Interview - Dr Kerryn Phelps, AMA President, with Jeremy Cordeaux, Radio 5DN

CORDEAUX: What brings you to town?

PHELPS: Well, I've come to town to attend some retirement functions for one of Adelaide's great doctors, Dr Michael Rice.

CORDEAUX: Oh, yes.

PHELPS: He's in charge of children's cancer care at the Women's & Children's Hospital in Adelaide. And there was an event last night at Government House, hosted by Marjorie Jackson, your Governor, and we have a symposium on today, which will be in honour of Dr Rice, who is the former AMA South Australian President.

And I've also, while I've been here, been visiting at one of Adelaide's oldest general practices in Beulah Park, …

CORDEAUX: Mm.

PHELPS: … and talking to them about their difficult decision to stop bulk billing.

CORDEAUX: Do you think we can afford to let Dr Rice retire?

PHELPS: Oh, I think he's going to be a great loss. But I'm certainly not going to let him retire from the AMA. I've already put him in charge of developing child intervention policy for the AMA. And he'll be doing a lot of work along those lines to ensure that the medical profession is consulted and is able to lead change in terms of what we can do for child health in this country.

CORDEAUX: Mm. In the paper this morning there's the story about, "People will have to come to terms with queuing and rationing", so it's not going to get any better. And if there's anything that is talked about on a program like this more frequently than health, I don't know what it is.

PHELPS: I think that the idea that the Governments have just really given up the ghost on health funding and saying that, you know, "If you want to keep having a health service, you're going to have to just lower your expectations"… really runs counter to everything that I believe about a health system. Which is that providing better health and adequate health services to meet the needs of our population reaps benefits in terms of productivity, in terms of people being healthier and able to enjoy their lives more.

And ultimately, I think, it's in the best interests of our community to have a

health system that meets the needs of the people. Now, we have a growing ageing population - we have more people who are requiring medical care as they get older. Now, if they keep those people well by investing particularly in preventive health, but in also making sure that they get the health care they need as they get older the whole community benefits.

To talk about rationing and increasing waiting lists as a way of managing the health system, I think, is very heartless.

CORDEAUX: Yeah. And it runs counter to logic. Because you keep hearing these stories about people being turned away from hospitals, ambulances arriving and they're just turned away because there's no room, yet they have closed down a ward, they've closed down beds. Where is the logic? If you've got people coming looking for the service, you don't cut down the service, surely?

PHELPS: It comes down to not what is needed, but what the Government is prepared to pay for. And I've been saying for some time, and we have a strong economic argument backing us up, that maybe Australia isn't spending enough of its Gross Domestic Product, its GDP, on health.

CORDEAUX: How much do we spend?

PHELPS: We spend 8.5 percent of our Gross Domestic Product on health, which is certainly not up there with America, although I think we have a better health service than America for the money that we spend.

CORDEAUX: God, I think so. You hear some terrible stories coming out of America.

PHELPS: Well, there are forty-four million uninsured people in America …

CORDEAUX: Yeah.

PHELPS: … and you can imagine how many disadvantaged people that leaves out in the cold when they have health care needs.

CORDEAUX: Why do I get the feeling that it wouldn't much matter how much money you put into the health system or the sickness system, it would never be enough?

PHELPS: Well, it would be enough. Of course it would be enough.

CORDEAUX: What would be enough? What would you put on your wish list? What should we be spending on health?

PHELPS: Probably a little more than we're spending now.

CORDEAUX: Only a little more?

PHELPS: Yes. I think if we went up to around nine point five or ten percent of GDP, the information I have is, that that would go much closer to meeting the needs that we have at the moment.

CORDEAUX: The other thing is to what extent, if I get sick, is it my right to expect heroics? I mean, how much money should the system be prepared to spend, say, keep me alive? It could be-- if somebody said, "Well, look, we can save him, but it's going to cost six million dollars", well, clearly that's not in the public interest.

It's not my right to say to the system, you know, "I don't care what you spend, I want my wife to have a baby. Spend five hundred thousand dollars to get her pregnant". I mean, where do you draw the line?

PHELPS: Well, I think that the line is drawn every day of the week. And people, as individuals, have to make decisions about what sort of medical care they want. For example, if someone has got cancer, on an individual level they'll be given the options.

They'll be told that if they take a particular type of treatment then it may increase their lifespan by so many years but, what will it do to their quality of life. And individuals are making that decision all the time. It's not just about money, it's about quality of life, it's about what is achievable and that's a conversation that doctors have to have with patients all the time.

If you increase much more, the argument that we're having about the economic aspects of health, that of course has to be considered, but it shouldn't be the primary motive when you're making a decision about somebody's life and death.

CORDEAUX: Yeah.

