Interview - Dr Bill Glasson, AMA President, with Jeremy Cordeaux, Radio 5DN - Australia's healthcare system
CORDEAUX: Federal President of the AMA is going to be with us. And if you would like to talk about things medical this is the man, this is the way to cut through all of the stuff that is around, the Federal AMA President, Dr Bill Glasson, in Adelaide today.
Sir, thank you for joining us.
GLASSON: Thank you very much indeed, Jeremy, it's nice to be here.
CORDEAUX: What brings you to town? What's on today?
GLASSON: Well, I've come down to see your State President, Dr Bill Heddle and, really, to look at the issues that are impacting on South Australia in the South Australian medical system, particularly both in your public system and also in relation to the workforce issues that are affecting South Australia.
And South Australia, apparently, has some of the lowest percentages from the point of view of the doctor-patient numbers in the country and so that's reflecting on the fact that patients cannot find general practitioners and, hence, are going to the public hospitals. And the public hospitals are in dire straits, not only in South Australia, but it's across the board.
CORDEAUX: Mm. I heard Bob Carr saying that part of the problem - and I guess it's reflected here as well - is that people are now going to the emergency section of a hospital with-- and I think Bob Carr was saying things like a splinter in the finger, a cold, just the most trivial of things.
And those people should be going to the GP, not clogging up the system in the hospital. But really should they, in fact, be going to the GP either? I mean, what-- are we not, perhaps, overusing doctors and going to doctors for the most trivial things simply because we have it in the back of our mind that it's not going to cost us anything?
GLASSON: Mm. I think you're right. I mean, there are two issues here. One relates to the accident and emergency departments first of all, number one. What Bob Carr was suggesting-- well, his suggestion was that if we took away all the GP patients that would solve the problems in our accident and emergency departments.
CORDEAUX: Yeah.
GLASSON: The reality is-- that is not the problem in A&E departments. The reality is that we just do not have enough, I suppose, beds in the hospitals and ultimately aged care facilities, beds for patients to go from the hospital, in other words the system gets clogged. And it's clogged with people in wheelchairs, people on trolleys, people, actually, that have got-- that are sick.
CORDEAUX: Yeah.
GLASSON: And so it's the sick patients that are clogging our public hospitals, not necessarily the well ones, in inverted commas.
I'll agree with you that from the point of view of the system across the board, where we've been used to sort of, I suppose, a system of bulk billing where we can receive medical attention at no fee, that often does send the wrong signal in the sense of, ...
CORDEAUX: Mm.
GLASSON: ... "Listen, I've got something minor, let's just pop off to the doctor".
And -- but I think the important message there is if there is going to be some sort of price signal built into the system - and, I suppose, philosophically that is the best way forward - but that price signal should not be so large that it actually stops people going to the doctor when they really have a true medical problem.
And so there's a balance there between having a charge or a small co-payment ...
CORDEAUX: Yeah.
GLASSON: ... in one sense, but making sure that if you've got a sick child or you are sick yourself that you don't say, "Listen, I can't afford to go to the doctor", ... or that, "I'll have to go to the public hospital". I think that we have to have a balance here and that's what we've been trying to achieve.
CORDEAUX: Yeah. Going back to the fifties, which is possibly what some people fondly think would be a nice idea, it seemed that we had a system there that really worked. You know people took their ... little book down to the local chemist and they paid maybe fifty cents or whatever the equivalent was back in the fifties and they had medical insurance, doctors seemed to be affordable. They probably didn't drive 'round in Mercedes Benz. But the system seemed to be affordable; everyone could afford insurance.
Then along came, I think, Medibank- although maybe something else happened between the good old days and Medibank - and then the whole thing just went through the roof. Presumably because a whole bunch of people said, "Well, gee, it's only an insurance company that's paying, nobody's really paying, let's stack it on". Do you think that happened?
GLASSON: Well, I think obviously there's an onus of responsibility on all of us to make sure that the-- to understand that the resources out there are limited. Now, if we're going to utilise those resources, they must be for the right reason. So I do think that in the old days we often saw a third of our patients at, in fact, no charge.
