Dr Pesce, speech to WMA symposium at the medical leadership: the view from down under

It is a great honour for Australia to host the World Medical Association and a wonderful opportunity for the AMA to co-host this Symposium on Medical Leadership.

Just as the WMA is a world leader in health policy and debate, the AMA and the NZMA play similar leadership roles on the domestic front.

Our Associations embrace the whole profession, which makes us uniquely placed to provide strong leadership across the profession and the health systems we represent.

We are fortunate to have with us this week some of the most respected medical leaders, both local and international.

The BMA President, Professor Sir Michael Marmot, is not just the head of the Association, he is a renowned health thinker and policy maker, especially in regard to the social determinants of health.

At the same time, he is a passionate advocate for the profession and for patients in the UK.

We are fortunate to have with us two of the highest profile leaders the AMA has ever seen – Dr Bruce Shepherd and Dr Brendan Nelson.

Both have maintained very high profiles in public life long after their time as AMA President.

Dr Peter Foley has forged a similar reputation across the Tasman as Chair of the NZMA – a policy thinker and an advocate.

Our respective Associations have influence.

We influence governments.

We influence our communities.

And we have influence in the media.

We are catalysts for change – and this is a power we must use carefully and responsibly to improve the health of our citizens.

Medical leadership delivers results.

Here is Australia, it is most often the AMA that provides medical leadership in policy and political circles.

I was extremely proud and honoured to be elected AMA President almost two years ago and to be given the opportunity to lead the most powerful and respected lobby group in the country.

The AMA is a strong brand.

It has unparalleled access and success in Canberra lobbying circles.

It delivers very positive outcomes for the doctors it represents and for the patients who have contact with the health system every day in every way.

I campaigned for the AMA Presidency on a platform of engagement – engagement with our members, engagement with the broader medical profession and the other health professions, engagement with patients and the community, and engagement with the Government of the day.

It is my strong belief that positive health reform – the type of reform sought by the AMA – can only be achieved by being at the negotiating table with the Government, which has the power to change things.

It is the AMA’s job to influence and shape that change where possible.

You cannot do that job if you are not engaged with the Government.

However, being engaged does not mean being captive to the Government.

It means having a strong relationship of trust and respect in which you can argue your case openly and forthrightly in public and behind closed doors.

It means you will win some and you will lose some, but you are always a part of the conversation.

This approach has served me well in my private and professional lives and I believe it has served the AMA well in my time as President to deliver good results for AMA members and
the community.

But just as engagement in the health reform debate does not mean accepting that everything new is better, we must also be mindful of leading the debate in a manner that is relevant to government, society, and the emerging health professions.

We cannot continue the narrative of half a century ago.

Without doubt, doctors must and will remain at the centre of the health system, but we must justify that privilege in a language that persuades everyone involved in health reform.

We must prove our worth with renewed vigour, and not rely on a presumption that monopolistic dominance is a divine right.

If we see problems, we must find credible solutions.

When we see barriers, we must find ways to overcome them. I will give a concrete example of this.

The AMA successfully convinced the Government to amend the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 to specify a formal requirement that midwives and nurse practitioners must work in collaboration with medical practitioners, rather than be funded for independent practice without a need for formal collaboration.

This risked fragmentation of care, and ran counter to the move towards team-based care that has inexorably emerged over the last two decades

I was recently contacted by a colleague who was aware of the requirement for collaborative care, but only came to understand the value of the AMA’s achievement when his University’s

Dean of Nursing raised the issue of incorporating nurse practitioners into his radiation oncology unit.

In the past, decisions such as these were made with little consultation.

But the collaborative care requirements mean that he and the other doctors in the units were consulted, and had meaningful input into the way in which the nurse practitioners would join his team.

I believe that as more doctors come to consider how they may work together with our nursing colleagues, they will come to see how important the collaborative care principles being reflected in the legislation are in keeping the medical profession empowered at the centre of health care reform.

This is a significant achievement by the AMA on behalf of the medical profession in the interests of patient care.

I am very mindful that I am speaking at a Symposium held under the auspices of the WMA, so

I would like to also comment on an issue of more global significance, which requires leadership from those at the helm of the profession.

We all understand that health is now very much part of a global economy.

The global economy facilitates the mobility of ideas, technology and pharmaceuticals, and of workforce.

All things being equal, such mobility and global integration should be a good thing. But not all things are equal.

As doctors and nurses move from countries with developing economies towards countries with more established health infrastructure, the workforce and advancement of the health systems in their countries of origin are depleted of many talented practitioners.

This phenomenon is not new. It has long been recognised, but it has not been addressed.

