QIP/AgPAL Conference Melbourne

MELBOURNE

AMA PRESIDENT DR ROSANNA CAPOLINGUA

Maintaining Continuity in the Face of Change

This session asks us to consider how the healthcare arena is changing and what our response should be.

Being a GP, I see constant change in health care.

There is no doubt that general practice has changed significantly over the years and general practice today is very different to what it was, say, 20 years ago.

While the medical profession is sometimes portrayed as conservative, there is no doubt that it is prepared to embrace change if it is for the better and patient care is the winner.

The medical profession is innovative and is behind the development of new medical technology, pharmaceutical, diagnostic procedures or treatments.

Progress in medical care means we can do much to treat infection, fight cancer, repair or replace failing organs, and delve into the inner workings of the body.

We have better systems in place to ensure the safety and efficacy of medical procedures and therapeutic treatments.

We have world-class accreditation of medical training.

We have recognised standards of practice, principles of best practice, and mechanisms for improving communication and the transfer of information between medical practitioners.

We have also learned to work differently. The profession has embraced team-based care, and new specialty areas have developed over time.

The face of the medical profession is also changing. More women are entering the medical workforce, there are more doctors with postgraduate medical degrees, and our male graduates also want a better work life balance.

More and more practitioners, both male and female, are working fewer than six sessions per week.

We will shortly lose many older doctors who grew up on a regimen of 60-hour weeks.

Recent BEACH studies show that more than 35 per cent of GPs are now over the age of 55. As these doctors retire, unprecedented pressure will be brought to bear on the medical workforce.

Our patients have changed, too. They are more informed than ever and often have very different attitudes to health care, sometimes preferring convenience over continuity.

Patients have a growing expectation of successful outcomes in their diagnosis and treatment. Our patients increasingly are ageing and suffer multiple conditions.

BEACH studies show that the number of problems managed at an encounter with a GP increase steadily with the age of the patient and that more than a third of the problems managed by general practice are chronic in nature.

The most obvious recent change in the health care arena is the election of a new Government.

It has now set out to implement its policy agenda and general practice will face more change.

Some commitments are particularly relevant to GPs including:

The establishment of the Health and Hospitals Reform Commission,

The development of a primary care policy and increased focus on preventative health,

The simplification of Medicare,

The introduction of GP Super Clinics, and

2000 additional transitional care places

More recently, the Government - along with the States and Territories - has agreed to create a single national registration and accreditation system for nine health professions.

This will cover medical practitioners; nurses and midwives; pharmacists; physiotherapists; psychologists; osteopaths; chiropractors; optometrists; and dentists. One big soup!

I want to make sure people understand the AMA's position on national registration and accreditation.

Let me be very plain and clear about this, the AMA has long been a supporter of a national register. We believe there is a simple, affordable and non-controversial way to achieve this.

However, the changes to National Registration and Accreditation contained in the Intergovernmental Agreement - the IGA - are NOT routine or uncontentious.

At stake are the most fundamental issues about who can be registered as a medical practitioner, who controls the registration decisions, the scope of practice of medical practitioners defined by registration, what qualifications are necessary to be registered as a medical practitioner, and who sets the standards for registration and accreditation of medical training.

The COAG IGA moves all these decisions away from profession-dominated or independent processes into a Government-controlled bureaucratic environment with specific workforce reform/substitution objectives.

Throughout the whole discussion of this issue, from July 2006, the AMA has consistently raised concerns about the need to maintain the independence of accreditation of medical education courses and medical training.

The need for independence is recognised by the World Health Organisation and the World Federation for Medical Education.

This independence is necessary for the maintenance of the highest standards and to assure quality and safety of delivery of care to patients.

Despite this, COAG has diluted the independence of the Australian Medical Council and its decisions will now be subject to bureaucratic and Ministerial control.

If, having regard to Government workforce reform agendas and other objectives, they prefer quicker and easier to complete medical degrees, which cost less money and provide less quality, they will now control the process to enable them to do that.

The AMC is no longer a bulwark against such a decline in standards. The loser in the end is the patient who gets the inferior care.

All sorts of non-equivalent medical qualifications could be approved in the name of workforce shortage or workforce reform.

The AMA unequivocally supports national recognition of registration based on harmonised State and Territory law and the maintenance of a national register so as to assure the public that only safe, qualified and competent doctors are on the register and can work across Australia.

COAG favours a more centralised bureaucratic, high cost solution to achieve this aim.

