Speech to the National Press Club Canberra Wednesday 14 July 2004, AMA President, Dr Bill Glasson
Good afternoon members of the press, ladies and gentlemen.
It is a pleasure to be back at the National Press Club with my friends in the press. I have enjoyed a good relationship with the media during my first year as AMA President.
I believe you have been very fair. You tick me off when you think I have made a mistake.
And you give me a tick when you think I have got it right.
You have also given me outrageous nicknames like 'Wild Bill' - and they have stuck.
Overall, I think have got it right for patients and doctors and the community a lot of the time.
The feedback I get from people has been overwhelmingly positive, I'm happy to say. The e-mails and phone calls and letters contain praise and criticism.
But even the criticism has been cordial.
That's what I like about Australians. They are smiley and cheery even when they disagree with you.
Doctors are especially good when they disagree with you. They have a big welcoming smile and a scalpel aimed at your jugular.
I'm not just an advocate for doctors. I'm an advocate for patients. I'm an advocate for a better health system in Australia.
And now I am back for a second year at the helm of the Federal AMA. So I must be doing something right.
With politics, I call the shots as I see them. I try to be fair and balanced in my comments on Government and Opposition policy.
The AMA is non-partisan. We cheer good ideas from both sides. We jeer rubbish from both sides. I'm happy to say that, despite the cheers and the jeers, both sides are still talking to me.
I'm pretty sure the Government hasn't got a 'dirt file' on me anyway. At least I hope not.
The policy advice from my team of retired nuns is still doing the trick.
When I spoke at the National Press Club this time last year, the medical indemnity crisis was still raging.
It was not an election year; so new health policies - or even new health ideas - were pretty thin on the ground.
As the political landscape has changed, so too has the health policy landscape.
Everybody knows there are votes in health.
That is why Tony Abbott and Julia Gillard have been at it like Punch and Judy for the last six months.
This is a good thing for health. We are seeing some action. We are seeing some ideas.
And today the AMA wants to throw a few more ideas into the melting pot. A lot of them are not new. People know where we stand. A few of them are updated. The AMA can move with the times. But all of them are relevant. We listen and we learn.
Our policies and attitudes reflect the views of the doctors and patients at work or being worked on in the health system every day.
We've now collected them into one volume for the election. You could call it The AMA's Greatest Hits, if you like.
And we'd like you to give them a spin. More importantly, we'd like the major parties to have a close listen and get into the AMA groove.
It may take a few listens, but I'm sure they'll eventually get our messages - especially if they play them backwards.
The AMA's Key Health Issues booklet is out today - and you get to see it here first. I'll be raising and explaining the issues in this booklet with you today.
My health policy mantra has always been about access and affordability. So today I ask the question - can we be healthy and wise without having to be wealthy?
Can we design and maintain a health system where patients can find a doctor when they need one, and be able to afford their health care?
Are our governments smart enough to properly fund the entire health system without forcing patients to pay more and more out of their own pockets?
That is the challenge. And the challenge gets harder and harder every year that governments do not attack it properly.
There is some good policy from both sides out there at the moment.
But the AMA firmly believes that the Government and the Opposition have a flawed basis to their policies.
They both believe that bulk billing is the great panacea to the woes of our health system.
That's what they are telling the electorate anyway.
Let me make it clear - bulk billing is not and cannot be the measure of the success or failure of the system. Bulk billing is a false prophet.
To back me up on this, I have the results of a poll conducted by the AMA the weekend before last.
The poll of a thousand people showed clearly that patients are more concerned about finding a doctor than about whether that doctor bulk bills.
Patients want access. But the medical workforce shortage is evidence of policies that are denying them access.
More than 70 per cent of the people polled put access first. Just over 20 per cent saw bulk billing as necessary.
The poll also showed that 69 per cent of people see health policy as a major vote winner at the election.
To back this up, 47 per cent want any budget surplus spent on health services, while just 14 per cent want it spent on tax cuts.
One other heartening result of the poll for me is that 79 per cent of people considered the loss of their GP would have a significant impact on their community.
According to the poll, communities would miss GPs more than their teachers, their banks, their pharmacists, their church, or even their lawyers.
But these communities are losing their GPs - in record numbers at an alarming rate.
Which brings us back to health policy - and what we are going to do about it.
I'll now run you through a few ideas from the AMA.
Some refer directly to Government and Opposition policies already announced or already in place. Others are a wish list, if you like. Things we'd like to see happen.
I'll start with general practice because GPs are the health system to many people - or at least the entry point to the health system.
