Transcript: Dr Gannon, National Press Club Q and A

SARAH MARTIN: Thank you very much for your address, Dr Gannon. As moderator, I have the privilege of asking you the first question and I would just like to take you back to the part of your speech where you're talking about the increased costs when things move from primary care to hospital-level care. What can the AMA do to assist Government to reverse that shift, to reduce costs overall, and increase funding to primary health care, and does the constant wrangling with State governments - the Federal-State government ongoing pot-of-money dispute - how does that get in the way of reform?

MICHAEL GANNON: Thank you, Sarah. I think the answer to that question is in why we're so excited about the health care home;   that's a really great change and what we would like to see is those investments really made. Now, the key is you've got to fund it. You can't expect GPs to do this work and not fund it so the devil will be in the detail. Exactly how do we fund- how do we get the definitions right of what is a complex and chronic disease, which conditions does it apply to, which patients should be enrolled in these arrangements, and making sure that it's appropriately funded. Doctors are very aware that things can be frozen on them, and then you can't continue to deliver the care. As to the issue you raised around Federal-State relations, that's the bugbear of every government since Federation. It won't surprise you that someone from a small State - and I know what you mean when I say small State - people in Western Australia feel as if they live a long way away from Canberra and that Canberra doesn't listen to them, and I think that you will find that that is the view of people in some of the smaller States, that they would resent any views that perhaps command and control might be taken away from State governments.

But clearly we've got a problem there when cost shifts do continue to happen between State and Commonwealth governments. What we want as a community is to see those responsibilities tidied up. So, for example, if the Commonwealth Government invests in primary care and reduces the number of people needing care in the State-run owned, funded public hospitals, then that that is recognised. But that is a very, very challenging area, but, again, one that the AMA is willing to support this, and any government on in the future.

SARAH MARTIN: Thank you. Next question is from Fleur Anderson from the Australian Financial Review.

QUESTION: Hello, Fleur Anderson, Financial Review. You mentioned that health financing is an area of genuine need of genuine reform and, in particular, the AMA has been concerned by Government moves to cut bulk billing incentives for pathology and blood tests. I just wanted to check with you, Sonic Healthcare announced its annual results this morning and there's been a 30 per cent increase in its profit for this year and during your speech, you kind of had a go at private health insurers about their pursuit of profit. Is there a distinction that some types of health businesses are more worthy of taxpayer support than others? Is there room for reform in the diagnostic imaging area? Just interested in your thoughts.

MICHAEL GANNON: Thank you for your question, Fleur. I haven't opened up the AFR today, so I haven't- I don't know about Sonic's spreadsheets. The last time I checked, their pathology business in Australia wasn't a big part of their profits, but you do raise an important point. The truth is that we're actually seeing a contraction of the number of providers in private pathology. Recently, we've seen- St John have got a healthcare cell, its pathology arm, it just couldn't make a profit out of it. The truth is that pathology's been squeezed so much that only the very, very biggest providers with their economies of scale can deliver the services and that's a problem going forward.

Our argument is that we know that there are patients who will defer having important tests, often with the smallest out-of-pocket expense. There are people - again, this comes down to health literacy - who don't see the value in having thyroid function tests, or they don't see the value in having an ultrasound or an X-ray. And they will defer those tests. So, the challenge for us as a community is to work out how we work out mechanisms so that those who can genuinely afford to make a contribution to the cost of their health care; that's an imperative going forward, as the population ages, and the pool of taxpayers contributing diminishes as a percentage of the population. It's absolutely imperative we start to have these conversations. But what we can't have is not in-built protections for the most vulnerable in society, and we mustn't have a situation where people defer important care, especially when some of these things are such good value for money.

Visits to GPs, basic investigations, are very, very good value for money. A cholesterol test might cost the community $20, an ECG might cost $30, a chest X-ray $40. If you had a stent put in in a major hospital, that might be $40,000 or $50,000. So we've got to get smart in investing in prevention, but also that primary care level, there's good bang for the buck in those things that happen out there in the community.

