The Quest For The Medical Dream Team

May I first say 'Happy 10^th Anniversary' to Government members here this morning. I'm sure it will be a long and joyful day for you celebrating a decade of Howard Government.

For Opposition members it is perhaps a not-so-happy 10th anniversary - more like a time to reflect and regroup for the battles ahead.

And for the minor parties and independents, may you continue to 'keep the bastards honest', whoever is in power.

This morning I could talk to you about many aspects of the Australian health system - the good and the not-so-good.

I could talk to you about the challenges of mental health ahead of the major COAG announcements later in the year. There was a welcome sense of cooperation between the Commonwealth and the States at their last meeting - especially on health promotion and illness prevention.

I could talk about the continuing crisis in Indigenous health, which I acknowledge is receiving a trickle of positive attention as we await the torrent of commitment that is truly needed.

I could talk about nutrition and obesity. This Week's ABS National Health Survey shows that we still have big problems with obesity, but also with smoking and alcohol abuse.

Aged care remains a major issue worth talking about. The elder abuse in nursing homes is horrific. We need to respect older Australians and provide greater assistance to the people who care for them.

Environmental health and climate change remain major concerns of the AMA and the community.

I could talk about child and youth health. It is our duty to help our kids get off to a healthy start in life. The Government has made some moves in this area, and Labor recently released its bold blueprint on children's health. It is an area getting deserved attention.

I could talk about health care for asylum seekers. There have been some big changes since this time last year. We have seen the release of children from detention. And Victoria, my home State, was the first to give refugees access to health care.

I would love to talk at length about the indexation of the Medicare Benefits Schedule - one of my favourite topics. Like you, I could go on and on forever about this…but I won't. Not today, anyway.

I could talk about electronic health initiatives. This is a riddle. We have some great technology tied up with stacks of red tape. The AMA has the knowledge and capability to help the Government realise the benefits of e-health. We must get it right. So please call us, Tony. Call us, Joe. We are here to help.

I could talk at length about the Pharmaceutical Benefits Scheme. We need to maintain access to quality affordable drugs in this country. AMA members prescribe every day of their working lives. We see first-hand the struggles of working Australian families as they balance the need for medicines with two safety nets and the threat of higher and higher co-payments.

I could even talk about a flaw in the WorkChoices Bill that could allow veterinarians to issue sick leave certificates. Yes, that's right. If the Bill goes through as it currently is, workers in the ACT, for example, could quite literally ring work and say: 'Won't be in today, boss - I'm sick as a dog'. But I won't talk about that here this morning.

I know all these subjects are of interest to you. All these subjects affect the people in your electorates.

But this morning I will limit myself to one major topic - the medical workforce.

Without a highly skilled medical workforce in the right numbers, all the programs I have just run through cannot be effective.

There is one simple fact about health: when people get sick, they want to see a doctor - a medical doctor. Despite what others are saying - a doctor is a doctor is a doctor. This still rings true for the great majority of Australians. It resounds across the country, and around the globe.

The political and medical solutions to the medical workforce shortage must ensure that access to doctors and professional high quality scientifically-based care is maintained.

We have to train doctors in the right numbers. We have to attract doctors to work where they are needed. We have to provide workforce support for doctors. And we must ensure that there is leadership in any health care team. And that leadership must be provided by the comprehensively trained, most highly skilled members of the team - the doctors.

Leadership is not a new role for doctors. The difficult life-and-death decisions and quality of life decisions - and the final responsibility for care - have always been the lot of the medical practitioner.

You will all be aware that some State Governments, and now COAG, are keen to fill medical workforce gaps with non-medical people. The AMA is opposed to this.

Some have accused us of 'turf protection'. I can tell you it is not 'turf protection', it is 'patient protection'.

All Australians - no matter their means or where they live - deserve to be able to get to see a doctor when they need one. They demand and need a medical diagnosis from a registered medical practitioner.

There must be equal access to the best possible health care, and the gateway to that care has to be the local family doctor, the GP.

