Interview - Dr Kerryn Phelps, AMA President, with Graeme Gilbert Radio 2SM, Tuesday 25 February 2003. Discussion: Reports of people who say they can no longer find doctors who bulk bill

GILBERT: We often get calls from people who say they can't find a doctor who'll bulk bill them, and with that goes the inference that people aren't seeing doctors as much as they, or as often as they perhaps should for the good of their health because they can't find, as I say, the GP who will bulk bill you.

Had a lady call the other night, you'll remember. The particular town she's in, there are 15 GPs but only one bulk bills. And the waiting list is so long. It sort of deters people from hanging around to see the doctor.

Today in the Sydney Morning Herald you may have seen an article that tended to link a drop in patient visits to the doctor to areas where bulk billing has declined the most. But the Australian Medical Association says that's not right. They say it's not the inability of doctors in bulk billing but simply a fact that there is a critical shortage of doctors across, particularly across, rural and regional New South Wales.

Joining us, the president of the Australian Medical Association, Dr Kerryn Phelps. Dr Phelps, how are you?

PHELPS: Good thanks, Graeme. How are you?

GILBERT: Not too bad. Now our sort of evidence would suggest that people aren't seeing doctors as much because they can't find one who'll bulk bill them. You're saying there's simply a chronic shortage of doctors.

PHELPS: I think it's a combination. I believe there is an affordability issue for some people, but there's no question that more and more people are going to have to rethink their priorities for their household expenditure and decide whether health care is one of the priorities that they're going to have to pay for out of their household budgets because bulk billing would continue to decline.

But I think perhaps of more critical importance is the issue of access. And that is where, if you were living in town and there are many country towns with either a shortage, or indeed in some cases, no doctors, then you will find it more difficult to be able to access a doctor.

Now there are a whole range of reasons for this, and many of them relate to the fact that general practice has become a very difficult specialty and it has a high administrative burden with relatively low rewards.

GILBERT: Yeah, and that's an interesting point, isn't it? General practice really has to some degree become a specialty at the moment. It used to be, without any disrespect, but it was sort of like the bottom rung, as it were of medicine. But these days, there's such a broad spectrum of skills needed by the GP, it's a specialty in its own sense.

PHELPS: Well young graduates, if they want to go into the specialty of general practice, have to complete specialty training just as you have to with any other specialty. It's in general practice that is virtually the only specialty that deals with the whole range of medical problems across every age group and particularly in the area of preventive and chronic disease.

Now it would only be your GP, for example, who would sit down and have a discussion with you about your immunisations, about whether you've had a pap smear, about your risk of colon cancer, about your risk of heart disease, would manage your diabetes, would look after your asthma, and could in fact deal with all of those things in one consultation and within the one practice setting.

So it is very much a specialty in its own right, and unfortunately the remuneration hasn't actually kept up with that recognition.

GILBERT: Now we have a couple of parallel issues here. And you and I have touched on some of them previously but individually. We know that we can't just train doctors over night. It's not even the case at the end of this year. It's eight or nine years before somebody is going to be qualified to practise. And also the issue of getting doctors to practise in regional and rural areas.

Does the Government need to step in? Do they need to look at things such as, you know, not providing a service number unless there's - I don't know - some sort of indenture done in a regional area?

PHELPS: Some of the problem in general practice is that government has stepped in too much.

GILBERT: Right.

PHELPS: And the Productivity Commission recently released a progress report looking at red tape in general practice. And they found that the - as a very conservative estimate - at least $10,000 per year per GP just to deal with the red tape. And you know, in fact, we estimated that if you halved the red tape, just from the Commonwealth programs, in general practice that you could probably find another thousand GPs in terms of the amount of hours it would save you.

So that's certainly an area that can do with some efficiencies. But if you're looking at the reasons why we have a shortage, I mean we have had in the past government intervention which said that we had an oversupply of GPs. Now that was counter to all of the intelligence that we had from out and about and from the grassroots communities and yet government policy was being dictated on that basis.

Now what we've been able to do at the AMA and one of the first things I did when I took over the presidency was to commission a report by Access Economics to find out how many GPs we actually have, but not just the numbers but what they're actually doing and what their plans are for the future.

And it's quite clear that, while we have a certain number of GPs who might be registered, doctors in the nation who are registered, it's what they're actually doing with their time that's important. And certainly this newer generation of doctors, both male and female, are not prepared to work in excess of 60 hours a week for the rest of their lives.

So we can't estimate a general practice workforce based on people doing that sort of hourly load per week.

GILBERT: Yeah, I was just thinking for people trying to put some sort of timeframe on this. You were talking about governments stepping in. Of course the Keating Government wound down the intake. We've now had three federal elections since then. People who went in in that last lot under Keating are really just now stepping into the workforce, aren't they?

PHELPS: Well that's right. I mean you quite rightly point out that, if somebody goes in say out of high school into medical school, that's six years of medical school, probably two years as an intern and resident and then they've got three or fours years at least of specialty training. So it is a long time before they are in independent practice.

But you know, when you talk about what governments do, government does control a lot of policy. For example, they set the number of student places in universities and we believe that that should be increased somewhat to meet the demands for the future.

They set the number of GPs who are able to train in rural and urban areas. They set the number of provider numbers that can be - where doctors can actually access Medicare for their patients.