SARAH MARTIN: Stephanie Peatling.

QUESTION: Stephanie Peatling from Fairfax Media. Sorry about the frog in my throat and thanks for being so nice to journalists in your introductory statements. We don't hear that very often, so that's always much appreciated.

[Laughter]

You mentioned the issue of preventive health and trying to take people to take better care of their own health so they don't end up with health problems later on. And the big one, obviously - pardon the pun - is obesity. We often hear a lot about the idea of a sugar tax. The Greens called for the idea of a 20 per cent sugar tax during the election campaign. Neither of the major parties are particularly interested in pursuing that idea. I just wondered about your thoughts on such a proposal. We often talk about it a lot. Is it a bit of a silver-bullet policy suggestion that we're hearing a lot about lately? Or how important is it as a genuine contribution to addressing that problem?

MICHAEL GANNON: The AMA supports a sugar tax, but we see it is as one of a broad range of initiatives. That won't fix the problem.

Too often - and I'm conscious of the fact I'm appearing on the ABC - but too often we hear the demonisation of Coca-Cola, we see the demonisation of McDonald's, when people make bad decisions about the food they put in their mouth every day, the food that they buy from supermarkets, the fact that we all eat so much processed foods.

The reason processed foods taste good is because they're full of sugar and salt and trans fats. It's also the reason airline food tastes so good. This is the real problem.

So, we can't just have a simple idea that this is the one solution. We need a whole-of-government, whole-of-society approach investing in public health campaigns, thinking about sport and recreation, thinking about how we design our suburbs, looking at traffic-light systems for healthy foods, investing in some really decent public health campaigns so that people know what it means when we talk about the percentage of sodium in processed foods, so that people understand alcohol labelling, so people are making informed choices when they do that everyday health promotion in their own homes preparing a meal for their family.

SARAH MARTIN: Tim Shaw.

QUESTION: Tim Shaw, Dr Gannon. Thank you so much for your address. 2CC Radio Canberra. Probably one of Australia's best-known doctors is Dr Google.

 [Laughter]

And it seems that more and more Australians are looking to the internet. You talk about a public health education campaign, you know, Federally-funded, State-funded, but what role could local general practitioners play within their local communities? With many, many more Australians from diverse cultural backgrounds coming to Australia, there's a fear and apprehension of going to see the white bloke down at the doctor's surgery. And what's the AMA doing to broaden its cultural acceptance within its own fraternity to make those new Australians feel very welcome in general practice?

MICHAEL GANNON: Thank you for your question, Tim. Thoughtful, as usual. You're quite right in saying that, sadly, a lot of Australians get their health information from Dr Google. I think the first thing to say is that Australian doctors aren't afraid of their patients being more assertive and seeking more information. It's something that … it's generational, it's much more common in younger patients. That idea the doctor knows best is ageing, as people who hold that view are also ageing. I think that the Australian medical workforce is, perhaps, reflective of the broader community. In fact, in many ways, our medical workforce is a lot more racially diverse than our society is. You raise, perhaps, the issue of people feeling comfortable in attending GPs and seeking information from them. I think that is so important that people feel that way.

I think we know that from all our statistics. We know that a very high proportion of Australians will identify their GP, a high proportion of Australians see that GP every year, and if they don't visit that GP, they visit another one in that practice. So, I think we're already succeeding in that area. What I would love to see is the start of a debate on how we fund general practitioners better so that they've got more time to spend with patients. The reality of a generation of undervaluing the value of general practice is that the only way that they can run their small businesses, sadly, is to churn through a lot of patients. Now, that means that we're missing out on the health promotion opportunities which are so important.

It won't surprise a lot of you in this room that doctors are uncomfortable with certain medications, for example, going off prescription. Now, that's because we see every visit to a GP as a health promotion opportunity, and I think that's so important.

SARAH MARTIN: Simon Grose.