PHELPS: And the point is, we do spend more amounts of money on people in the last few years of their lives because that is what a compassionate society does.

We don't cast people out in the snow to walk until they drop dead; we look after people, we care for them.

There are all sorts of different options for looking after people in their final years and, that's certainly something that we can look at in terms of efficiency and compassion. But to say to people, "You cannot have a treatment that we know is available because we're not prepared to pay for it", I mean that's a pretty tough call.

CORDEAUX: If you take the prescription, the subsidised … the taxpayer subsidised prescriptions, I think that blew out four billion dollars or something like that.

I mean, to what extent are we to expect the latest CAT scan machine, mirror-imaging machine? To what extent do we have the right to expect drugs that are-- we want them free and they may cost fifty dollars per tablet. There is a finite-- the resource is finite, isn't it?

PHELPS: Of course, it's finite and I think all of those public resources have to be managed prudently. And in particular, if you're talking about the Pharmaceutical Benefits Scheme, that is a mainstay of good quality medical care for every Australian in this country.

CORDEAUX: But am I entitled to want the very best for free?

PHELPS: Decisions have to be made and they are made on the basis of effectiveness, of safety, of what is available, there's usually a range of medications available.

But if you're, for example, looking at an expensive medication for the treatment of acute leukaemia, something that will save somebody's life and they will go on to have more productive years with their children and their grandchildren …

CORDEAUX: Mm.

PHELPS: … and in their workplace, and that they have to have that treatment maybe for a few years to cure them, to give them a chance at life, then that's a decision that has to be weighed up. And I think most families would say it's worth it. But what we don't want is a situation where the wealthy can afford treatment and the poor are left begging.

What is the controversy that's going on at the moment with regard to bulk billing. Less and less or fewer and fewer practices are doing it, is that the story?

PHELPS: Yes, that's the story. And, really, it is something that has to happen. It is the result of the Government failing to keep up to pace with the cost of providing medical care in terms of what it deems to the Medicare Benefit Schedule, which is the fee the Government sets for the rebates for medical care.

And general practices are saying that they can't continue to maintain the services in their practices by paying staff, providing the cost of premises, all of the dressings and supplies and everything else that they have to pay to run a practice, like any small business, and accept the bulk billing rate, which is only eight-five percent of the scheduled fee, which is already way too low.

CORDEAUX: So where do we go from here?

PHELPS: Well, I think patients are increasingly going to find that their general practices are going to be privately billing them rather than bulk billing them, and that's just, I guess, something that patients will have to become accustomed to. Our concern is for people who are disadvantaged and who might have to think twice about going to the doctor because they don't have the money upfront.

CORDEAUX: Yeah.

PHELPS: Doctors, of course, will do as much as they can to try to assess when people are disadvantaged and make some arrangement with them, but it shouldn't really be up to the doctors to subsidise Medicare.

CORDEAUX: And the professional negligence insurance issue won't go away, I gather.

PHELPS: There is a very great crisis looming in our country unless we can get a solution to the medical indemnity crisis. The Federal Government has been working very hard on trying to find a solution and they've been having discussions quite extensively with the AMA, on behalf of the medical profession, to try and find a solution.

It's up to the State Governments, also, to do what they can to reform the laws around negligence, to, for example, define what negligence actually is, because that shouldn't be defined by courts, it should be defined by the medical profession. And also too, I think, for the people in the public to think to themselves, "If I have an adverse outcome, if something goes wrong during my medical treatment, do I need to look to blame somebody or do I want the problem fixed?". And, frankly, we think that the practical way of going about it is to make sure that people who are injured get the care that they need.

CORDEAUX: Yeah. But to go back…what, is it 25 years people can go back?

PHELPS: That's right, they can sue for 25 years. If it's a birth injury, for example, a minor can still sue for almost in perpetuity in some states. So we need to have what's called a statute of limitations …

CORDEAUX: Yeah.

PHELPS: … or a limited period of time from when an injury or a problem is discovered

CORDEAUX: Yes.

PHELPS: … that the patient can actually sue their doctor.

And I think that we need to have different ways of managing adverse medical events or things that go wrong rather than people dragging each other through courts. What people want is an explanation, they …

CORDEAUX: Yeah.

PHELPS: … often want an apology and they want to be looked after.

CORDEAUX: Yeah. Yeah.

PHELPS: And if we can find a way of doing that practically and efficiently, then that's

ideal.

CORDEAUX: Obstetrics is one of those fields of medicine that seems to be most affected. And are we really saying that a woman is going to give birth without an obstetrician and she's better off than having an obstetrician who will simply do his best?

