Transcript: Dr Andrew Pesce, with Richard Aedy, ABC Radio National

Subject: Election health policy; Collaboration between obstetricians and midwives

RICHARD AEDY: Health is really on the agenda now in the election.  The Prime Minister made it front and centre in her campaign launch.  The big-ticket item, of course, and the bit that Julia Gillard made sound exciting was the use of broadband to offer doctor consultations from a distance, and not just for the outback.

RICHARD AEDY: That sounds pretty good.  The appeal, you'd imagine, would be broad, especially when the plan extended to being able to show your child's rash to a doctor on the internet from the comfort of your living room.  Though, of course, if you're that desperate, you're not going to be feeling comfortable.

But how realistic is it? Well, Dr Andrew Pesce is the President of the AMA and he joins us now.  Welcome, Andrew.

ANDREW PESCE: Hi, good morning.

RICHARD AEDY: Which party does the AMA think is worth voting for on health policy?

ANDREW PESCE: Look, I think the AMA's role is to make sure that both parties have the best policies, not to influence the outcome of the election.  But I will answer your question in a way that helps, I hope, your listeners make whatever decision they want to make.

I think what we've got here is a Government which has invested significantly in doing a whole lot of research and background work to study what the problems are in our health system and where we need to go to improve them.

The National Health and Hospitals Reform Commission, primary care reform, preventative health reform, they really got a lot of information from experts.

They did their consultation tour, going around the country, and heard at the coalface what the problems were.

So it's not surprising that they have put this altogether and come up with very fundamental and ambitious projects for healthcare reform in this country.

The Coalition has been much, much more targeted, has narrowed its commitments to very much smaller areas of the health system where they've identified that aren't working well and they can build on existing structures, rather than involving themselves in a more ambitious reform agenda.

And I guess, depending on whether your listeners believe whether a Government is able to deliver on its commitment to fundamental reform in the health system or whether they see that that is too risky a thing for a Government to aim at, and prefer to be more comfortable with a targeted approach to supporting the structures that we currently have, well I guess that can help make up your mind whether you support one side or the other.

RICHARD AEDY: Right.  That almost sounds like a Clayton's endorsement, Andrew.

ANDREW PESCE: Look, I think - I really think that people do have a different approach to this.  And if you're talking about me representing my membership, there are a lot of doctors who are very, very, very excited by a commitment to make some fundamental changes to a health system which is really creaking at the seams.

On the other hand, there are those, especially our general practitioners, who have been complaining for years that the current system hasn't allowed them to deliver the care that they believe they could and really wish to be supported better to do that.  And so, you know, it really, really depends, you know, where you believe we will get the best move forward for our health system.

RICHARD AEDY: Alright.  Well, I wasn't really expecting an endorsement from the AMA. But okay, well let's talk about the things that Julia Gillard mentioned - internet consultations from doctors' surgeries, with a specialist at the other end, Medicare rebates for both of them. What are the specialists and the GPs saying about that?

ANDREW PESCE: Look, I think it's a great precedent because so far essentially there is no ability for Government-funded services to fund anything other than face to face consultations.

And for the most part, that's probably a good thing, because I think the best quality care is when it can be delivered in a face-to-face consultation and treatment.

Having said that, and especially in remote and rural areas, where there - you know, there are whole swathes of the country where there just will never be a psychiatrist.  If you do want a consultation with a psychiatrist, this actually now gives (a) the potential capacity - and I stress the word potential - and (b) a funding structure to help models develop which just aren't there at the moment for lack of funding.

RICHARD AEDY: It occurs to me it can only work or it's going to be restricted in terms of it working if the GPs in your area bulk bill.  Otherwise, this new kind of healthcare will be just as out of reach as for some people as healthcare is already?

ANDREW PESCE: Yes. I think there needs to be a recommitment to making the Medicare Benefits Schedule pay for the affordable cost and universal access to health services.

RICHARD AEDY: There's also the concept of the midnight crisis.  When there's something wrong, you want to call the new GP after-hours hotline.  But by 2012, you'll be able to see the doctor, show the doctor, over the internet.

ANDREW PESCE: Look, I can understand why that is seen as a very, very important part of this and it will be but the commitment and the infrastructure - just imagine I'm the doctor on-call at my public hospital at Westmead.

RICHARD AEDY: Yes.

ANDREW PESCE: And I now have a thousand people who are trying to beam in images of their children's rashes tonight.

RICHARD AEDY: Yes.

ANDREW PESCE: You know, you can see that it's not the panacea.  It isn't the answer to every problem.  And I think what we need to do is pick what it can do well, target it properly, do it in consultation with the healthcare providers and the hospitals and the GPs and the private practitioners and say what is actually do-able?

Because, you know, if people expect that, in 10 years time, every time they feel unwell they'll be able to switch on their computer, sit in front of it and get an instant diagnosis from a doctor, well, we are light years away from that.  Even if the technology of broadband capacity was there.

RICHARD AEDY: Because the risk, it occurs to me, is there are some things that you just aren't going to be able to pick up without being face to face.  You can't do a temperature measurement, for example.  And at the end of the day, there's going to be, for some conditions, and in many circumstances, no substitute for being in the same room.

ANDREW PESCE: Absolutely, and I cannot emphasise this enough.  And even though, you know, the medical profession and our rural doctors will go along with any change which does help improve care for their patients, we don't want to see this as an excuse for failing to support those face to face services, especially in those remote and rural areas.

