Speech to the National Press Club - AMA President, Dr Bill Glasson "Where Have All The Doctors Gone?" - Wednesday 30 July 2003

WHERE HAVE ALL THE DOCTORS GONE?

Good afternoon members of the media, fellow doctors, ladies and gentlemen.

It is a pleasure to speak to you today as Federal President of one of Australia's most respected and influential associations - the Australian Medical Association.

I am proud to lead the AMA.

I am proud and privileged to be able to represent the views of our 28,000 member doctors - and through them the views of the entire medical profession.

More importantly, it is an honour to speak as an advocate for the millions of patients who see a doctor or visit a hospital or seek medical treatment or advice of some kind every minute of every day of every year.

What I say today has come up the line from doctors and patients at the coalface to me.

The AMA is a grassroots organisation.

Our messages and our policies come from the surgeries, the aged care hostels, the hospital wards and the outreach medical services of Australia - the places where the health system happens.

We know the successes and the failures of the health system instantly.

That is why we are vocal.

That is why we seek change and reform.

That is how we get a better health system for all Australians.

Doctors listen to their patients and respond to their needs.

But it is clear that our governments are not listening...or not hearing...the same messages.

Australia is facing a medical workforce shortage that will take years - perhaps decades - to turn around.

Medicare is crumbling and, so far, the major parties have put forward policies that will not fix it.

Medical indemnity is a problem that refuses to go away and threatens to engulf medical practice at any moment.

The health of Indigenous Australians continues to lag well behind the health of other Australians.

Our young people face newer and more dangerous threats to their health.

Obesity is quite literally 'eating away' the health of our people, especially our kids.

Our public hospitals suffer because of a dysfunctional relationship between the Commonwealth and the States over funding and responsibility and accountability...or lack therof.

The integrity and fairness of our Pharmaceutical Benefits Scheme - the PBS - is under threat.

The Government and others, in an effort to contain costs, want to, in effect, price the PBS out of the reach of the sickest and the poorest in our community.

They seek economic outcomes ahead of health outcomes.

Political bloodymindedness and wedge politics seek to deny medical attention to asylum seekers who are, by law, in our care.

And now they want to conscript our medical students and tell them where to live and practice for six years with no thought to their personal situation or needs or rights.

I'm talking about unfunded bonded medical student places. We don't need this sort of social engineering in 21^st century Australia.

Our health policy landscape is not an oil painting, I assure you.

I may be an ophthalmologist but I cannot see eye to eye with our political leaders or our health bureaucrats on where they are taking the Australian health system.

There is no vision for the health of all Australians into the future.

Health policy is geared to short-term re-election strategies rather than what will benefit future generations of Australians - our kids and their kids.

There is no plan...

Under our new leadership team, the AMA will continue to put forward ideas, arguments and suggestions on how to improve things.

I will share some of them with you today.

The loss of services in recent years has been heavily influenced by increased bureaucratic interference and red tape.

By failing to fund Medicare properly the Government has failed in its duty of care to patients, particularly low income and older Australians.

It has no right to try to substitute intervention in the place of adequate rebates for patients.

Their approach is based on lots of sticks and very few carrots...if any.

Patients and doctors have had to wear the increased costs of providing care.

It is time to give patients more time with their doctors.

And we must put an end to the perception that doctors are employees of Government. We are not.

Government policy that seeks to rob doctors of their independence will only exacerbate the problems affecting the health system.

The wrong policy responses - and we are seeing a few at the moment - will shift access and affordability of proper medical care further out of the grasp of the most vulnerable patients.

This is happening right now with medical indemnity and medical workforce.

Medical indemnity remains a crisis for patients and the community.

I remind you that this week is AMA Family Doctor Week.

It is a fitting time to discuss the reasons why the local family doctor is disappearing from local communities.

We are sadly seeing the end of another Aussie tradition - the family doctor.

We are all familiar with Doctor Who? We now have a new concept in primary care - Doctor Where?

Where have all the doctors gone?

They are doing other things.

General practice is no longer a viable full-time career option for many doctors.

One major factor is medical indemnity.

Medical Indemnity

We have come to the point where Australians must ask themselves if they really want the medical indemnity system we have.

In the event of a medical accident, people are tied up in the courts, possibly for years.

They face an uncertain outcome and a large proportion of any settlement will be swallowed up by legal costs.

If you have a road accident or a workplace accident, the States have arrangements to ensure that you are covered.

This is not the case with medical accidents.

The costs and uncertainties surrounding medical indemnity are starting to eliminate the availability of private medicine in vital areas such as obstetrics and neurosurgery.

I am very grateful that the Government has stepped in to avert the collapse of the medical indemnity system.