QUESTION: Simon Grose from Canberra IQ. A couple of months ago, we had Pat McGorry here. He was putting his pitch for funding for mental health. He agreed with you on a couple of points. He agreed that the annual health budget was about $150 billion. He agreed that health funding is an investment. He would disagree with you, what you said in your speech, about shifting money across within the health budget.

He argued for a major structural change in the health budget. He said that mental health funding now is 7 per cent of the health budget. He wants it up to 13 per cent. Now, he declined to take the opportunity to identify which 6 per cent he would like.

 [Laughter]

I thought I might invite you to nominate just a few, 2 or 3 per cent where you see you could get halfway. And, if not, what should Pat's plan B be?

MICHAEL GANNON: Thank you for your question. There's no question that, as a society, we face an increasing burden of mental health issues and it's not exactly clear why that might be the case. We certainly know there is a significant contribution to mental health problems from alcohol abuse. We know there's a significant contribution from the use of illegal drugs. We're really concerned about high levels of methamphetamine use in our community. One of the things I've often reflected on is the great pace of life that … we all lead such busy lives, and that's at least making some contribution to the increased burden of anxiety and depression in our community.

The truth is that the vast majority of mental health services in our community are provided by GPs, not so much by psychologists, counsellors or even psychiatrists, and it's so important that we fund that really important area.

I have no surprise that individual doctors, given the profile like I've been afforded today, would choose to push their own barrow, if you like. I, too, would like to see greater investment in mental health. We know that, when you fix mental health, you reduce the risk of heart disease. You reduce the amount that people smoke. You reduce the amount they drink. You reduce their use of illegal drugs. So it is a worthwhile investment.

There's not a person in this room who hasn't, at most at one degree of separation, been touched by the tragedy of suicide. It's something that we think about lot. There are no easy solutions. There are no areas of obvious saving in the health budget. But what I've said in the past is that Government is much more likely to get it right if they engage with clinicians at the front line in deciding where we should be spending our money in the health system. If they do that, and especially if they talk to bodies like the AMA, who are charged with representing not only GPs and psychiatrists, but vascular surgeons and ophthalmologists and obstetrician/gynaecologists, maybe we're the group that's able to give the balanced view of where there's greatest value in the health budget.

QUESTION: Can I just follow up, when you say there's no savings to be found in the health budget, when you talk about the extra cost of hospital admissions, for example, does the AMA have any view as to what the potential savings could be if you could shift that demand to the primary care level?

MICHAEL GANNON: Well, you're exactly right and you've picked me up on the point. Of course there's savings to be made, but that requires investment in other areas, and it might take many years to see the benefits of that kind of investment. It sometimes will take, you know, more than a generation. But I would like to see a pivot in the way we think about the health system. The truth is that those of us who get paid for doing specialist procedural medicine in hospital are better remunerated for what we do than those working in public health departments and those on the front line in general practice.

Now, again, it will take time to see these savings, but we know they're there from the international evidence. It requires brave reform.

What I said in my speech is that the AMA has every intention of cooperating in a really positive way, and there are loads of our members sitting on the panels of the MBS review so that we can look at the procedures that aren't providing a great deal of value and, where possible, focus those funds on areas where we know are evidence-based improvements in people's health.

QUESTION: So, surgeons could take a pay cut, perhaps?

MICHAEL GANNON: I don't think I said that, Sarah.

[Laughter]

But I think- look, the MBS review is important work. The AMA fully supported the relative value study, which insiders will know about the last attempt 15 years ago to look at what was worth what in the health system. When the Government was presented with the numbers, which looked at the skill, endeavour, training of doctors and ranked it against engineers and lawyers, et cetera, and then they got the total bill, they got the shock of their life and walked away from it. The truth is, there are so many areas to the health system that represent outstanding value for money, and anyone who's had their colon cancer cut out or has had their hernia fixed and managed to get back to work will tell you that that is a real investment, not a cost.

SARAH MARTIN: Next question from Michael Keating.

