Speech by Dr Kerryn Phelps, AMA President, AMA Victoria Dinner for Surgeons

I found a doctrine of doctors. A hive of allergists. A void of urologists. A series of radiologists. A colony of bacteriologists. A host of epidemiologists. And a helix of geneticists.

But nothing for surgeons. Maybe we should invent a term. Perhaps a suture of surgeons. Or maybe a scalpel of surgeons.

Tonight I want to talk to you about why I think the collective term should not be a union of surgeons.

I want the surgeons to be part of the AMA. There is strength in a united medical profession and tangible benefits for members of a large diverse association like ours.

I understand that an application for registration as a union under the Workplace Relations Act 1996 has been filed with the Australian Industrial Registry by the Society of Australian Surgeons. Gazettal is expected in a couple of weeks.

There is still time to change this strategy and the AMA Federal Executive will be discussing this issue as a matter of urgency at its meeting next week.

The issues that the AMA has been speaking out on are the same issues that some surgeons believe they need to speak out on via a different agency. No need - you already have coverage, and effective coverage at that.

The RVS, medical indemnity, the ACCC, private health funds, public hospital funding, Medicare Benefits Schedule, training, privacy, corporatisation. These are all issues that affect all doctors.

And the AMA has the runs on the board.

Trade Practices Act

Just last week, after six months of intense lobbying from the AMA and the RDAA, the Government announced an independent inquiry into the effects of the Trade Practices Act on the recruitment and retention of country doctors.

While the terms of reference of this inquiry may sound narrow to you, the fact is that the findings of this inquiry will have important and telling ramifications for the whole medical profession.

For instance, the expensive and unnecessary authorisation process foisted on the College of Surgeons by the ACCC may well be exposed as the farce and the injustice that it is.

Medical Indemnity

We have made real progress, too, in the area of medical indemnity.

Insurance premiums for doctors, particularly obstetricians and neurosurgeons, have entered the realms of science fiction.

This insanity must stop and, thankfully, we are seeing some movement at the station.

In NSW, there is now tort law legislation that will at the very least stall increases in the level of indemnity insurance premiums. Further work we are undertaking with the NSW Government should lead to more easing of the financial pressure on doctors.

As the Federal election draws nearer, we are confident that both the major parties will unveil structured settlement initiatives as part of their health policy.

More importantly, active campaigning by the Federal AMA and the State branches has created an unprecedented level of public awareness of the threat that medical indemnity poses to the provision of medical services in local communities.

Country and suburban newspapers are regularly awash with stories about doctors either being forced to leave areas or cease providing certain services because of outrageous premiums and fears of litigation.

Australians are sick of disappearing services. They want to keep their doctors in their communities.

Corporatisation and vertical integration

Corporate medical practice is seen as a threat to the family doctor, too.

It has the potential to impact on the clinical independence of GPs by influencing the volume and direction of general practice referrals through vertical integration of primary, specialist, diagnostic, hospital and allied health services.

These developments have created tensions between the ethical and clinical obligations of doctors to their patients and the obligations of corporations to their shareholders.

Falling GP incomes, rising levels of stress, the changing demographics of the medical workforce and the increased complexity of running a small business are all significant factors driving this change.

The AMA believes the viability of doctor-owned family medical practice will continue to be under pressure unless Medicare rebates are increased.

The AMA continues to advocate for the implementation of the RVS, but increases to rebates will not be enough.

The AMA is leading the medical profession in pressing the corporate sector to accept its responsibility for contributing to the maintenance of high quality medicine, ethical standards and the clinical independence of medical practitioners.

The AMA has been strongly advocating the development of a Corporate Code of Conduct to regulate the contractual and business relationships between the Corporates and the medical profession.

The AMA considers professional and industry self-regulation will be more effective than external legislation in ensuring the ethical and clinical standards of the medical profession are embedded into the new corporate medical practice business structures.

The impact of vertical integration of primary, hospital and diagnostic services could be significantly reduced with a rigorous industry Code.

This approach has not received the universal support of the major Corporates, which have been slow in responding to a draft Corporate Code of Conduct put to them by the AMA in late June.

This issue is currently being discussed with the Corporates individually and with the Government.

Unless there is real progress in developing a Code with teeth that is acceptable to the AMA, we may need to go public with our concerns.

This is not just a GP issue.

If the corporates get control of GP referral practices, surgeons, among others, will be seriously affected. It is an area where GPs and Specialists have to work closely together to produce the results and come up with credible policies and pursue them vigorously.

The AMA has the structure and the resources to make this happen.

Private Healthcare System

When we went public with our concerns about private health cover, we got results.

Three years ago, private health insurance participation in Australia was poised to fall below 30%. The annual decline of 2% of the population dropping private health insurance, was, if anything, about to accelerate.

By a combination of a Medicare Levy surcharge, the 30% rebate and Lifetime Health Cover, participation now stands at close to 45% of the population - a 50% increase.

The three reforms mentioned above were AMA policy and the AMA strongly supported their implementation and their passage through the Parliament as legislation.