We favour a simpler cheaper way of achieving the same thing. After all, patients pay all the bills in the end.

Government has overstated the benefits of its national registration scheme in sorting out rogue doctors.

It is already possible to look at a medical registration register on line and to view any restrictions placed on the doctor. These restrictions go with the doctor if he or she moves interstate.

However, if an employer does not look at the register before employing a doctor, the restrictions will not be picked up under any sort of scheme.

More effort should go into ensuring employers look at the register before they make a decision.

The greatest protection against rogue doctors is to have the highest standards of medical training in the first place.

Australian medical training is amongst the highest in the world and Australian doctors pass entrance examinations to work in comparable OECD countries at close to the 100 per cent rate.

The AMA supports reasonable measures to identify rogue doctors and prevent them from practising, such as has been put forward in New South Wales.

There has to be greater encouragement of doctors to report instances of gross misconduct or gross negligence. There has to be greater protection of doctors who report their colleagues in these instances.

Our opposition to COAG's national registration and accreditation proposal is not motivated by the protection of rogue doctors from disciplinary action.

Rather, we believe the new arrangements will not assist in dealing with rogue doctors, and may be less responsive than existing processes.

The COAG proposals will not deal with rogue doctors per se.

The existing Medical Boards all have well-developed mechanisms and procedures for dealing with rogue doctors once they become aware of them. The weakness is in becoming aware of their activities in the first place.

There was a low level of consultation by the previous Government.

Despite making our concerns known to COAG in March 2008 and requesting further consultation with the medical profession prior to a decision being announced, no attempt to consult the medical profession was made by the current Government.

The AMA cannot support the COAG scheme for Medical Registration and Accreditation as is defined by the IGA.

So what does the AMA want? We want:

The introduction of an improved rapid response mechanism for handling cases of gross misconduct and gross negligence by medical practitioners,

The establishment of a national medical register to be managed by the existing medical registration boards,

Uncoupling national registration from the workforce reform agenda. This agenda treats health like any other commodity in the market when we all know the issues are different and the consequences for people are very grave, and

The independent AMC to continue to perform the accreditation function for medical education and training independent of Government, the medical schools and the medical profession to keep standards high across the board.

When Australians get sick, they want to see the doctor. If the Government wants to stop or limit Australians' access to doctors, they should come out and say so.

People in some parts of Australia are struggling to get access to GPs.

The AMA identified this problem some time ago and has lobbied to extensively to boost the GP workforce - not just through more graduate numbers, but through better retention policies and improved remuneration.

The former Government put in place measures to double the output of medical schools, and we must work to ensure that many of these new doctors choose a career in general practice.

There is an urgent need to fund more opportunities for pre-vocational and vocational training in general practice. By giving people a taste of what general practice is really like, we allow young doctors to make their own minds up about being a GP.

We must also stop talking down the role of GPs.

General practice is a rewarding career by any measure. GPs are blessed with a variety of clinical work, opportunities to pursue special interest areas, better work-life balance, and flexible training opportunities.

GPs can also claim to have responsibility for a person's health care from the cradle to the grave. The reward of developing a long-term relationship with patients and their family is immense.

We cannot let Governments undermine the role of GPs.

Current issues around access to care should not be addressed by task substitution and the fragmentation of health care into compartmentalised tasks. This will not improve patient care.

Health system reform must be evidenced based and clinically driven to ensure it is change for the betterment of patient care. Clinically-informed and driven reform will always be patient focussed. Patient care and the clinical priorities in delivering that care must be paramount. Reform must be patient-focussed and not influenced by political ideologies or bureaucratic concerns for cost containment. Maximising quality patient care and properly resourcing service delivery must be our objectives.

The task substitution agenda places on others the responsibility of a profession when they do not have the competency of that profession.

This is unfair on all involved - the doctor, the provider and the patient.

Task substitution will not allow for the all-important clinical engagement with the patient beyond the carrying out of the 'task'.

The AMA fears patient health outcomes would deteriorate as a result.

We as medical professionals cannot wash our hands of our responsibilities to our patients. We must ensure medical competence drives service delivery for the patient's sake.

GPs have embraced new models of service delivery.

The integration of practice nurses into general practice has been an enormous success.

GPs work extensively with allied health professionals to ensure patients get the care they need.

The fundamental key is that the GP is at the centre of the patient's care.

