Speech by AMA President, Dr Bill Glasson to AMA Tasmania GP Issues Seminar, Launceston - "She's Not Apples": The state of general practice in Tasmania

Good afternoon all.

It is always a pleasure to visit Tasmania and it's great to be here in the beautiful city of Launceston.

And hasn't Tasmania been in the news lately.

The irony of Tasmania's Mary Donaldson marrying into the royal family of Denmark should not be overlooked...because something is rotten in the State of Tasmania.

The 'something rotten' is what is happening to the once-proud profession of general practice.

Things are so crook that some GPs may indeed consider 'getting thee to a nunnery' or some other more rewarding activity.

GPs have been turned into Government clerks.

The regulation, the red tape and the lack of reward have taken the gloss off being a community doctor.

Your independence has been taken away.

Welcome to the Commonwealth Public Service, GPs of Tasmania.

And congratulations.  From 1 May you were given a $7.50 bribe to bulk bill certain patients.

A $7.50 bribe to further devalue your skills, your service, your contribution to the community.

A $7.50 bribe to erode your pride.

Tasmania's GPs were booted and bashed as a political football in the Federal Senate this year.

You were the pork that got Tony Abbott's Medicare Plus package through the Senate.

But in reality you have been put over a barrel.

And all for a narrow political fixation on preserving bulk billing rates.

Our politicians must learn that bulk billing is not the measure of a quality health care system.

It all comes back to the access and affordability argument.

There is a medical workforce shortage in this country, and it is being felt hardest in places like Tasmania.

Patients want access to a doctor first and foremost.

Draconian measures and short-term incentives for discounting services for some patients will not provide that access for the long-term.

You are supposed to be grateful - and perhaps you should be for at least some recognition of your plight - but how long will it last?

Sure, the incentives may ease the financial burden for some of you for the short term.

It may allow you to minimise out of pocket costs for your most needy patients.

But what about the future?

What is really needed is structural reform of Medicare for the benefit of all patients.

It is the AMA's view that for Medicare to maintain any hint of universality or equity, there should be Medicare patient rebate increases right across the board.

Along with the Government, we established the real value of general practice through the Relative Value Study - the RVS.

The Government chose to ignore the RVS and all the work that went into it.

They have belatedly acknowledged that something needs to be done, but they offer the crumbs instead of the full loaf.

What is really needed is an MBS that reflects the true cost of providing quality patient care.  The RVS was proof of that.

The Medicare Benefits Schedule must reward longer quality consultations.  More on this later.

We need radical change that provides incentive and security and confidence for general practice for the next generation, not just the next election.

No one in the medical profession can even pretend to understand the major political parties' obsession with bulk billing.

Under the current Medicare system, GPs cannot afford to bulk bill all their patients.

The explanation is not rocket science.  It is simple mathematics.

The real cost of an average GP consultation is around $52.00.

The Medicare patient rebate is $25.70.

The Medicare schedule fee must be increased so it matches the value of each consultation.

The onus should be on the Government to ensure the patient rebate is adequate.  It should not be up to the doctor.

GPs have subsidised the care of their patients for a long time.

They can no longer do this and stay in business.

Doctors are leaving general practice or moving to part-time work.

Without replacing them with full-time equivalents, we have an access problem.  Simple.

Without the Government increasing the Medicare patient rebate across the board to a suitable level for all, we have an affordability problem.  Simple.

But not simple enough, it would seem.

Both sides of politics are ignoring access and affordability, choosing instead to engage in a pre-election bulk billing bidding war.

Bulk billing rates in Tasmania have been steadily falling.

Although there was a lift in the March quarter 2004, which can be attributed to the $5.00 bulk bill incentive payment, the State still has one of the lowest bulk billing rates in the country at around 57.7% (for all out of hospital services)

The national average co-payment for a GP service is $14.92.  This clearly shows the $7.50 will not come close to bridging the gap.

The $7.50 may help some GPs here bulk bill some patients for a bit longer but it will not make bulk billing sustainable into the future.

The payment is not properly indexed.  While practice costs continue to rise, the value of the incentive will decline.

Worse, it is an incentive for incentive's sake alone.  It does nothing to help GPs provide the quality of care they want to give their patients.

The Medicare system has long encouraged "six minute medicine" and this initiative won't change that.

GPs get the $7.50 whether they see a patient for six minutes or an hour.

The AMA has a better way.

Along with the other GP groups, we strongly advocate introduction a fully funded 7-tier general practice consultation item structure. The 7-tier structure was developed by the Attendance Item Restructure Working Group (AIRWG).

Evidence from around the world shows that longer, more comprehensive consults deliver greater patient satisfaction, which in turn delivers better health outcomes.

The 7-tier structure is a better way to reward longer quality consults.