However, the fundamental problems that brought it to the brink of collapse are still there.

Doctors and their patients are propping up a failing system...but for how long?

Something will have to give...and it will happen sooner rather than later.

Premiums are still high. Too high. And they will get higher. They will cause greater fee gaps for patients.

Patient expectations are getting higher as well. They expect perfection. They want the impossible to be possible.

If the courts can order a doctor to pay the costs of rearing a child born after a failed sterilisation or contraception procedure - as happened recently - patients will find these services harder to find and more expensive as premiums will keep going up.

The courts should not decide whether a seriously injured person gets adequate long term care on the basis of who, if anyone, was at fault.

Patients must have access to a community funded long-term care scheme if they are seriously injured.

If the doctor is negligent, he or she should be liable - through their insurer - for the patient's loss of earnings and other losses but the care and rehabilitation should not depend on negligence being proved.

More State law reform is required before the court system can be relied on to provide an equitable and reasonably contained framework for deciding medical indemnity cases.

Statutes of limitations, thresholds for cases, caps on certain types of damages, and a workable definition of negligence all need to be addressed more thoroughly.

Doctors and their patients are insecure.

It is difficult to convey the anger, frustration and uncertainty that doctors feel about the impact of the medical indemnity crisis on their patients, their families and themselves.

The medical indemnity landscape remains fragile.

Anything that may shatter that landscape must be avoided.

Which brings me to the Government's proposed IBNR levy for the tens of thousands of doctors who had medical indemnity cover with United Medical Protection (UMP).

Contrary to claims by the Health Minister last week, the AMA has never given unqualified support for the levy.

It was always our position - and still is - that a levy would only be supported by the AMA if the tort law reform process was completed, if a national care scheme was introduced, and if premiums started to come down.

We do not want a levy that will increase overall costs and fees for our patients.

So far, the tort law reform process is incomplete and uneven.

We are yet to see a national care scheme.

Premiums continue to rise.

We cannot and will not support an additional impost on patients and doctors at this time.

Imposition of this levy will reactivate the indemnity crisis with dire consequences for Australia's medical workforce.

The levy - estimated to range from a few thousand dollars to more than $20,000 for some specialists - to be paid every year for at least ten years - will be the last straw.

Doctors will not be able to absorb this extra cost. It must be passed on.

Patients will have to pay more for their medical care.

More communities may lose more doctors, especially regional communities, as practice costs swamp them.

If the Health Minister proceeds with the levy at this time as she has publicly promised to do, she does so in the knowledge of the harm it will cause.

The IBNR levy will become known as "Patterson's curse".

Let me remind the Minister that the plant variety of 'Paterson's curse' was introduced to a fragile Australian environment in the mid-nineteenth century...and it's still here.

Since the late 1980s, more than seven biological control agents have failed to control it.

Minister, be aware that, once introduced, the medical indemnity levy version of 'Patterson's curse' will be equally destructive.

Like the noxious weed, it will infest the health system and stifle productivity.

You may think it looks pretty, but its harmful effects will spread and spread until it is out of control.

Don't wait until it's done irreparable damage to remove it. Get rid of it now.

It is not a desirable legacy for you as Minister, especially after the earlier good work that has been achieved.

Medical indemnity continues to destroy the confidence and security of doctors.

Medical indemnity continues to threaten the equality of access to and affordability of important medical services to all Australians.

Resolving this issue for the long-term will be a priority of my Presidency.

Access and affordability of medical services for patients are threatened also by the pressures on general practice.

GP and Workforce Issues - Access and Affordability

Australians should be able to see a doctor where and when they need one.

Something we have taken for granted is fading away.

There is a shortage of GPs and general practice is becoming increasingly unattractive as a career option for graduates and students alike.

The profile of the medical workforce is changing too, and rapidly.

There are more female doctors. They need flexibility to raise and care for families.

There are more doctors - male and female - working part-time.

The Government and Opposition are just starting to acknowledge the shortage of GPs...at long last.

The AMA and the general public have recognised the problem for years, particularly in rural and outer urban areas.

Country towns are being forced to compete with each other to attract medical services.

The medical workforce shortage is now extending to many of the specialty areas such as anaesthetics, psychiatry, geriatric medicine and rehabilitation medicine.

These are all areas that are important to our ageing population.

An appointment with a dermatologist or an orthopaedic surgeon can take months.

Medical indemnity, too, is taking a rapid toll on higher risk areas such as obstetrics and neurosurgery.

Successive Governments have tried to hold down health costs by rationing the number of doctors available.

Training places and medical provider numbers have been restricted to the point where the number of Australian graduates has not nearly kept pace with the health needs of the country.