PHELPS: Well, that is what you would think, but the medical indemnity crisis is forcing obstetricians out of business. And we're seeing this really starting to hit hard, now, in New South Wales and Queensland where the indemnity crisis has hit first; but it will come to South Australia as sure as night follows day because the litigation system in Australia has gone crazy.

CORDEAUX: Yeah. Yeah. But wouldn't I be better off with a negligent obstetrician than no obstetrician?

PHELPS: Well, I think a negligent obstetrician is extremely rare. Things can and do go wrong. because it's a very volatile business having a baby, …

CORDEAUX: Certainly.

PHELPS: … things can go wrong. If you have an obstetrician who is experienced and you're in their hands, they're well trained, then you have less risk of something going wrong than if you don't have an obstetrician.

CORDEAUX: Yeah. Yeah.

PHELPS: But we are fast reaching a stage where many women will not have access to an obstetrician because we don't have junior doctors lining up to train for obstetrics because of this crisis. And we've got our senior people, who are maybe forty-five, in the peak of their careers, who are saying, "I just don't want to do this anymore". And, you know, why should they take the risk of being sued, …

CORDEAUX: Yeah.

PHELPS: … getting up in the middle of the night, being on call twenty-four seven. And it's a difficult lifestyle, it's one they choose to do because they just love what they do … but they are weighing up their options now and saying it's just all too hard.

CORDEAUX: If any doctor is involved in what you might call orthodox medical practice or procedure and something goes wrong, what is the claim for negligence?

PHELPS: Well, quite often doctors are being sued for things that go wrong, and one of the areas that they are often being sued is failure to warn of complications that might occur in one in a hundred thousand cases. Now, it's very hard for a doctor to prove that they did warn the patient. They were sitting in their rooms and they said, "Now listen, Mrs Smith, if we do this particular operation, this is a possible outcome that is an adverse event" …

CORDEAUX: Yeah.

PHELPS: … now it's only the doctor's word against the patient's in that event. Doctors are moving more and more to providing that information in writing.

CORDEAUX: Sure. But can't I sign something which simply says, "I expect that you will employ orthodox medical procedures and that you will do your best", and that is my…and that is the disclaimer?

PHELPS: Well, the Government commissioned a report, which was chaired by Justice Ipp, and that did recommend a return to what's called the Boland Principle, where if a doctor behaved in a way that any reasonable peer would have considered an appropriate way to behave in practice, …

CORDEAUX: Yeah.

PHELPS: … then it's not considered to be negligent, and so we don't have lawyers trying to redefine how medical practice should be conducted.

CORDEAUX: Caller 1, hi.

CALLER 1: Good morning. I'd like to say this morning, Jeremy and to you, Dr Phelps that a very important point has just been made by the Government, that they've said to the medical insurance that they can raise their fees according to the CPI. Now, if that is so with them, why can't they raise the doctor's patient fee according to CPI or whatever, because if it's good for the goose, it's good for gander.

PHELPS: You make a very good point, Peter. And I have to tell you, I think we're probably going to be seeing the health insurance funds still having to go to Government for permission to increase their premiums. Because the cost of providing hospital and medical services does not go up with CPI, it goes up in excess of CPI, so I think we're still going to see the health insurance funds having to approach Government for permission to go up by more than the CPI.

When you look at the Medicare Benefits Schedule, you're quite right, I mean it's starting from an inadequate base anyway. It's about half the level that it should be at the moment. And even if it was increased by CPI, which it isn't and hasn't been for the last 20 years, it's still going to be behind the eight ball.

So I do not think that we are going to see a solution to the bulk billing problem. I don't see any solutions coming from either side of Government at this stage. And I think that doctors are simply going to have to be charging a private fee whatever happens with the Medicare Benefits Schedule. But it's up to voters to approach their local MPs and say, "Listen, I don't want to have to be paying increasing gaps for health care, what is your Government going to do about this?".

CORDEAUX: Hi, Caller 2.

CALLER 2: Hello. Good morning.

CORDEAUX: Morning.

CALLER 2: I'd like just to raise another point. My wife, she had a stroke two years ago, and she's not able to use her right arm at all, she can hardly walk, you know? She had a bad stroke; she was in Hampstead for about four months. Anyway, she's now torn a ligament in her left arm, in the shoulder, and she's had x-rays, she's had ultrasound, and the results went back to the doctor and she said that she'll have to see a specialist because she thinks she might have to have an operation.

So I got in touch with Lyell McEwin, or the doctor got in touch with Lyell McEwin; we had a letter back to say that my wife won't be seeing … couldn't see a specialist not for nine months. Now, she's in pain, and she's got enough to do with the stroke, and it seems for her to have to wait nine months to get in to see a specialist, it seems wrong to me.

CORDEAUX: Yeah, I think if Dr Phelps could wave a wand and do something to help, she would. But what can be done?