So you know, government has a lot of hands on the levers as it were, and there is a very strong case for them to go back and look at the numbers again and indeed that's what they're doing. They are working with the AMA at the moment and the Department of Health on a workforce liaison group. So that we're trying to solve this workforce issue.

But quite apart from that is this bulk billing issue. And I do think that the Australian public are going to have to change their thinking about Medicare and about bulk billing because the notion that health care is free is a big, fat lie. It never was free. Our taxes pay for Medicare. And doctors who have accepted the bulk billing rate have been now accepting about a 50% discount on what their fee ought to be. And they just can't run their practices on what Medicare is prepared to pay on behalf of the patient.

So in having to charge a private fee, patients are going to have to learn that health care is not free. It's either from taxes or from household incomes. And the debate we're now having in our community is where that balance should be. Should some people pay more for their health care? Should others have a safety net that's provided by government out of taxes? Where should that balance lie?

GILBERT: But that's the thing, isn't it, and again you and I have discussed this before. In reality the Medicare levy needs to be probably at a minimum about 9%. But let's face it, governments aren't game to go to an election suggesting that we go up from - what's it at the moment, 1½% or something?

PHELPS: Yes.

GILBERT: Up to 9%.

PHELPS: Well you see most people think Medicare is paid for out of consolidated revenue or out of general taxes. Now the Medicare levy is really a way of charging some people a bit more. And if you want a bit more, you pay a bit more.

And that's one way of going about it. Certainly people are now paying a lot more out of their household incomes towards their health care but the concern that I have is that's the sickest people who are then paying more their health. And quite often they're the people who have their incomes limited because of their illness. So that's not share.

So we really are at the point and in the next few months I'll be making some presentations about how we can go forward into the future and sustain Medicare and provide a safety net for people who can't afford to pay more.

And I think that that's really where we need to have some vision and some firm direction from government because government does have a lot of control over the framework, if you like, in which we are able to deliver health care to people.

GILBERT: Yeah and parallel with that, because we get a lot of calls about it, where are the talks between the AMA and the Department of Veterans' Affairs in regard to the Gold Cards?

PHELPS: Well this is so frustrating. I talked to the Minister, Danna Vale, and she says, yes, yes, we have a commitment to the veterans. And the Prime Minister has a commitment to the veterans. But you know it seems to me it's getting bogged down in Treasury and the Treasury doesn't have a commitment to the veterans.

And unless they do and unless they're prepared to pay what the private treatment is worth that they have promised the veterans, then that system is going to fall over. And it really can't last past June because the GPs who have agreed to stay in the system an extra six months on the promise that things are going to be improved are not going to stick around after June unless the Government has done something about it by then.

And so, if we don't get a substantial announcement in the May budget, then I think we can see the Gold Card being - losing its lustre, put it that way.

GILBERT: And it'd be heart-breaking, wouldn't it? It would be almost unforgivable. I'm not saying against the doctors, but it would be unforgivable if the Gold Card did have to be downgraded?

PHELPS: Yes well the doctors have been hanging out for a long time now. I mean the Government knew that the current agreement was running out. They knew that - you see the problem once again here is that the amount that doctors are paid if they accept the Gold Card for veterans is like bulk billing but just a bit more. Instead of 85% of the scheduled fee which is too low anyway, it's 100% of a fee that's too low.

And so that had to be renegotiated and doctors are prepared, as a service to our veteran community, to provide them with effectively a substantial discount in any case. It's not at private market fees. And frankly, if the Government is serious about providing private style care through the Gold Card system to its veterans, then it should be paying what that fee is worth.

I mean nothing less is really acceptable. And we've got something like 340,000 veterans in Australia. It's not a huge number and most of them are very elderly. And I think that, you know, they've given war service and I think they deserve a better deal.

GILBERT: Yeah, they certainly deserve a lot more than we're giving at the moment. I mean as a community.

PHELPS: I think so. Look, the Department of Veterans' Affairs do a fine job. And within the constraints that they have, and they certainly do their best to look after the veterans. But if they're constrained by unrealistic budget restraints, then there's only so much they can do. And it really is down to the Government generally to say, are our veterans a priority and are we prepared to fulfil our promise of private health care for them? If they are, terrific. Let's move forward. If they're not, then the Government's going to have to wear that.

GILBERT: Yeah, and just finally a caller off air. I don't know if you'd have these figures or not, but they've asked, would you know how much is taken in by the Medicare levy and does it all go back into the health system or disappear into consolidated revenue.

PHELPS: The Medicare levy goes into consolidated revenue. It's not what they call hypothecated into health care. It raises - I couldn't give you the number off the top of my head...

GILBERT: Yeah, fair enough.

PHELPS: But certainly - I mean there is room to improve the health system by increasing the Medicare levy. And that's part of the AMA's budget submission. And most Australians I talk to who are thinking compassionate people say, look, I'd be prepared to pay a bit more if I knew that it was going to health care and if I knew that it was going to mean that we had security, particularly in our old age for our health system.

GILBERT: Yeah it's about time governments got serious about health. Always good to talk to you, Dr Phelps.

PHELPS: Nice to talk to you too, Graeme.

GILBERT: Thanks for your time. 'Bye. Dr Kerryn Phelps there, the President of the Australian Medical Association.

Ends