CORDEAUX: Yes.
GLASSON: When there was no Medicare out there, the doctors sort of carried the load.
CORDEAUX: Yeah.
GLASSON: The doctors still carry the load in the sense they compassionately discount probably, you know, half or more of their patients to try and ensure that the patients can access the care and to make it affordable. The reality is that to try and provide high-quality general practice today they cannot continue to accept the Medicare rebate as full payment.
And so doctors are making a decision, "If I'm going to provide the type of medicine that my patients want". And my patients want time is the reality. They want to be able to talk to their doctor not about the one problem, the single problem; they want to often talk about the whole of their body. And they might only be visiting the doctor once a year, therefore they do want to have their full physical check. That takes time, which means money.
And so I think doctors are saying, "Listen, we're going to have to charge what we think we're effectively worth". Patients on the whole are willing to pay for that.
CORDEAUX: Mm. That's reasonable, yeah.
GLASSON: And so long as there are sufficient safety nets in the system, then I think that's the way forward. And that's the way-- and given the increasing medical costs out there, the ageing population, the fact that we can do more and more to keep you alive and hopefully give you better quality of life, ... someone has to pay.
Now, in reality, does the taxpayer have to fit the full bill or does the person who actually receives the service fit some of the bill?
CORDEAUX: Mm.
GLASSON: I think there has to be a balance there ...
CORDEAUX: Sure.
GLASSON: ... and I think it's the balance that we've got to get right.
CORDEAUX: Yeah. And I would rather have doctors playing God than politicians playing God or bureaucrats playing God.
GLASSON: Absolutely. And the reality is if they don't fix this situation, this workforce problem is going to get worse and worse. And for those of you who are listening out there, I'm sure your major problem is not the fact you can't find a bulk billing doctor, it's the fact you can't find a doctor at all. And so we have to make sure that the workforce we have at the moment we must keep them in practice and to keep them in practice we've got to make sure we fund the system appropriately. And the other issue we have to get right is the one of medical indemnity.
If there's one single issue that's actually destroying this profession in this country, and destroying the fact that you and I when we get in our rocking chair will be able-- or hopefully be able to access some sort of medical services in this country, it's medical indemnity. We have patched the system up, it is not working, it's not sustainable, it's unaffordable and, basically, it'll mean that you and I, as patients, will be paying more and more in gaps to fund a system that is just unworkable.
CORDEAUX: Well, there you are, let's say a woman is about to have a baby. Now, she can have choice. She can have no obstetrician or she can have an obstetrician to whom she says, "I will sign a waiver, I just want you to do the best you can". Now, what's wrong with that system?
GLASSON: Mm.
CORDEAUX: It'd be far better to have a doctor, an experienced doctor doing the best he could to deliver your baby safely, than having no doctor to deliver your baby. There doesn't seem to be an alternative.
GLASSON: You're absolutely right. I mean in reality, I suppose, the balance we strike there is that your-- that we want to preserve the obstetricians in this country. Who by the way, I think, we've lost two hundred out of the five hundred we had five years ago and we're about to lose another hundred and fifty of the three hundred left. You won't have an obstetrician to access.
So the question of waivers. I suppose all I ask from the community point of view is that if you have an adverse outcome or your child has an adverse outcome at birth, we just need a system to make sure that you can attain services in the community like anybody else can from the point of view of having any sort of child with a disability.
What I say there is that if there are ten cerebral palsy children sitting in a room, one can be assigned to the fact that the nurse was too slow or the doctor was too slow in putting the forceps on, the other nine can't. One baby gets ten million dollars and the other get none. Tell me about the justice of that system.
CORDEAUX: Yeah.
GLASSON: What I'm saying is that we need a system in place whereby anybody who has an adverse outcome can access services. But the reality is that if you tax that, or you fund that through ever-increasing premiums for obstetricians, you will not have any obstetricians full stop.
CORDEAUX: Sure. When did it go crazy? I mean, there must have been a point at which time either-- was it the courts that went crazy?