GPs are highly trained, they are skilled at diagnosis, and they are skilled at managing simple, complex and chronic health conditions. They can detect what is abnormal in a patient's health and then help them negotiate the healthcare maze.

If your health requires particular expertise, your GP will help you see a health professional with the most appropriate skills for your condition.

Australians make, on average, 11 visits to the doctor each year. The average GP consultation is about 15 minutes face-to-face. Non face-to-face time is about five minutes per patient.

For that, you get excellent holistic care and continuing management. And all for less than $200 per person a year, on average. It's more affordable than most other services in Australia, let alone professional services. It's great value for holistic care, continuity of care, and the comfort and security of the doctor-patient relationship.

Now, the AMA is all for more clever ways to use the entire health workforce to fill the gaps where there are no GPs, too few GPs, or where the GP resources are stretched.

It is already happening. The health system is evolving all the time.

In the last couple of years, the Australian Medical Council has been asked to approve new specialties in:

• Sports and Exercise Medicine
• Pain Medicine
• Palliative Care Medicine
• Addiction Medicine
• and Rural and Remote Medicine.

Nothing stands still in health. Optometrists now do a lot of refractions previously done by ophthalmologists. Midwives are doing antenatal care and normal deliveries. Practice nurses in general practice settings are now routine - even in my practice.

And there are many new opportunities to further improve care delivery. Under the direction of the GP, general practice nurses can become more involved in the delivery of medical services to the aged, particularly in residential aged care.

Psychiatrists are looking at ways of working with allied health professionals in the delivery of mental health services. If we can get this right, we can extend the reach of the psychiatric workforce whilst increasing their numbers, which takes time. They currently work in teams, and will continue to do so. But, again, the psychiatrist has to be the key decision maker for mentally ill patients.

All this is being achieved under existing Medicare Benefits Schedule (MBS) arrangements.

Opening the MBS up to another 200,000 providers - as advocated in some quarters - is not responsible or sustainable.

It is barely able to cope with rebating services from current providers.

The AMA team-based care model is both practical and affordable.

The models being put forward by COAG, the Productivity Commission, and the States are based on substitution - somebody else taking the place of a doctor. They want somebody other than a doctor to perform what they term 'low risk' or 'normal' tasks. Where human life is concerned, there is no such thing as 'low risk' or 'normal'.

A doctor is trained to expect the unexpected and detect the otherwise undetected. These skills are a long time in the making and the acquiring. The question for patients is: who would you prefer to read and interpret your X-rays or analyse and explain your pathology results?

I think - I know - the answer is 'my doctor' and the experts he or she can call on.

The AMA model is a collaborative model designed to deliver the best medical care to patients. It is all about flexibility - a sharing of duties based on skills and experience - but the ultimate responsibility of patient care rests with the team leader, the doctor.

The thing about flexibility, though, is if you push it too far, something will break - and that's what will happen with out-and-out role substitution.

I can hear some of you thinking 'but there aren't enough doctors in my electorate to do the job'. And that is the challenge - that is our quest. We have to set the game plan for the 'medical dream team'.

We have to find the way to overcome the tyrannies of distance and isolation to ensure equity and fairness in health care for all Australians. And we have to be realistic. We can't have every member of a medical dream team in the same place at the same time.

That is just not possible in rural and remote areas. It is not even possible in some outer metropolitan areas.

But we can have systems whereby each member of the team - the GP, the nurse, the specialists and the allied health workers - can tap into the expertise of the other team members to provide the best possible care for each and every patient.

We will need to embrace new and emerging technologies to make team-based care work in all settings - especially in rural and remote areas.

And we would need to incorporate existing successful outreach services like those operating in many Indigenous communities today.

But the AMA's plan for team-based care needs doctors if it is to succeed. So where are we on that front?

The Government has responded to medical workforce shortages by announcing significant increases in the number of medical schools and medical school places. Private medical schools are a reality and universities will be able enrol up to an additional 25 per cent of students in full fee paying places.