Total disaster has been avoided by bringing in overseas trained doctors under various temporary, short term and long term arrangements.

The AMA supports the inflow of overseas-trained doctors provided they meet reasonable standards of medicine and have the ability and the experience to communicate with their patients.

Many regional communities are now served exclusively by overseas trained doctors.

However, we must question the morality of recruiting doctors from developing countries with much needier health systems than our own.

Most importantly, however, the worsening shortage of doctors in the United Kingdom, Canada and the USA is going to make the availability of overseas doctors much tighter in the future.

The responsible thing to do is train our own doctors in the required numbers to serve the next generation.

Since 1995, the number of full time GPs per 100,000 people in Australia has been falling.

At the same time, the demand from patients has been rising as the population ages and a more affluent Australia expects more from its health system.

It has become commonplace for people to have to wait weeks for non-urgent appointments.

It has become commonplace for GPs to be forced to close their books to new patients due to overwork.

It has become commonplace for communities to rely heavily on the already over-stretched accident and emergency sections of their local hospital for GP services.

The traditional GP home visit and a locum when your GP is sick or on leave are becoming less and less possible to provide.

For some time, Governments have been offering incentives for GPs to move to areas where the shortages are most severe.

But these incentives have ignored the fundamental problem - the current GP workforce cannot meet the needs of Australian patients.

In recent months both the Government and Opposition have agreed to increase the number of medical places in universities and the number of training places for GPs.

However, this will only, at best, produce an extra 150 GPs per year, when the national shortage is around 2,000 - arguably more like 3,000.

The extra university places will require the student to enter into a bond to serve for six years in an area of need before attending his or her first lecture of their university course.

They won't even start serving the bond period until after completing all their training, usually seven to ten years, and then will have to pay the full HECS for their course.

The AMA believes this amounts to conscription and that it will further contribute to an unhappy medical workforce in the future.

The bonding scheme is flawed and unfair and won't deliver the result the Government is so optimistically predicting.

One, the scheme will steer students away from general practice, the specialty where shortages are greatest.

Two, it will steer students to the specialties that will provide the necessary rewards to allow them to pay out their bonds as soon as possible.

Three, the scheme will create a new group of unhappy, poorly remunerated doctors with low morale who - ten years down the track - will regret having taken up a bonded place back when they were just out of school.

Their lives, their circumstances, their ambitions will have changed so much.

Patients expect a caring GP who can spend time addressing all their concerns and provide counselling when it is needed.

But, increasingly, they are finding instead an overworked, harassed person who is snowed under with red tape.

Dedicated professionals with little time for their own families.

One thing is certain. The new crop of medical graduates will not opt for the GP career lifestyle currently on offer.

Working 60 hours a week - including about eight hours of red tape time filling in forms - is not attractive, especially when face-to-face time with patients has to be cut back.

Training twice as long to earn less than peers in other professions is singularly unattractive.

Unless there are major changes of policy, the new wave of GPs will be merely a ripple.

There won't be enough to meet patient and community need.

Indeed, I think you'll find that is already the case and this will become more evident over the next two to three years as the gaps in training take effect.

More doctors will only want to work part time in general practice.

Raising a family or other medical and non-medical employment alternatives to full time general practice will be the preferred options.

While this change in work patterns might seem a good outcome for the individuals involved it will have a major impact on the overall availability of GPs.

A fall of just two hours in the average working week of Australian GPs has the effect of reducing the available workforce by about five per cent - or equivalent to about 1,000 GPs.

The Government estimates that there are about 24,000 GPs practising in Australia.

Because many are only practising part time, the full time equivalent workforce is around 16,700 - a participation rate of 70 per cent.

With the younger 45 per cent of GPs only supplying about 30 per cent of GP services, this participation rate seems set to fall.

The GP workforce situation will get worse despite the increased number of training places.

So what should the Government be doing to ensure that Australians can find a GP when they need one?

Policies must change to encourage GP careers that can offer access and affordability for patients, and which are satisfying for doctors.

The 2001 Australian census showed that about one in six medical graduates under the age of 65 have given up the practice of medicine entirely.

As a nation we cannot afford this shortage.

A highly trained medical workforce cannot be trained and deployed overnight.

There must be less Government intervention.

Doctors value their independence and their capacity to decide who should be rebated and who should pay a co-payment.

They accept responsibility and they structure their practice to meet their patient's needs, but the Government and the Opposition want to treat them as medical clerks.

Their policies are based on using financial pressure to make them sign on to schemes that proscribe and limit both their clinical practice and their financial arrangements.

For example, doctors who opt in to the new Government scheme cannot charge concession card holders - not even after hours or on weekends.