We don't want to see this as the easy option to addressing the very significant infrastructure issues in rural health, which mean that if you live in a rural area in Australia, you have about a third of the Medicare funding spent on you than if you happen to live in a city metropolitan area.

And that's just a health inequity, which we need to address.  E-health and telemedicine can be part of how we can address that, but it won't be the entire solution.

RICHARD AEDY: On Life Matters today, my guest is the president of the AMA, Dr Andrew Pesce. We're talking about health policy in this election.

On healthcare more generally, Julia Gillard emphasised local control, local networks.  Do you support that?

ANDREW PESCE: Absolutely. I think that, having worked in a hospital system, the hospital part of that is absolutely essential.  In fact, I can say that, you know, the main differences that I now see, from when I went into the public hospital system as an intern in 1984 and what I see now as a senior doctor, is the disengagement of the clinicians, the fact that they are turning up to work just doing their nine to five job and they've stopped trying because no-one listens to them.

Often solutions do come from the top down.  Distribution of health resources at a State level has to be decided by State departments of Health.

But once we decide that there's a hospital that has to provide a service, then we believe that the doctors and nurses will work very creatively in coming up with the solutions that are required.

And more importantly, I guess, if you think about it, if doctors and nurses actually have ownership over the solutions that they have suggested and they've put forward and then we commit to saying, yes, local management will support that.  Well, if we have ownership we will then work really hard at implementing those decisions.

What we've seen in recent years is, because of a failure to engage and consult the local clinicians, solutions are coming from above which don't address the concerns, and clinicians don't place any credibility in them and they don't work hard to implement them.

So we have this disconnect between the clinicians at the coalface and the administrators that were referred to by Mr Garling in his review of the acute hospital system in New South Wales as the great chasm - that there were two really important parts of the health system that aren't working together at the moment.

RICHARD AEDY: So less of a role for, I suppose, the State Departments of Health in the future?

ANDREW PESCE: I would say appropriately identifying what decisions are best made at that central management level and …

RICHARD AEDY: It depends on who you ask.

ANDREW PESCE: Well, no, no.  Look, you know, if you go to the Director-General of Health and say, last night at Westmead Hospital a woman miscarried in the emergency department, she's not going to be able to tell you what the answer is, in Macquarie Street or Miller Street.  Whereas, you know, the midwives and the doctors who had to care for that patient on the ground could see exactly what the problem was and come up with solutions.  And that's what we do.  And that's what we do best.

So we need to find that - you know, micromanagement of all decisions from a central authority is bound to fail at that local level.  Whereas resourcing decisions, allocation to regional areas, saying this is how much you need to look after your population, go away and do what you can with it, well they're the ones that are quite properly made at a central level.

RICHARD AEDY: Andrew, you've been very careful not to endorse either political party today.  But would it be fair to say that the AMA has been seen as pretty conservative and more likely to be aligned with the Coalition?

ANDREW PESCE: Yes, I agree.  And historically, because the AMA has needed to reflect the needs and the interests of its member doctors, often the Coalition policies have supported doctors better than the ALP, especially when most of our members have been in private practice.

Increasingly now, however, we have more and more doctors who are salaried doctors in public hospital systems, we've got part-time GPs, women in the workforce who, you know, don't have the same values necessarily.  And it is harder and harder for the AMA to come down and say, you know, it's all one way or the other.

And I must say, you know, I think, you know, we had been criticised for actually being too pro-Government in supporting the health reform agenda.  We had decided that it was time that we needed health reform.  No change wasn't an option.  And we didn't want to see the impetus to health reform stymied, if you like, by wanting to concentrate on a whole lot of detail, which we do need to fix and we do need to consider, but we wanted health reform to proceed.

And so we have been very, very supportive of the Rudd Government and, you know, since his departure, the Gillard strategy to continue fundamental health reform in our system.

RICHARD AEDY: You're an obstetrician.  Last week we discussed on this show midwives' and parents' concerns about the new collaborative arrangements between private midwives and obstetricians, and that story page on our website has, at last count, something like 51 comments, many of them - most of them angry and many of them angry with the AMA.

You lobbied the Government to retain control of those working arrangements with private midwives, is that right?

ANDREW PESCE: Well, what we did was ensure that the need to enhance access to continuity of care from a midwife, which we recognise and see as a good thing, that was done without fragmenting of our health system.

Our health system already has too much fragmentation.  We know that doctors, obstetricians and midwives work very, very well together for example in our public hospital systems.  Why? Because there are protocols and guidelines that make it clear who is responsible for what and how they interface and when a midwife is required to refer to a doctor.

And what the AMA has done has been to roll out that successful model of collaboration into a sector where now there is going to be independent MBS funding for midwives and nurse practitioners and try to replicate that successful model, which has seen such good service in our public hospitals - roll out and coordinate the care that is needed to be supplied by both midwives and obstetricians in the private sector.  And I am working very, very hard to make sure my colleagues see this as a great opportunity to move forward and improve our health services.

I understand the midwives say doctors are protecting their own interests, but we are moving very much forward and we will encourage good collaboration, and I am absolutely confident in 12 months' time we'll be seeing evidence of good collaboration and it will be for the benefit of mothers and babies.

RICHARD AEDY: That is where we'll leave it.  Thank you very much for joining me today.

ANDREW PESCE: Thank you, Richard.

 

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17 August 2010

 

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