In the quarter to June 1997, there were approximately 2.7 million private inpatient medical services.

In the quarter to June 2001, this had risen to 3.3 million services or an increase of 22% in the volume of services going through the private system.

Over the same period, average private health fund benefits per service increased from approximately $22 to $36 - or 64%.

While this does not translate necessarily to higher incomes (it may just reduce gaps), someone must be smiling out there.

The AMA has been a driving force for this change.

Gap Cover Schemes

On another private health front, however, the debate over Lawrence contracts has moved on.

We now have Gap Cover Scheme Legislation and most funds have put forward schemes for approval.

The AMA has established a negotiating group to talk to the funds and make sure they understand the AMA position on gap cover schemes.

The negotiating group has been effective in moving the debate in the direction we want and one product, the Australian Health Service Alliance, goes very close to meeting all the AMA core principles.

With more effort, we might just get there.

In the meantime, we need to remain vigilant. We are up against the combined might of the health funds and the Government and we will need to use every weapon at our disposal to keep the doctor in the driving seat and protect the doctor/patient relationship.

The funds are desperate to move us out of the seat as they have in the US. We cannot allow that to happen.

Their first serious step in this regard is the publication of preferred provider lists.

It represents an erosion of the GP referral decision based on quality, expertise and cost. It elevates cost as a major factor and encourages patients to go to cheap doctors rather than good doctors.

It does this by financial inducements rather than direct control but we must nevertheless oppose these measures strongly.

The AMA has done that through the mainstream and is now providing members with resources to resist the move such as posters, published articles and advocacy through the media.

A key ingredient is to speak with one voice on these issues.

If we give the Government and the funds mixed messages or confused messages, we will lose out.

Impact of hospital-fund contracts on patient access to services

If the health funds and the Government cannot control us, the private hospitals may try.

We cannot afford to aim our guns in the one direction. Mayne Health and other chains are such significant players in the health business now that we need to establish bilateral relationships with them rather than through their peak bodies.

We also need to make it clear to them where the line is beyond which they cannot go. Mayne Health has relationships with approximately 10,000 medical practitioners in Australia and we cannot afford to give them mixed messages, either.

Health funds are attempting some third line forcing of the medical profession through their contracts with private hospitals. This can affect admission policies, length of stay, prostheses, high cost drugs, and so on.

In short, it affects quality of care and we need to continue to keep them on their toes through constant vigilance and through the media who are strong allies on these matters.

RVS

At the core of nearly all recent AMA activity has been the RVS. Contrary to some rumours, the RVS fight has not ended or subsided.

No political party will receive our seal of approval as being committed to Medicare unless they agree to properly fund the Relative Value Study.

The Government cannot logically complain about medical gaps while at the same time not provide extra funding for the RVS.

We have made this crystal clear to both sides of the political spectrum and they are aware of what is necessary to bring us on board. The RVS is hibernating, but not dead.

Our modelling indicates that the Government needs to inject about $1.3 billion per year to implement the RVS.

Conclusion

I'd like to finish up - before taking questions, of course - with a couple of anecdotes that accentuate the importance and value of AMA membership and a united profession.

I recently attended a GP meeting in Campbelltown, in Sydney's outer south-west.

There were 14 GPs there that day, only one of them was a current AMA member, and a couple were former members.

They all looked upon the RACGP as a lost cause.

They saw the Divisions as only serving a chosen few.

All but one of them - a current Divisions office-bearer - expressed strong support for the way that the AMA was working for doctors and patients.

When asked why they weren't members, there was only one reply - they couldn't afford it.

Why? These doctors work in low-income suburbs where there are endemic health problems.

They bulk bill because they want to provide affordable care for the poor people in their communities even though they are barely making a living themselves.

One doctor said he would love to have a card that said "AMA member" so he could show it to his patients and his colleagues because he supported what the AMA was trying to do to fix the health system - a system that was failing him as a doctor because of his altruism.

He has asked if the AMA to introduce a discount membership for doctors like him. He doesn't want any other benefit than membership. I'd like to bottle that sentiment. Membership does matter!

The other story comes from a member of the AMA Secretariat who this week returned from a study visit to the United States.

He will prepare a report into managed care in the US and why managed care should be banned from our shores.

As a guest of the American Medical Association, he visited Washington.

Can you guess how many medical organisations are headquartered in the US capital to lobby Government?

Forty two! Forty two medical groups who agree on nothing. And you thought we had it tough here.

In my view, a separate union will dilute your message. Stay with the AMA.

Until you are convinced that you will have greater advocacy, stay with the AMA.

Until you are convinced that your membership dollar will gain you an ounce of sway in public opinion, stay with the AMA.

For unity of the medical profession, stay with the AMA. Lots of little voices are easy to ignore. One BIG voice must be heard.

Thank you.

CONTACT: John Flannery (02) 6270 5477 / (0419) 494 761

Sarah Crichton (02) 6270 5472 / (0419) 440 076