As a result, we have a situation where census reviews found that, for example, 24 per cent of Ghanaian born nurses resided in foreign countries, as did 51 per cent of Kenyan born doctors,

I am not for one minute arguing that doctors and nurses should be prevented from exercising their right to emigrate and work in other countries.

But what right do these wealthier countries have to address their own health workforce shortages with recruitment policies that worsen workforce and skills shortages in developing countries?

Unfortunately, our health planners have hidden their own workforce planning failures by importing trained doctors and nurses. Inevitably, developing countries are most at risk of a net workforce loss.

In 2003, the WMA published its Statement on Ethical Guidelines for the International Recruitment of Physicians. Among other points, it recommends that:

Countries that wish to recruit physicians from another country should only do so in terms of and in accordance with the provisions of a Memorandum of Understanding entered into between the countries.

Without doubt, this was a thoughtful aspiration, to ensure wealthier countries made some meaningful contribution to assist the development of health systems and, in particular, play some meaningful role in replacing emigrating health professionals.

However, I see very little evidence that my country, or any others, have made a commitment to discussions with countries from which doctors and nurses are recruited to ensure that there is a balance of benefit so that all countries’ health systems may benefit from international health workforce mobility.

I would encourage all Medical Associations to pursue this example of global health inequality with vigour and persistence.

Meanwhile, the AMA works hard to support and expand our domestic medical workforce.

We speak out regularly in support of general practice, calling for more support for general practice nurses, and the slashing of red tape.

Most of all, we have urged the Government to keep general practice as the foundation and leader in primary care.

We have also worked closely with the Government as it moved ahead with plans for new approaches for funding and delivering long-term disability care and support – along the lines of the AMA’s long-term care scheme policy.

The Government appointed me to its independent panel of experts to work on this process.

We have been a major player in the development of the most significant health reforms in this country for more than 30 years.

Going into the election last year, the Government sought our views and the Opposition sought our views.

But what a difference a year makes in politics and health lobbying.

A year ago, we were on the cusp of a health reform revolution - led by a Government that was still rating well in the opinion polls.

All the taskforces and reviews and commissions and consultations had been completed and we were waiting breathlessly for all the good ideas and innovations to be put in place to make our health system better.

The then Rudd Government was popular and health reform was one of its more popular actions with the voters.

The Federal AMA took the position that the momentum for health reform had to be supported.

It was our view then - and it is our view now - that ‘no change’ is simply not an option.

The health system cannot meet the needs of our communities without significant reform.

Our approach was to remain engaged with the Government to ensure that the views of the profession and our patients and the communities we serve were reflected in any new policies.

Our role was to support policies that we knew would provide better services and outcomes for patients, and which were based on clinical input from doctors locally on the ground.

Likewise, we would oppose policies that we knew would interfere with doctors providing care to patients and communities.

The AMA was always at the health reform negotiation table. We had an impact. Our opinions were respected.

Then Prime Minister Rudd spoke at the AMA Parliamentary Dinner.

Then Prime Minister Rudd spoke at the AMA National Conference.

Then Prime Minister Rudd invited the AMA President and Vice President to private meetings in his Parliament House office.

The Government – through the Prime Minister and Health Minister Nicola Roxon – kept the AMA in the loop all along the health reform path.

Then all of a sudden the wheels fell off the Rudd juggernaut.

The honeymoon with the Australian people came to an abrupt halt and it wasn’t long before we had a new Prime Minister.

Julia Gillard took over as PM just weeks before the Federal Election.

AMA lobbying had significant impact on the election policies of both the ALP and the Coalition.

That election is now history and we live in difficult political circumstances with a minority Government.

The health reform dynamic has changed dramatically.

Big health reform has just got a lot harder – a lot more confused and lacking in detail.

Nevertheless, the AMA’s appetite and enthusiasm for good health reform has not slowed or eased.

We advocated for changes to the Government’s plan for care for people with diabetes. We got the changes.

We sought further consultation on GP after-hours and general practice nurse arrangements.

We got that too.

The AMA is still at the reform table with the minority Labor Government.

Major reform is needed. The AMA will seek to manage and massage that reform for the benefit of patients, communities and the profession.

Much work still needs to be done.

My term as Federal AMA President ends next month.

It is rare for one to be given the privilege of representing the medical profession in public and on the political stage.

I hope that I was able to be the public face of the profession that it deserves, and focus our priorities on issues recognised as crucial to the public interest.

I will end my term as AMA President satisfied in the knowledge that my Federal Council and my Executive provided the medical profession and the Australian community with medical leadership of the highest order.

5 April 2011

CONTACT: John Flannery 02 6270 5477 / 0419 494 761
Geraldine Kurukchi 02 6270 5467 / 0427 209 753

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