You may have heard a bit about the new GP After Hours clinics attached to public hospitals.
At a time of workforce shortage, a good idea in theory - and a bipartisan one. But something has gone terribly wrong on the ground with this one.
The AMA will not support any proposal that includes "in-hours" services and compulsory bulk billing.
Such unfairly subsidised clinics would directly compete with established local general practices. They will force existing services to shut down because they cannot compete.
It's already happening in Western Australia, and heads have rolled because of poor implementation.
They got it wrong. There was no benefit for patients. No better access.
Any funding for these clinics must be "new" funding and cannot rely on cashing out of existing after hours funding.
New clinics can only be established with full support from local GPs. New clinics must complement, not compete.
Using taxpayer money to force existing medical services out of business is just plain dumb. And using bulk billing as the motivation is even dumber.
The AMA rejects any Government interference in GP billing practices. Any pressure on GPs to bulk bill is unacceptable, as it will act as a disincentive to participation by GPs in the workforce.
It is a signal to GPs that the quality of care that they provide is of little or no value. It drives 'six minute' medicine.
When patients find a GP, they want and need more time - more quality care - not less. I'd go so far as to say that bulk billing has become an impediment to access.
If the Government and the Opposition are serious about nailing their colours to the bulk billing mast, they have to fund Medicare properly.
They must dramatically increase MBS patient rebates. They must establish schedule fees that more closely reflect the true value of GP services.
And I truly believe that patients know and appreciate the value of their GPs and the services they provide. They pay more for a plumber, a sparky, a gardener, a painter, a lawyer or an accountant.
There is no comparison. The GPs are getting the rough end of the pineapple. And so are their patients.
The patients could probably get to spend more time with their doctor if the Government got rid of all the red tape.
I note the Government announced on Monday a small concession to cutting red tape but that's only a very small start to a much bigger task.
GPs spend so much of their time filling in Government forms they may as well be bureaucrats. They are treated like clerks. And junior ones at that.
Every hour on red tape is an hour stolen from patients. And a GP can spend 10 to 20 hours a week on the paperwork.
This is a major workforce issue. A major access issue. Patients are missing out.
As a solution, the AMA is calling for a fully funded and appropriately indexed 7-tier general practice consultation item structure.
This structure puts a realistic value on the time and skills of the GP. It would promote longer consultations and higher quality primary health care. It would eliminate bulk billing-fuelled revolving door medicine.
It would particularly benefit patients with chronic and complex care needs. It would greatly benefit families with young kids.
Importantly, it would allow GPs to establish their billing practices based on the real value of the services they provide, and the cost of delivering those services.
It would allow GPs to avoid any practices that compromise the viability of their business and their personal and family security.
It would deliver access - quality access. As I keep saying, access depends on having enough doctors to go around.
There aren't enough in the system. There aren't enough working full-time. We're not training enough.
We need policies to encourage more GPs to enter the workforce, stay in the workforce, and increase their participation rate.
Training numbers must be increased to take into account the growing trend within general practice for a better balance between work and home life.
Increased workforce participation and retention is key to the future of service delivery.
Flexible training opportunities and exposure to quality general practice and GP mentors early in a career are important.
An important and topical element of the medical workforce debate is overseas trained doctors.
As you know, overseas trained doctors - or OTDs as they are known - are filling many of the workforce gaps in Australia, especially in rural, regional and remote areas.
Rather than speak on this today, I'll alert you to an AMA position paper on OTDs, which I hope to release in a couple of weeks.
I believe it will be an influential contribution to the debate on OTDs, especially following Bob Birrell's paper last week.
We have to properly utilise OTDs, but at the same time we have to train our own new doctors. But our Governments are getting it wrong on this front, too.
As you know, the AMA is strongly opposed to the unfunded bonding of medical students.
This is a bipartisan policy that should be thrown out.
It will turn students away from general practice and that's the last thing we need.
The AMA has proposed a scholarship-based scheme to the Government. I hope they listen. Just as they listened to us about medical indemnity.
After a long and painful operation, the Government surgically removed the word 'crisis' from medical indemnity.
The AMA and the Government formulated indemnity arrangements that provide doctors and their patients with affordable cover that gives the security they require.
We'll review the success of these arrangements over the next year. But so far the signs are very good indeed.
Tony Abbott listened to our concerns and the concerns of the community and delivered a comprehensive rescue package.
The Opposition did not stand in the way of the necessary legislation. This was bipartisanship at its best.
There is still some work to do, however, to ensure the crisis does not rise from the grave.