Australian research shows that patients who have access to longer consultations with their GP will use other areas of the health system less often, saving the health system and the community money.

In order for this model to be sustainable it must be fully funded and properly indexed to reflect increases in GP costs.

We will be shortly presenting a proposal to the Government on how they can ensure the MBS is properly indexed in the future.

Even if these affordability issues are addressed, Australia still faces an access crisis.

It is estimated there is an overall shortage of between 2,000 and 3,000 full time equivalent GPs.

This means patients sometime wait weeks for an appointment or, worse, they can't get to a local doctor at all.

According to 2002 figures from Access Economics, 25 to 50 per cent of the Tasmanian population lives in an area defined as 'having a severe shortfall of GP services'.

Statistics from the Tasmanian General Practice Division estimate that, in December 2003, Tasmania had 93.7 full time equivalent GPs per 100,000 population.

This is well below the national average of 110.1 per 100,000.

There is now ample evidence that people in regions with inadequate access to medical services experience poorer health.

These areas are characterised by long waiting times to see GPs, and overworked doctors.

The shortage is exacerbated by a falling participation rate in the workforce.

Many GPs are either choosing to work fewer hours, planning early retirement or finding alternative work.

The participation rate in general practice is now about 64 per cent and falling.

The "feminisation" of the workforce is the most significant factor that will impact on participation rates into the future.

Almost 59 per cent of those applying for GP training places in 2004 were female and AMWAC predicts women will make up more than two-thirds of the profession by 2010.

AMA figures indicate a current average working week of GPs of 50 hours, with a preference to reduce working hours to an average of 36 hours face-to-face.

This is the type of working week we expect GPs to embrace in the future.

A drop in average GP time of 2 hours per week is equivalent to the loss of about 1,000 GPs from the workforce.

If we do not get more doctors practising in Australia and encourage those already in the profession to work more hours, we will find more and more communities with inadequate health care services and providers.

Immediate measures - both short and long term - are needed to reduce the retirement and drop-out rates from the existing GP workforce to cover the immediate shortfalls.

First we need to encourage doctors to keep up their hours and provide lasting incentives for them to stay in the profession.

There is currently little incentive for GPs to work more hours.

One in six GPs do not work in medicine.

Some are being forced to reduce their hours and take a second job that has a higher rate of pay.

We need to train more doctors in Australia.

Medical school numbers must take into account the participation rate and the intake must rise accordingly.

It is no good training a doctor who will work 30 hours a week to replace a doctor who works 60 hours a week.

Contrary to the Government's belief, bonding is not the way to get doctors to areas of need.

The first group of bonded students started this year and already the AMA has heard of a number who are looking to buy out their bond.

Bonded schemes will actually act as a deterrent for students to select general practice.

Ultimately students will select a career that will allow them to pay off their bond as soon as possible and that, as we all know, is not general practice.

Training doctors where they are needed has been shown to be successful.

Tasmania has a medical school.  The more who train here means that more are likely to stay and practice in Tasmania.

Start a practice.  Start a family or establish personal and professional networks.  Become a local.

Other ways of encouraging students to practice in areas of need include:

• giving them early and continued exposure to rural practice
• and preferential access to specialist training for doctors who have completed a period of rural service.

We could develop a national program to encourage GPs to work in rural/remote areas for a portion of their career.

This could be achieved through providing financial assistance to relocate after 5, 10 and 15 year periods of rural or remote service.

Such grants would be matched by similar bonuses for those choosing to remain.

Other ideas to increase GP numbers throughout Australia include:

• Targeted incentive schemes for areas of need and rural and remote practices;
• Retention incentives for GPs aged 55 and over who continue full-time practice;
• Improved IT support; and
• Support for practice nurses in all areas.

Both Federal and State Governments have been showing a lot of interest lately in getting involved with after hours care.

Some of the areas they are targeting will benefit, but others already have successful programs in place.

The AMA has made it very clear that the only way these GP clinics can go ahead is with thorough consultation and support from local GPs.

I understand that in the past when this issue has been raised, Tasmanian GPs have chosen to support their existing services.

The Government must listen to and respect Tasmanian GPs feelings on this issue.

More importantly, they must do what is in the best interests of Tasmanian patients and Tasmanian communities.

Their policies should be visionary.  Their policies should look to establishing a good health system for our children and their children.

But no health system and no health policy can be effective without doctors.

Current policies unfortunately are not geared to keeping doctors in the system.

If you look at general practice in Tasmania, 'she's not apples'.  In fact, things have gone pear-shaped.

Tasmanian GPs are looking to greener pastures.

They may not all be able to find a Danish Prince of their own, but escape they will...and that will be tragic for Tasmanian communities.

Thank you.