PHELPS: Well, I certainly would, Ron. What I'd suggest you do is to talk to your GP and say, "My wife can't get into this particular doctor". What GPs will often do is to do a bit of ringing around to other shoulder specialists perhaps and see if they can get your wife squeezed into an appointment earlier than that so that she can have the treatment that she needs, because obviously your life and hers is going to be miserable until you can get this problem fixed.

And it's simply not fair. Making people like you and your wife wait for nine months for an appointment for an operation is jut not on.

CORDEAUX: Dr Phelps is my guest, and you can join us if you'd like to on 8305 1323 here in the Court of Public Opinion, where it's nine to eleven.

CORDEAUX: You talked about the baby boomers and the demands that they are going to make progressively on the system. Then we've got people who do harm to themselves, lifestyle choice-type harm things. You were involved in the Obesity Summit, weren't you?

PHELPS: Yes, in the New South Wales Parliament yesterday, I spoke at the Childhood Obesity Summit, looking at what community members can do in terms of taking responsibility for this growing social and health problem.

CORDEAUX: Yeah.

PHELPS: We are looking at a time bomb.

CORDEAUX: Yes.

PHELPS: I think that children who are allowed to become obese through poor diet and lack of exercise, it's a form of child abuse. And I don't believe that, as a community, we can tolerate this any longer because it is setting these children up for a lifetime of ill-health.

We're seeing children getting diseases in their childhood that they shouldn't be expecting, if at all, until middle age, things like Type 2 diabetes, problems with their hips and ankles and joints, because of being overweight-- liver problems, gastro-oesophageal reflux.

Now, apart from all of the social implications that children might have from being overweight, …

CORDEAUX: Mm.

PHELPS: … it's also just not fair on their health as they grow older. And I think parents, schools, governments, the medical profession, whoever is in a position of some influence--

CORDEAUX: Sure. And this business-- and television-- because you look at the stuff that is being promoted to those kids.

PHELPS: Well, we'd certainly approve-- the AMA would approve of a national approach to a review of the advertising industry, which should be an independent review looking at the way junk food and foods in general are promoted to children and what effect that has on children's habits.

But parents also need to fight a bit of a rearguard resistance action here, because parents control the family finances, they do the shopping, they determine what is in the fridge and the kitchen cupboards, …

CORDEAUX: Mm.

PHELPS: … they control what pocket money children get, and so parents are in a much greater position of influence than many of them choose to exert.

CORDEAUX: Yeah, sure.

PHELPS: Now, parents can only-- can choose to have rubbish food in the house or they can choose to have only good food in the house. And the children will make healthier food choices and be healthier …

CORDEAUX: Yeah.

PHELPS: … if they're getting good role modelling from their parents and if their parents actually take a stand on this.

CORDEAUX: Yeah. If you're going to ban advertising of cigarettes and control the advertising of alcohol, you have to have a similar attitude towards junk food and fast food.

PHELPS: Any food in general. I mean we can, as a nation, look at food as the essential fuel of our next generation.

CORDEAUX: Yeah.

PHELPS: And we can either say it's OK to be promoting all this rubbish food - but we know what it's doing to our children's health, or we can say-- even talk to the manufacturers of foods and say, "There must be ways that you can make this food fast and healthy".

CORDEAUX: Yes. I'm sure there is, yeah.

PHELPS: There's nothing faster than picking up an apple, for example.

CORDEAUX: Absolutely. It just doesn't seem to have the fat in it though and the fat seems to make it taste good.

Do you-- from general practice to medical politics, do you miss practice?

PHELPS: I practise three to four days a week still.

CORDEAUX: Do you really?

PHELPS: Yeah.

CORDEAUX: How do you find the time?

PHELPS: Well, I quarantine the days that I practise, and it's usually in the earlier part of the week. And I do my share of Saturdays because I have a team of GPs that I work with in Sydney, near the city.

CORDEAUX: Mm.

PHELPS: And we have a terrific team, we all work well together, and they understand that what I'm doing is important for the profession and they're very supportive of that.

But my patients I see at least on three days a week, I assist a surgeon one afternoon a week, and so I'm very much, still, involved in clinical practice, and the medical politics I do in parallel with that.

CORDEAUX: How many approaches do you get from both sides of politics to become a politician?

PHELPS: I get the odd suggestion.

CORDEAUX: Any ambition?

PHELPS: I don't think that that's the direction that I want to take. I'll never say never, I've been around too long to say never, but at this stage it's not in my plans.

CORDEAUX: Doctor, good to see you.

PHELPS: Thank you, Jeremy.

CORDEAUX: Enjoy your stay in Adelaide.

PHELPS: Thank you very much.

CORDEAUX: Dr Phelps, President of the AMA.

Ends