QUESTION: Michael Keating from Keating Media. Dr, again, thank you for your speech. There's been discussion within Government of moving to a more consumer-driven health system with a My Doctor website, much like the My Schools website, as a centrepiece of that policy. What's your reaction to that idea?

MICHAEL GANNON: We've expressed concerns about rating systems and exactly how they might work. One of the basic ethical principles of medicine is that my colleagues are my brothers and sisters, and I don't like that idea that we might open up this idea. If you asked a similar question about advertising, where I could promote myself as the most outstanding gynaecologist in Western Australia, I would say that was probably wrong and I would say that that's not particularly helpful. The problem with those ratings sites is that the information on them might not be particularly well-controlled. There's the capacity to damage the reputation of individual professionals. They would need to be very seriously vetted. One of the more recent proposals was to expand the Whitecoat website, owned by some of the private health insurers, that they would own.

Doctors aren't afraid of patients having more information. We might occasionally get annoyed by some of the questions but it's our job to recognise that that's a positive with patients being armed with more information. But sometimes those are unhealthy.

We've seen this in other health systems. In Britain, for example, when they published complication rates from surgery amongst various NHS trusts, it just led to area health services gaming the system, denying care to people.

We can't have a situation where someone says, look, you're 170 kilos, you're morbidly obese, I'm not going to operate on you because you've got a high rate of breakdown wound infection.

We want to see people having access to the best care. Hopefully that's around the corner and not the other side of Sydney with someone with a flashy website.

SARAH MARTIN: John Millard.

QUESTION: Thank you, Sarah. John Millard, freelance. Dr Gannon, you said in your address that 86 per cent of patients with private insurance don't pay any gap. Now, some of us who live in Canberra might find that surprising, but I'm sure you're correct. Now, I'm sure that most people- most medical practitioners do, there are some who just don't charge anywhere near the rebate. I'm not talking about your hardworking GPs or physicians, and I have no direct experience of either gynaecologists or obstetricians.

[Laughter]

We both know who we're talking about; they're usually procedural specialists who can charge thousands of dollars more than what they're likely to get back from either the medical rebate or, even if they can afford private insurance. Do you think that the cost to those of us who need such specialists might become more accessible to us if they reduced their fees to perhaps four or five times the Prime Minister's salary?

[Laughter]

MICHAEL GANNON: Look, thank you for your question. Part of the answer to that question is the failure of the Medicare Benefits Schedule to maintain any sort of parity with other measures you might use of increasing costs, whether that's CPI, average weekly earnings, from time to time there are issues in our indemnity insurance. So, I promise to show you the graph which shows how the MBS has long ago lost parity with the true costs of providing high-quality health services, and of course the private health insurers then base their fees on that.

If you're talking about excessive fees, I think that they are a millstone around the neck of those of us trying to provide care to people. We believe in the ethical principle that a doctor is entitled to charge a reasonable fee. The reason that most practitioners choose to accept the insurer's fee is, one, because it's out of consideration for the patients. Secondly, it sometimes makes sense in terms of small business practice that you're not chasing bad debt all the time and you're not collecting co-payments - dare I mention that word - but excessive fees are not appropriate. I'm pleased to say that I didn't have a torrent of resignations when I asserted that I've never seen anyone who's worth five figures for two hours' work.

I sit in awe of the skills and the training of many of my colleagues. I think that there's some quite amazing work that gets done out there every day by urologists, by general surgeons, by vascular surgeons. At the same time, I would not stand before you and try and defend $5,000, $10,000, $15,000 gaps. I think that they are difficult to defend. I would defend the principle that we should be allowed to levy our own fee. I would equally say that it's up to individual doctors to be very considerate of their patients and their means, taking into account how afraid they are, let alone the limited means they may have to pay for out-of-pocket expenses.

SARAH MARTIN: Next question from David Speers.

QUESTION: David Speers from Sky News. Dr Gannon, thank you for your speech. Neither side of politics in the election campaign offered any long-term certainty on hospital funding. Labor offered a bit more, $2.9 million more than the Government but only over four years. Given we could be facing another election in, believe it or not, a little more than two years' time, how quickly does this need to be addressed? How pressing is the need for some long-term certainty to end this never-ending Federal-State clash over hospitals?