We need a national long-term care and rehabilitation scheme for those severely disabled from medical accidents. Both the Government and the Opposition have been slow to commit to this scheme.
Some States and Territories need to do more on tort reform to take the sting out of medical indemnity settlements. We have to avoid the adversarial court system.
Medical indemnity premiums must come down in response to the reforms.
And it's not all one-way traffic here. The AMA is leading the medical profession to get more serious about risk management.
We want to create the safest and highest quality medical practices and procedures. The profession will deliver on this one.
I'll move now to one of the great challenges facing modern Australian society - aged care.
Demand for aged care services is rapidly growing as the population ages.
In 1998, the number of Australians aged over 65 years was 2.3 million. This figure is projected to increase to 4 million in 2021 and to 5.7 million in 2041.
Those people aged 85 and over are projected to rise from about 1.3 per cent of the population to 2.1 per cent of the population by 2021. That's a big change in a relatively short time.
That's a change that creates huge demand and need for health services and health workers - doctors, nurses and carers.
Older Australians must have access to quality aged care services. But thousands of Australians are trapped in the wrong environment for the type of care they need.
There are many people in hospital who no longer need acute care, but are unable to care for themselves at home and cannot access appropriate residential or community care.
Similarly, there are people in nursing homes who should be in hospital. And there are people in the community who should be in a hospital or an aged care home.
The Federal Government provided a 6.4 per cent boost to aged care in the 2004-05 Budget. The Opposition is yet to detail its aged care policies.
GP participation in Residential Aged Care facilities has declined. Only 16 per cent of GPs visit nursing homes on more than 50 occasions per year. That's less than one visit a week.
There must be more incentives for GPs to visit aged care facilities more often, and stay longer. There must be additional beds in aged care homes. More community care places. And more transitional care must be provided if ageing Australians are to receive adequate and appropriate care.
Dementia must be made a National Health Priority.
All aged care workers must be better paid for the work they do. There must be better integration between the health and aged care sectors.
Aged care is the new frontier of health in this country. We are yet to see if the Government and the Opposition have what it takes to be pioneers in the aged care frontier.
But they both seem to be taking the Medicare debate seriously.
Punch and Judy - Tony Abbott and Julia Gillard - have been putting on quite a show. It's been a bidding war and a biffing war. And it's not over yet.
Labor has its New Deal to Save Medicare. The Government had A Fairer Medicare, which became Medicare Plus, which is now known as Strengthening Medicare.
I think there will be more policy changes and name changes before election day. I fully expect to see a Climb Every Mountain Medicare and a Ford Every Stream Medicare.
But I don't care what they are called. Just as long as the hills are alive with the sound of health policy and it is good health policy.
Governments need to be seen to be making genuine efforts to improve access and affordability for patients. They need to be actively delivering reforms that guarantee high quality medical services for all Australians.
And they have to get smarter about it.
Tony Abbott regularly floats the idea of the Commonwealth taking over responsibility for public hospitals. I don't believe it will happen, but it's a debate we have to have.
The Opposition has promised a National Health Reform Commission to be established in the first month of taking office to develop a plan for long-term reform. I agree the decision makers must get together to set health priorities and build a more cooperative relationship, but I need to know more about the Commission.
The AMA wants any reform of health financing arrangements and health responsibilities between the Commonwealth and the States to be evidence-based.
It would have to provide access to health and hospital services for all patients. It would need to be affordable to patients and governments. It would have to be integrated with related health services. It must be based on quality of health services. It would require minimum levels of bureaucracy. It would need to encourage a move to national standards.
There must be political accountability and responsibility for performance. The public would have to understand it and like it.
The AMA strongly believes that these conditions must be met for changes to the system to be accepted. We also believe that fee-for-service must remain the dominant method of payment for medical services in our health system.
I don't want people to be in any doubt about the AMA's position on private health.
Today, 50 per cent of surgery is done in the private sector and nearly 40 per cent of all admissions are in the private sector. The public system relies on the private system to carry a big share of the load.
The Government is committed to the maintenance of the rebate and Lifetime Community Rating. After all, it's their policy.
The Opposition has said it will retain the 30 per cent rebate but has not ruled out some form of capping on rebate expenditure.
The AMA supports both the 30 per cent private health insurance rebate and the Lifetime Community Rating policy. These measures have given Australians greater access to health care and have reduced the demand on public hospitals.
The private health insurance policies will have a strong bearing on our public hospitals and their ability to meet demand and maintain quality.
The AMA is a great supporter of our public hospitals. We recently convened a group of public hospital doctors to advocate specifically on behalf of these great institutions.