GLASSON: Essentially I blame here the judiciary, who basically have been playing Santa Claus for the last ten to fifteen years.
CORDEAUX: Again it's the perception that nobody's paying. It's an insurance company; that's nobody, that's--
GLASSON: That's exactly right. You know I've got a-- the judge says, "I've got a child here with a disability", often they don't particularly care whether there's fault or no fault, they just say that, "I'm here to, you know, be the social security person", so they hand the money out. But the reality is that it's the sick patient that pays for the system and they're paying for it in ever-increasing premiums, through their doctor's premiums. So doctors don't pay for medical indemnity premiums, patients do.
CORDEAUX: Yeah.
GLASSON: And some of these women are paying up to fifteen hundred dollars co-payment to have a baby just to cover the indemnity.
CORDEAUX: Mm.
GLASSON: Now, this is a ridiculous scenario.
And the other issue is that if you are a doctor and you have a feeling that, you know, the next person who comes along is going to sue you, the mental, I suppose, anguish, the mental ...
CORDEAUX: Mm.
GLASSON: ... feeling that I'm doing my best-- I'm not here to try and hurt or harm anybody, I'm trying to do the best by every patient I see. But if you've got this underlying feeling that, you know, the next person's going to sue you and you're going to get dragged through the courts, it's really demoralising. And, I suppose, the profession just says, "I don't want it. I just want to move on and do something else".
CORDEAUX: Mm.
GLASSON: In reality that's what's happening and that's why we're heading for the biggest workforce crisis ...
CORDEAUX: Mm.
GLASSON: ... this country's ever seen.
CORDEAUX: And do you know where most of them are going?
GLASSON: Well, a lot are going overseas, a lot are retiring, a lot are going-- I've heard of people actually becoming flight attendants, driving taxis, running other businesses.
CORDEAUX: These are doctors?
GLASSON: These are doctors.
CORDEAUX: But what's happening here in South Australia is that every second person who buys a vineyard is a doctor.
GLASSON: and my children.
And so I think that governments have to actually make a move on this hard and fast, and that's obviously particularly at a state level, to have laws that really make it so difficult to smoke ... and make it socially-- you know there was a-- I'm sick of seeing it in movies as well.
CORDEAUX: Mm.
GLASSON: They should ban it from movies and so that my children don't see people smoking on TV. And essentially through an education campaign-- and I must say our kids, I suppose, are the best advocates in a way. Yet can I say that Australia has one of the worst teenage smoking rates in the world.
CORDEAUX: Yep.
GLASSON: And I think that's a terrible indictment on Australian governments, who actually should be legislating about this issue, because I think that unless something's done, we're going to continue to suffer the consequences of smoking. And again, for every admission in our public hospitals, a significant percentage of those are related directly to people that have smoked over their lifetime.
CORDEAUX: Well, we've got some callers to get to, but let me say this: you doctors could play a part in this. Because when somebody comes in and he's maybe had a triple bypass, and he's gone back to his lifestyle problems and he comes back to you, maybe just ruthlessly you've got to draw a line in the sand and say, "I'm sorry. I mean, I'm not going to do this for you anymore. You are the cause of your problems and you think that the system is going to pull your chestnuts out of the fire". That's ruthless but it could send a very strong message, would it not?
GLASSON: It would. I mean at the end of the day-- I keep talking about responsibilities and we talk about the individual responsibilities. And I think each of us have individual responsibilities out there that really are outweighed-- well, they shouldn't be outweighed, but you've got a balance between community responsibilities and individual responsibilities. And if you don't take responsibility for your own health or whatever you do in life, then I don't think that the rest of us should.
And so I agree with you in principle that as medical practitioners if we're saying, "Listen, your condition's related to smoking, we're going to have, you know, a bypass or whatever", and in reality if you keep smoking, then that obviously has--
CORDEAUX: But there should be a penalty, shouldn't there, for doing the wrong thing.