MICHAEL GANNON: I don't think I could have made it too much clearer in my speech that I think it's the Commonwealth's job and that certainty is what we need.

The unedifying spectacle of State Treasurers or State Premiers going to COAG to ask for the latest pile of money, they went quiet during the election campaign, so the State Premiers, even the Labor State and Territory Premiers and Chief Ministers were obviously happy with what had been offered up, but again, I think what we've done is just kicked the can down the road.

The AMA's job is to try to make this argument that public hospital care - just like other aspects of the health system - is a real investment. We need to change the language from it being regarded as a cost.

People are healthy, they get back to work, they get back to paying taxes. Older Australians get healthy, they can look after the grandkids so someone can get back to work and pay taxes. That is something that we should aspire to. We should aspire to be the healthiest society, we should be aspiring to winning the most gold medals when it comes to health prevention and different measures of quality like life expectancy, like perinatal mortality, any other measure you care to name.

SARAH MARTIN: Next question from Mark Kenny.

QUESTION: Mark Kenny, Dr Gannon, from Fairfax Media. I wonder if I could ask you about political culture and get your interpretation of what the recent election result was. Could it be said that the bulk of Australian voters said they want the budget deficit addressed, they believe the Coalition is perhaps the sounder economic manager on balance, but they also want health spending protected, education spending protected? So, essentially, they're saying we want these things done in some sort of unified way in pursuit of the national interest, and yet the system itself seems to deliver up, every time, yet more hyper-partisanship. We're seeing that played out again today. And if I could just have one quick follow up, what's your message to politicians who are still opposed to those tobacco health measures that have been instituted - plain packaging and the like - but which take money from tobacco companies?

MICHAEL GANNON: Thank you for your questions, Mark. The first one: I think that the right answers in any area of political endeavour often lie towards the centre of politics. I would love to see more- we would love to see more bipartisanship and more centrist policies. I think that Australians have got used to Medicare. They've got a different idea of what it means. I've often reflected to people having lived in the United Kingdom, you can't say anything against the NHS. The NHS is good. It can't be questioned and Medicare's the same. The word has achieved a- it's a totem. It means something more than what it actually- what it's meant to mean underneath that.

But when Australians say Medicare, what they mean is that they want ready access to public hospital treatment, free treatment in public hospitals, and they want subsidised treatment to see their GPs and for their basic health care. I don't see any desire from the Australian people- I take your point and I agree with it. I think that, wherever we sit as individuals on an ideological continuum, I think collectively the Australian people have said that they are very comfortable with the State, to a large extent, being in charge of their health and their education.

I've reflected on this a lot as someone who's had the choice of whether or not to privately educate their children and working in the private health system about what those systems really mean. I believe they value add. I believe that that means that there's more money, on the example of private health, going into the Australian health system and I believe in the ratchet effect. Private health needs to be better, otherwise, why would people pay- they're already paying their taxes, why would they then go and pay for their insurance policies? And why would they then, unfortunately, often pay significant gaps for their treatment unless they were getting superior treatments? And then the instruments of our democracy - you people in this room, talkback radio, the newspapers, knocking on the door of your politician - make sure that the public system is always at or just behind that level.

So I think the private system adds to the quality, it adds to innovation, and it adds to dollars in the system. But I take your point - the Australian people have spoken. Basic health and education services, they want the State to provide and they don't want the right of politics fiddling around with them.

As for your answer, we had a brief conversation earlier about libertarianism. There are many, many aspects of liberty that everyone in this room supports. There are even more aspects that I would personally support. But there are limits to our individual freedoms. I would like to drive home the wrong side of the road from time to time, but I can't. And I think that there is clear evidence on tobacco that these changes save lives and they save billions of dollars for the taxpayer. I remember the arguments against plain paper packaging; they were false, they are false, I'm delighted to see nation states in Europe one by one copy that legislation and those olive green packets. I can say nice things about private industry; I will not say anything nice about the tobacco industry.