A key part of that advocacy is to push for greater funding on one hand, and greater cooperation between the Commonwealth and the States on the other.
The reform agenda under the Health Care Agreements needs to be pursued. The AMA wants the Federal and State Governments to work co-operatively to resolve the issues confronting the public hospital system.
Governments need to be collectively responsible for access and waiting list problems.
Funding initiatives must address the obstacles brought about by the interaction between the hospitals, community and residential care sectors.
The primary cause of overcrowding and access block in Emergency Departments is the restriction of funding to the public hospitals and the consequent shortage of beds and hospital workforce.
These things must be understood.
We want the training role of our public hospitals not just maintained - it must be strengthened. They are key to the training of our next and future generations of doctors.
Public hospitals are national treasures, and so are our war veterans.
Our veterans are also in need of better care and funding. GPs are contracted to provide services to veterans as Local Medical Officers - LMOs. The LMO payment is now insufficient and doctors will drop out of the system if the Scheme is not properly funded.
Specialists are currently paid the scheduled MBS fee for treating veterans. The LMO Scheme must now be given priority to bring it in line with the specialist consultations.
The GPs are treating veterans with complex and multiple conditions. They need more time and care. Our veterans gave their time freely. They now need ours more than ever. It is the very least the Government could do for our veterans. Proper care delivers on the promises the Government has made to them.
I turn now to people who have escaped other wars and conflicts - asylum seekers.
Australia's international reputation and tradition of a 'fair go' have been diminished because of treatment of asylum seekers in recent years. The AMA continues to speak out on issues concerning the health of asylum seekers. The AMA believes that those genuinely seeking asylum within Australia have the right to the same standard of health care as all Australians.
It should be without discrimination - regardless of citizenship or visa status. Asylum seekers should not be used as an issue to divide the community.
Nor should the health and welfare of the first Australians be used as a political football.
Indigenous Health is our national shame.
We see occasional glimpses of genuine concern backed by genuine funding and policies, but then it falls away again.
On a recent trip to the Northern Territory, I was disturbed to hear from a doctor up there that Indigenous health is worse than he has seen it in 20 years.
That is tragic. We should not be hearing this in 21st century Australia.
There are very few votes in Indigenous health. We have to get our Governments to do more because it is the right thing to do.
Genuine political will is needed to increase the present funding levels. As a starter, the AMA calls upon the political parties to make election commitments to:
- increase funding to integrated primary care services provided principally to Aborigines and Torres Strait Islanders by $500 million a year recurrently
- provide a clear four year plan to achieve this full increase
- and to fully fund the Workforce National Strategic Framework.
There are many acknowledged determinants of health. These include income and social status; social support networks; education and literacy; and employment and working conditions; to name just a few.
It is impossible to expect changes in the health service provision to Aborigines and Torres Strait Islanders alone to transform the present health reality. An integrated approach across all these areas and Government Departments is required.
Any solution to Indigenous heath problems will involve empowering communities and individuals to take control across the whole range of economic and social areas.
The Government must commit to raising the health of Indigenous Australians to at least the levels achieved in the equivalent populations in New Zealand, Canada and the United States. In the longer term, it must be raised to the same level as the rest of the Australian population.
This will involve a whole of Government approach involving the integration of health, education and social policy - and all the resources that go with them.
The Indigenous medical workforce shortage is worse than the national shortage - and that's hardly surprising. The AMA will have more to say on this very soon.
With Indigenous health, it is important to remember the focus is not just rural and remote. There is equally a need for this workforce in the cities and large rural towns.
I feel the pain and suffering of poor Indigenous health every time I look into the eyes of sick Aboriginal kids.
We must help them and we must help all our children.
I have been talking a lot lately about childhood immunisation, childhood obesity and stopping young people taking up smoking. These health issues are important for our children. They are our future. We have to look after them. We have to give them a good start in life.
But there is one important health subject that doesn't get talked about enough - and that is child abuse.
The prevention and treatment of child abuse and neglect in Australia needs a multi-disciplinary approach. It involves people from the medical, nursing, teaching, childcare, social work, and law sectors. It needs non-government and government agencies working together.
Governments must provide support and education for parents to help prevent child abuse and neglect from occurring.
We held a summit earlier this year to raise community awareness of this taboo subject.
The AMA endorses the World Medical Association Statement on Child Abuse and Neglect. It states that the rights of children to be free of abuse and neglect take priority over any rights of adults.
The AMA recognises the need to view child abuse and neglect as a serious public health issue.