GLASSON: Should be? Well, yeah. But you know, I mean, the trouble with our society is there's all this sort of, you know, "We can't impinge upon people's rights, et cetera", all the time. But the reality is that those rights often ...
CORDEAUX: Yeah.
GLASSON: ... go against the community's rights or the best interests of the community.
CORDEAUX: Sure. And in Sydney, instead of trying to get people off heroin, they set up a room where people can safely, in inverted commas, use the thing, and fail to refer one of those people to rehab.
GLASSON: Mm.
CORDEAUX: I mean, we are a very strange group of people in this country.
GLASSON: Yeah. I think the ways we address issues, often you wonder why in the hell-- how-- you know how in the hell we actually set up these systems and schemes. I think if you totally ban things, often, I think, history shows it doesn't really work. But we've got to have sufficient, I suppose, negatives in the system that patients do not pursue, you know, a particular activity, ...
CORDEAUX: Yeah.
GLASSON: ... whether it be smoking--
CORDEAUX: They've got to get the message and somebody has to send that message.
GLASSON: They've got to get the message. Yeah, absolutely. No, we do.
CORDEAUX: (08) 8305 1323 is the telephone number if you would like to join us. Dr Bill Glasson is the head of the AMA and he is making a house call.
And they don't do that very often these days.
GLASSON: They don't, Jeremy. No, no, they don't.
CORDEAUX: No. Here you are, John. Hi.
CALLER 1: Good morning, Jeremy. May I direct my question to Dr Bill Allison?
CORDEAUX: Go ahead. Bill Glasson.
CALLER 1: Bill Glasson?
GLASSON: Yes.
CALLER 1: I beg your pardon.
GLASSON: That's alright.
CALLER 1: Dr Bill, may I call you that?
GLASSON: Yes, certainly, certainly, John.
CALLER 1: Religiously every year for many years I've had my flu vaccine shots ...
GLASSON: Mmhm.
CALLER 1: ... and have never contracted flu.
GLASSON: Right.
CALLER 1: Now, my question is, since there's now an epidemic almost throughout Australia, why indeed can't they incorporate into the influenza vaccine shots a flu vaccine thing?
GLASSON: Mm. Yeah, John, in reality what they do each year is they try and define what are the most likely sort of viruses or flu viruses to affect us and then incorporate that in the vaccine. So I understand this year's vaccine had two of the viruses from last year plus a new one that you would have received in your vaccine.
I suppose the argument is that everybody, you know where possible, should have to have their flu vaccine, and we try and encourage that, both from the point of view of you not getting the flu and you not getting it and passing it onto other people in the workforce. So we encourage certainly those above sixty-five, those who are working with children, you know the indigenous population, et cetera, et cetera, to make sure they have their flu vaccine because it works very well.
And even if you do get a dose of the flu, you'll find that it's of a much lower, you know, severity. So they do incorporate-- to answer your question, they do incorporate the common viruses that they've seen in, say, the Northern Hemisphere over the previous twelve months in the vaccine that they'll distribute to you.
CORDEAUX: OK. Thanks, John.
Hi, Pat.
CALLER 2: Oh hi, Jeremy. I just wanted to talk to Dr Bill.
GLASSON: Hi, Pat.
CALLER 2: My query is, I know of an old doctor who has-- I worked in the medical profession for twenty-odd years and this doctor went from being, you know, a consultant down to working locally.
GLASSON: Mmhm.
CALLER 2: And I find that in the-- he mentioned to me just casually that, "Well, I can't get indemnity insurance", mainly because of his age. Is there not something that the insurance companies-- I mean, this man's knowledge is just-- the community can do with it, ...
GLASSON: Mm.
CALLER 2: ... and I just wonder if that's something they're going to work on?
GLASSON: Pat, the saddest about this whole issue is that doctors either have to be working sort of full-time, flat out in other words, or sort of stopping overnight. Because, I suppose, the current medical indemnity situation doesn't allow you, particularly, to wind down because of the cost of the system. And this is impacting-- for instance in relation to the current UMP debate all doctors over sixty-five, as a consequence of what's happened in the last couple of weeks, will be retiring out of the system full stop.