By 2011, the combined effect of increased HECS-funded and full-fee-paying places will see the total annual output of medical schools increase to around 2400 graduates, compared to 1270 in 2004.

Reforms to speed up the Australian Medical Council overseas trained doctors assessment process mean that around 320 overseas trained doctors will require intern places each year, compared to 116 in 2005.

Around 133 overseas full fee paying students currently require intern positions each year. Taking this into account, by 2011, Australia will need 2800 intern positions to meet the demand for places.

To illustrate the challenge ahead, in 2005 there were 1553 intern places available, and 1780 specialist training places.

The Government has in place plans to address medical workforce shortages - but we have to concentrate on quality, not just quantity.

Which part of an intern's training would you be happy for them to omit? Or which part of the specialist's knowledge would you be comfortable with them not having?

Rather than going down the substitution path, the focus should be on addressing shortages in nursing and allied health professions as well. What the substitution advocates forget is that the medical workforce shortage is also a health workforce shortage. There are not enough substitutes to fill the substitutes bench.

It is important to consider that if substitution does somehow gain acceptance and momentum, the increased medical graduate numbers in the system will hit a training vacuum. There may not be enough positions available to train these new doctors, or they may struggle to get access to a decent training experience.

Six years is a very short time frame to put in place steps to ensure that the quality of training can be maintained during undergraduate, post-graduate and specialist training. Infrastructure, resources and supervision will all need to be increased significantly.

The use of alternative training settings - including private hospitals and community settings - will need to be considered.

The States mainly affected by these increases are Western Australia, Queensland and New South Wales. Both Queensland and Western Australia have formed committees to examine the implications, but little progress is being made.

It is worrying that jurisdictions such as Queensland are looking at how they can 'cut' training requirements - such as accident and emergency terms - in order to provide sufficient places - rather than build available resources.

Again, which core and essential bits of medical knowledge can now be relegated to the 'don't need to know' basket? COAG asked Senior Officials to examine a range of workforce issues, including the organisation of clinical education and training.

This reflects concerns expressed by the Productivity Commission over the capacity of the system to account for increased medical school student numbers. The Government needs to work through COAG to quantify the medical workforce challenges ahead.

We need a better picture of what each State is doing, or is planning to do, so we can get a national perspective.

The Australian Health Care Agreements must reflect the new era of Commonwealth/State cooperation to properly fund medical training. And the States and the ACCC have got to stop hammering the Colleges over workforce shortages.

The Medical Colleges have an enviable reputation for producing highly skilled medical practitioners and they cost the taxpayer nothing.

I would remind you that the services of the Fellows of Colleges who are training the next generation of their colleagues and competitors do so willingly and pro bono.

Far from limiting numbers, the opposite is the case.

The 2005 Medical Training Review Panel Report shows there has been an increase of 40.6 per cent in first year specialist training positions since 1998.

There must be greater scrutiny of the role of State Governments in specialist training.

Cutbacks to theatre time - and the closure of beds and outpatient services - place increasing pressure on the training environment.

The media grandstanding where the States refuse to provide funding for additional training positions - and then blame the Colleges for restricting the number of trainees - must end.

It is not productive.

If you look at our health system, it may have a few design faults - but it is delivering high quality services to patients at a reasonable cost.

Through Medicare alone, in 2004-05, Australians received assistance to access:

• over 120 million professional attendances
• nearly 80 million pathology services
• over 18 million diagnostic procedures, imaging and other investigations
• and nearly 15 million therapeutic procedures.

Many additional services of all types were rendered in hospitals to public patients.

This is evidence that Australia has a very hard-working and productive medical workforce.

It is hardly a case to throw the doctors out of the system - as some are proposing.

I urge all of you here today to push the case for team-based care as the way to solve medical workforce shortages.

Substituting lesser-trained health workers for doctors is not a symptom of a high quality health system.

I doubt that voters would be thrilled by promises of lowering the quality of health services.

As I said earlier, the simple truth is that people want to see a doctor when they are sick.

There is no substitute for the skills and experience of a doctor - a doctor is a doctor is a doctor.

Thank you.