice expenses and so on, people maybe going home with $60,000.

DOOGUE: And now, there might be a lot listening to say, what's the complaint there?

HAIKERWAL: Well, that's right. There maybe some people saying that indeed and then you'd have to say, "Well why would people actually go through and do medicine, you know, and take all that responsibility, each decision that a doctor makes is, has an awful lot of responsibility".

DOOGUE: It's not commensurate with your training, in otherwords?

HAIKERWAL: Yes.

DOOGUE: All right. Now Bob Birrell, you used those same figures - if I understand you correctly, having read your paper - to argue the opposite case?

BIRRELL: Yes. Our figures on the relationship between patients and doctors, indicates that almost all of the areas of Melbourne and Sydney are well-served, relative to regional populations. Even in outer areas like Dandenong, in Melbourne, which are relatively poor, the number of population to, equivalent to full time doctors, about 1000 to one, which is quite low. And it compares with about 1,500 to one, that is 1,500 persons to one full time equivalent doctor in regional Australia.

And in none of the areas that Dr Haikerwal is talking about, does the ratio of population to doctors, exceed about 1,100 or 1,200 in Melbourne or Sydney.

DOOGUE: Do you think that's about ideal, do you?

BIRRELL: Well, relative to the past, it certainly is. And just to look at a bit more historical depth, and in the mid 80s, the situation in Melbourne and Sydney, it was around 1,400 persons to each full time equivalent doctor. These days it's around 1,000, so there's been a massive improvement in the servicing of patients by GPs …

DOOGUE: …Right, but …

BIRRELL: …But not in regional Australia, which is still, as I said, around about 1,500 persons to one full time equivalent doctor.

DOOGUE: But you are also saying, are you not, that evidence of wide bulk-billing suggests that the market has got it about right. Because it suggests that doctors, under competition, can't charge extra, extra fee-for-service in their surgeries. And actually, rather than that being a complaint that is, suggests somethings working well. Am I portraying you correctly?

BIRRELL: Yes. Well. Certainly, I would disagree with Dr Haikerwal and the AMA, which is in the midst of a campaign to try and get a 50 per cent increase in the Medicare rebate. And they're trying to argue that shortages are emerging, and that in order to justify more doctors in regional and metro areas, there should be a significant increase in the rebate. Now, I think the evidence of very high bulk-billing, you mentioned 95 per cent of services bulk-billed in western areas of Sydney and Melbourne, are indicative of competition for patients. Doctors simply cannot afford to anything other than bulk bill, because if they direct bill they simply lose their patients around the corner.

DOOGUE: Yes. But look, what they … sorry to interrupt you … what they're saying is that there's not enough money to attract good doctors, to really beddown and make a profession of these areas - which needs stability. And that one way of doing that would be, to up the payment to them.

BIRRELL: Well, first of all I don't think it's true because, the data, as I've indicated to you, does not support the view that there's a significant shortage of doctors in outer Melbourne or Sydney. But even if it was true, it substantiates my larger concern, which is that doctors are unwilling to serve in areas which they don't feel are salubrious. Like, they're now saying they're reluctant to serve in outer Melbourne or Sydney, and we know from them that they are reluctant to serve in regional Australia. And what we're saying is that, yes, they have a case, that the payment for their service, if it's done properly, a standard service at 10 to 15 minutes, on $24, is low and they can't really practice good medicine in that kind of setting. So they tend to push through the patients, what we call, 'high through-put-medicine'. But what we're saying is really necessary is, that there should be some administrative arrangement so that doctors actually serve where they're needed. And if we just push up the price of their service, then there'll be even less incentive for them to move outside Kew or Leichhardt, to go where they're needed.

DOOGUE: In fact, Mukesh Haikerwal, … 30 per cent discount on that, was acceptable. Because it took into account all those administrative costs, you know, the patient signs a form, doesn't have to worry about going to Medicare and doctor gets the money guaranteed by the Government. However, that difference, there is now a big difference, which this latest Relative Value Study showed, which showed that instead of being paid $24 that the fee should actually be $45.

DOOGUE: Okay.

HAIKERWAL: It's quite a large difference, there.

DOOGUE: We'll see …

HAIKERWAL: …And that has to be addressed.

DOOGUE: Could I go back, very quickly from you Bob Birrell. What's your message to the Government? Not to keep spending money on doctors?

BIRRELL: No. I think that certainly, there is a case, as I indicated, to increase the rebate for Medicare services, GP services. But the problem is that there has been no improvement in the imbalance and services, GP services, for regional Australia and metropolitan Australia, despite all the peacemeal efforts have been made. No improvement over the past three years, they've just managed to hold the line by various incentives to training and other incentives. I think something much more fundamental is necessary. If we're going to increase rebates to doctors then I think a trade-off should be acceptance of a more rational distribution …

DOOGUE: …I see, a conditional …

BIRRELL: … of the medical workforce, yes.

DOOGUE: Okay. Well look, thank you. I don't suppose that'll be debated in the election campaign - can't see it somehow - maybe it ought to be. But thank you very much for joining us today.

Dr Bob Birrell, from Monash University Centre for Population and Urban Research, with some provocative thoughts there and his article on GPs co-authored with Leslie Anne Hawthorn, appears in the latest issue of People and Place published by his Centre for Urban and Population Research.

And also, my thanks to Dr Mukesh Haikerwal, the President of AMA Victoria.

Ends