Now, you're losing a huge amount of knowledge, experience. These are the doctors that are seniors, these are the doctors we turn to in times of crisis to help us with particular cases, they assist us in theatre; we can't afford to lose these doctors. And the reality is, I reckon within less than twelve months there'll be programs in place to track these doctors back into the system, because we are desperately short of them across the board, we cannot afford to lose them.
And this is, again, just a symptom of this mad indemnity situation that we find ourselves in. And so I empathise with your senior doctors out there not being able to attain appropriate indemnity cover because the reality is he probably can't afford it in relation to the limited number of hours he does.
CORDEAUX: And the thing that is so crazy about it is even when the doctor retires, he's got to go on paying his premiums because these things ...
GLASSON: Of course.
CORDEAUX: ... can come back and bite you on the bum twenty years later.
GLASSON: That's exactly right. I mean, the reality is that we've still got these statutes that are twenty, twenty-three years long. And so we've had numerous cases where doctors have retired and in retirement for ten to fifteen years and find they have a claim that comes back and haunts them, you know, twenty to twenty-five years later.
Now, this is, again, sending a bad signal to the profession. Obviously, for those who deal with children particularly, they say, "Listen, you know, can I continue in an environment where I can be sued for this far ahead?".
So I'd suggest to the South Australian Government - particularly at the moment they're looking at their tort law, their common law changes at the moment - that they must make sure that those tort law changes are tight and strict and much, much-- and must make sure that there's enough rigidity in the system so that doctors aren't exposed to these claims twenty or thirty years down the line.
CORDEAUX: Might be a dumb question, Doctor, but why wouldn't the AMA, as the key group, ...
GLASSON: Mmhm.
CORDEAUX: ... the kind of head group, ...
GLASSON: Mmhm.
CORDEAUX: ... the lead group, why not set up your own insurance company and do it yourselves?
GLASSON: Yeah, obviously as you know in Australia we've got seven medical indemnity organisations that are sort of providing indemnity cover and that has been sort of historical. Could we set up our own medical indemnity cover? Well, I mean, it's-- really it's an insurance sort of business I suppose.
CORDEAUX: But if all the doctors got together and bought their own company?
GLASSON: Yeah, I mean, the reality is could we have one single medical indemnity organisation?
CORDEAUX: Mm.
GLASSON: I mean, that has been argued don't worry, rather than having seven, having one. We'd obviously need to look at that, in reality how it would work, to ensure that it was, you know, feasible in the long term. But I think, at the moment, we're trying to look at different models by which we can pursue this whole issue.
Because the current model we're working under, particularly the adversarial model where you've got to prove fault, is not fair on the patients and it's certainly not fair on the system, because the sick patients are having to pay more and more for medical fees to fund this system. And so I think we've got to go back to the drawing board and decide what we need in the long term.
CORDEAUX: Hi, Gail, here's the doctor.
CALLER 3: Oh, good morning, Jeremy. Good morning, Dr Bill.
GLASSON: G'day, Gail. How are you?
CALLER 3: G'day. Good, thank you. I'm a registered nurse and I've been nursing in the public system for about fifteen years. And--
GLASSON: Well, we need more of you, Gail. You're in such short supply out there.
CALLER 3: Oh absolutely.
GLASSON: You're little gems.
CALLER 3: I don't need to tell you that we're also in very short demand Mr Howard says that critics are bagging the system for political gain. Which is probably true. It's hard to think of politicians who are not being political.
He says while there are deficiencies in the health system, it is definitely better than those in other countries - as Dr Bill just told us - including Britain, America and Japan. Mr Howard has told Radio 3AW Queensland Premier Peter Beattie's comments that the new Federal Health Agreement could cost lives was silly, alarmist and quite irresponsible.
Last month, the states reluctantly signed up to the Federal Government's forty-two billion dollar health package - sounds like a lot of money to me - with many claims that they were blackmailed, or many claiming that they were blackmailed into a lousy deal. Well, if that's a louse deal, please, give me one.
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