Many doctors make some extra charge after hours to dissuade unnecessary visits on weekends and to make the extra work worthwhile.

The so-called Fairer Medicare package will in fact provide a disincentive to offer patients evening and weekend appointments.

Again, the policies will put more stress on the profession.

Worse, the policies will make it harder for patients to get to see a doctor.

I make the point also that attacking doctors is not helpful.

I cannot let the opportunity pass without comment on recent statements by the Health Minister, Senator Patterson, and Senator Sue Knowles from Western Australia, who is a member of the Medicare Senate Inquiry.

To paraphrase Senator Patterson, she said on the weekend that she was not about policies that give more money to doctors.

Senator Knowles is now regularly using the 'greedy doctors' mantra - a throwaway line so often used by a certain former Health Minister.

The Senator should not fall into the trap of comparing gross medical practice income with average weekly earnings.

That argument goes nowhere and does her no credit at all.

The 'greedy doctors' line is only used by people who have run out of positive policy ideas.

The Medicare debate is not about doctor incomes.

The Medicare debate is about how much of their household income Australians should pay to receive high quality health care in their own community.

If doctor incomes are so attractive, why is there a medical workforce shortage?

Why aren't our brightest and best students queuing up to do medicine?

Why are towns and suburbs and whole communities losing their doctors?

Dear Minister and Senator Knowles, the 'greedy doctor' line doesn't wash anymore. The public doesn't believe it. You'll have to do better than that.

Australian Health Care Agreements

Looking at the bigger picture, all our Health Ministers meet in Perth tomorrow to discuss the Australian Health Care Agreements.

We understand Senator Patterson will be attending this time because it is a scheduled meeting.

It is an important meeting for Health Ministers. It's a once in five year opportunity to make a difference.

We had a promising start to the renegotiation of the Health care Agreements with the nine reference groups but it has descended into the usual name-calling.

The Ministers must rise above that tomorrow to deliver some certainty to the health system.

The AMA has always supported the public hospital system strongly and we will continue to do so.

We must guarantee patients access to high quality public institutions that do all the more complex health treatments and which train the next generation of medical practitioners.

Our public hospitals provide an essential service and we need to be proud of their achievements and capabilities.

The Federal Government must increase its public hospital funding offer.

The current offer of $42 billion over five years is almost one billion less than was announced in the forward estimates.

This offer is mean and shortsighted. It is not a generous offer.

It amounts to just 5.1 per cent growth per annum in Commonwealth funding over the five years of the agreement.

The Government really needs to get its priorities in order.

If hospital admissions increase, even by a small margin, these funds will fall seriously short of meeting demand.

The States must likewise commit to specific funding and indexation.

This would provide very real increases and give hospitals some certainty about their long term funding.

Official figures indicated that the States have lowered their share of public hospital expenditure from 50.3 per cent to 47.5 per cent between 1996-7 and 2000-01.

The States can't complain about the Federal Government's offer if they are not prepared to match it.

If these issues can't be resolved in the time available, the AMA will call on the governments to come up with an interim agreement of up to 12 months, where each state agrees to spend specified funds, until the full agreement can be worked out.

Conclusion

I'll close with some comments on the importance of the health system to the community.

We are told by the Government that we have never had it so good.

We are told that we live in a land of milk and honey.

Everyone can own a house, we are told...if you can handle the big mortgages, that is.

We have the lowest interest rates in living memory.

There is money on tap for border protection and to send our troops to the world's trouble spots.

And we're paying off the national debt at a rate of knots.

Why is it then that money for health and education - the things that bind communities and equip future generations of Australians - is given so grudgingly and with strings attached?

We have the makings of a great health system that could be the envy of all the world.

There should be no greater public policy for a Government than the health of its citizens.

All Australians - no matter where they live or whatever their means - should have equal access to affordable high quality health care.

The Australian people deserve better than the Medicare policies currently on offer.

We need solutions to medical indemnity and the medical workforce problems.

Without doctors, the health system simply cannot work.

We are doctors because we want to care for the needs of our patients.

We want to provide the best possible health outcomes.

We want a healthy Australia for this and our future generations.

Our patients understand us and respect us and appreciate us.

It is time for the Government to equally understand the role of doctors and our importance to local communities.

It is time the Government understood the importance of the health system in building a better Australia.

Health matters. Good health policy is a vote winner.

I'll leave you with the words of one of my patients.

These words guide me in my work and reflect the approach and attitude of most doctors:

"Above all - Be Kind

Treat your Patients with Warmth

Guard their Dignity

Treasure their Uniqueness

And Know Well the Worth of Each and Every One."

Thank you.