The patient gets a medical diagnosis and the GP is responsible for coordinating the patient's care. This is the right model and it's a model we can build further upon. There is little doubt, for example, that we could expand the role of practice nurses for and on behalf of GPs.

GPs are increasingly working in larger practices - offering multi-disciplinary services.

Recent BEACH data shows that since 1998/99 the number of GPs working in solo practice has declined by half and, increasingly, more GPs are working in practices of five or more practitioners.

There is no doubt that this is a more sustainable model and many benefits will flow from it. Clearly, the profession is responding to pressures for better work-life balance and special interests.

Patients like it as well because of its convenience. Again, this is about the profession finding clinically-driven responses to the challenges it faces.

Chronic disease for the most part belongs to the aged but increasingly, with the rising incidence of obesity and our sedentary lifestyles, its prevalence is shifting into younger age groups.

Chronic diseases detected and treated in their early stages are far easier to manage. In many cases, the old adage of 'prevention is better than the cure' remains the same today especially in light of this increasing burden of preventable chronic disease.

Medicare will need to better accommodate the provision of preventative health services.

Helping the Government to understand the resources, capacity, infrastructure, and workforce needed to place an emphasis on the prevention of disease as well as its treatment is one of our challenges - not only for the future, but for the here and now.

GPs need to be supported in spending time with their patients, to hear their concerns, and discuss appropriate actions or solutions with them, especially when we talk about reducing the risk of chronic disease or managing chronic disease.

Engaging patients in the management of their health involves the doctor spending more time with the patient.

We know that with the increasing age of the population we will need better care arrangements for older Australians.

The aged live longer due largely to the wonders of modern medicine. But without appropriate facilities and services, what will be the quality of that life?

There must be significant Government investment in capital funding to ensure that sufficient infrastructure is in place to meet future demands for residential aged care and community care. We know that.

We also know that the simplest way Government can assist the aged is by ensuring GPs are supported to visit them either in their homes or at their residential aged care facility.

The challenge here is that there will be a greater number of people who can't get to the doctor's surgery.

We are going to have to have to think about how these people will be able to access the medical care they need. Perhaps GPs and their team will have to be more mobile or alternatively, we might need to get more creative in ways to bring patients to the GP.

This will have an impact on practice costs for time lost travelling to and from the surgery.

Medicare rebates will need to be improved for services provided outside of consulting rooms.

There will be more non-face to face time in managing the complex care needs of older Australians.

There will need to be facilities and IT resources where the patient is so that they can be provided with the same medical care they would have received had the patient been able to attend the surgery.

There must be technologies to enable the GP access to the patients' charts and medical records from a remote location.

GPs' work time unfortunately is not able to be wholly devoted to patient care due to the imposition of bureaucratic red tape.

Doctors' time must be freed from these constraints as much as possible in order to let doctors practise medicine.

The Government is sometimes confused about what the solutions are. For example, GP Super Clinics are hailed as the saviour of public hospital emergency departments under the false assumption that they will reduce the number of patient presentations.

We know that GP type presentations to emergency departments take up only around one per cent of resources.

The challenge for us is to help Government to gain clarity.

Improving patients' access to their GP and supporting that GP in preventing chronic disease or its advancement is one way to keep patients out of hospital.

Assisting GPs in providing after-hours services and streamlining the after-hours Medicare items to reduce the red tape is another.

The AMA has engaged the Government in constructive dialogue with regard to Super Clinics.

The real solution to many of the issues faced in these changing times is to empower GPs across the country to offer patients access to a wider range of services, whether that be directly or through a team of health professionals led by the GP.

Improving the communication platform between medical practitioners, allied health professionals, and medical institutions is another important step in facilitating quality health outcomes for our patients.

The e-health agenda is gaining momentum.

Maintaining the principle of quality patient care will be vital in the development and success of safe and secure pathways for transferring relevant patient information to practitioners, service providers, and care givers.

e-technology provides an environment for improved communication between medical professionals where medical records can be shared, diagnostic images can be viewed remotely, as can patients, consults can occur and prescriptions refilled via the internet.

These are developments that will be vitally important in assisting GPs and specialists to provide quality care to patients whether it is in their home, across the State, or across the country.

The challenge for us is to ensure mechanisms are in place to protect patient's privacy, ensure the appropriate use of these services, and appropriate recognition and remuneration for the service provided.

There are many challenges ahead for general practice.

The AMA will provide the leadership to ensure that patients get the best possible care from these challenges.

Thank you.