We call on the Government to form a national policy for child abuse and recovery that is accepted by all States and Territories.
Up until now, I have talked about the health policies for the coming election.
It is time now for a little indulgence on my part.
I want to talk about my pet subject area - and that is the link between health policy and other areas like education and social policy.
I suppose you could call it 'health policy as social policy'. I touched on it when talking about Indigenous health earlier.
For me personally, it comes from my observations during visits to remote Indigenous communities.
I have seen complex initiatives fail miserably. I have seen the most simple things work wonders.
Clean water, better housing and sanitation. These things improve health. Education. If kids can read and write, they are in a better position to look after their own bodies and their own health to get them safely to adulthood.
Some of the greatest gains in the health and wellbeing of Australians over the past 200 years have not come from health policies. They have come from social policies.
Social, economic and related environmental conditions have dictated the patterns of illness and disease in our societies. Changes to these factors over time have had an effect on our health.
Up until the mid 1800s, the single biggest factor in helping people to live longer was improvements in their nutritional intake.
Put simply, when people started to eat healthier food - and more of it - they lived longer. There's a lesson in that for all of us today with the obesity debate.
From the mid 1800s until as recent as 50 years ago, improved water supplies and better housing and sanitation had the greatest impact on people's longevity. People were living longer because of improvements in their physical environment. They were healthier.
Then the second half of the twentieth century saw remarkable progress in health technology and medical marvels.
Better hygiene, better hospitals, new technology and smarter ways of practising medicine.
And great advances in preventive medicine.
People today are much more aware of their own health.
But if you look at global health trends today, history may be repeating itself.
New health threats are emerging and maybe the solution to them will not come exclusively from the domain of health or medicine. We are seeing greater links between environmental health and human health.
We see new health risks in society today - every day.
People are falling through the cracks because of social and economic factors.
Some lack educational opportunities. Some lack important social support networks.
Some lack family support. For many others it is low income and low self-esteem. And for others, it is addictions to smoking, alcohol, drugs or gambling.
It is ironic that so-called improved living conditions in modern society have created new health problems. We are living in what some call an obesogenic society.
It means what it sounds like. As a society, we worship daily at the temple of excess and over-consumption.
Morbidity and mortality rates have increased in recent decades due to health problems such as cancers, cardio-vascular diseases and obesity.
Certainly, these health problems may be caused by biological factors, but human behaviour and the physical environment play a major role in their development.
In today's world, medicine alone will be insufficient to improve health and wellbeing.
Health policy, therefore, has to be more complex and must embrace more than one Government department. We need a whole of government approach to improving the health and wellbeing of all Australians.
While treatment of established diseases remains important, much more emphasis is needed on prevention. Improving health should no longer be the responsibility of the health sector alone.
I would like to see us move to a system where no Government department should act in isolation on policies or initiatives that may impact directly or indirectly on health.
Again, I cite Indigenous health. Out in the remote communities you can sometimes see cooperation between Department and agency representatives that delivers positive outcomes.
You would not see that same level of cooperation among the Departments back in Canberra or in the capital cities.
To make it work you need smart people at the local level - social entrepreneurs.
These people are doers and I've seen a few - but only a few. They know the local needs and the local ways.
But the health solutions for one area may not work in another. For instance, what Noel Pearson does in Cape York may not work in Tasmania.
We must develop more flexible health policies that reflect the diversity of our great country.
Health policy that is designed to span generations cannot and must not be developed in isolation. All of us in the medical profession and the health bureaucracy and Government must learn to wear many hats.
It is not a change that will happen quickly, but the thinking must start now. I will talk further on this matter after the election.
Unfortunately the long-term does not always feature in election policy.
But I hope today I have given you a snapshot of where the AMA wants health policy to head.
Not just for the coming election, but for the future - our long-term future.
We want the health system to be in a position to look after us in our old age.
We want the health system to sustain our kids as they go through life and have kids of their own.
To do this, we have to look after the fundamentals.
We need more doctors. We need more nurses. No health policy will succeed without them.
We need to fund Medicare properly to reward and support medical practice. We need to fund Medicare properly to ensure that patients do not have to pay more and more for their care.
We have to defend our public hospitals. We must build an efficient aged care system for our ageing population.
We must properly fund child and youth health programs. This is a vital investment in the future of our country.
We must restore pride in our national reputation by improving the health of Indigenous Australians.
The AMA has a few ideas to help the Government and the Opposition get it right.
They are all in this book - Key Health Issues for the 2004 Federal Election. I commend it to you.