SARAH MARTIN: Tony Melville.

QUESTION: Tony Melville, Dr Gannon, Director of the National Press Club. We dropped the ball on doctor training some years ago as we did with nurses and we ended up relying very heavily on the immigration program. Now, I'm just wondering what your views are about reducing our reliance on imported doctors, if you like, and also where we should be- are there some areas of doctor training that we should be focusing on?

MICHAEL GANNON: Thank you for your questions. You're quite right, we dropped the ball. My early incarnation in AMA politics was talking to then-minister Wooldridge and telling him that limiting medical student numbers was wrong and we would pay for it. And, in many ways, I think we've seen an overcorrection. I think that we don't need more medical schools and we certainly don't need an increase in the number of places in the existing medical schools. We have relied for a long time on international medical graduates. Can I say that they are greatly valued by our health system. I count them amongst my closest friends, colleagues, teachers, and mentors. They have been a huge part of our health system and wherever we go in the next decade as hopefully we achieve greater and greater self-reliance from our own medical schools, let's hope that we maintain the abilities to have flexibility in migration programs so we can continue to attract the absolute best from other parts of the world.

I think there's a moral issue to this; taking doctors from second and third world countries is dubious and I think that we need to think about that. We need to think about the areas where we've traditionally relied on international graduates, like rural areas, and try and fix that. Now, we do not need a rural medical school, we do not need more students. But what we do need to do are things that, again, are proven to work. So, if you give medical students positive experiences during their undergraduate terms in the bush, if you give junior doctors positive experiences, if you recruit medical students from rural and regional areas, all of those people are far more likely to go and work in the bush.

We also need to change the way we think about it. At the peak of your career to go and spend seven, eight, nine years in a regional town and then, if you want to, to move to the city to educate your children or to go to the next phase in your life and the next phase in your career, that's not a failure. So, that's an area where perhaps State governments can invest in seamlessly making it so that you inherit the practice or you inherit the car, you inherit the arrangements that are there so that doctors maybe can afford themselves of those opportunities.

From my experience of it, it is incredibly rewarding work in rural areas and our regions. It's an absolute imperative for the AMA to contribute to those measures but to come up with policies that actually work. Quick fixes like a medical school in the bush, they don't work.

SARAH MARTIN: And our last question from Peter Phillips.

QUESTION: Dr Gannon, Peter Phillips, Director of the National Press Club. Thank you very much for your address and for your step in sustaining the now quite long established tradition of presentations at the National Press Club by a leader- national leader of the AMA. I take you back to you address: you mention the wafer-thin majority enjoyed by the Government following the election, wafer-thin majority in the House of Representatives and you … I take you also to where you said we're a country where levels of health literacy are surprisingly low and about the bad choices we make in terms of foods we eat, fluids we drink, levels of fluid- of physical activity, and then you went on to say and that is before we even think about the latest dietary fad, flaky herbal remedy, unproven manipulation, or anti-vaccination rant on the web. Can you tell us what arrangements or plans you have in place for your engagement of the now rather colourfully-composed Australian Senate?

[Laughter]

MICHAEL GANNON: Well, the Australian people elected the Senate and there is no argument about that when you look at the new Senate rules; this is who people voted for. You quoted me accurately on all of those things and I did make reference to the fact that a lot of those Senators have been elected on very populist platforms. I announce my very clear intention to make myself available and the full resources of the AMA to inform and educate any Parliamentarian, from the Reps or the Senate, in these areas. That's something that we've done in recent years and I want to talk to those people. I've looked at the policies of some people in the Upper House and some of them are interesting. I think that it's perhaps good for the last question to remind us all that we're in National Science Week, and underlying the thousands of years of ethical medical tradition and what I like to call the art of medicine, there is medical science and we will always go back to evidence for what works and doesn't work. So I don't believe in the freedom to take the fluoride out of the water and I don't believe in the freedom to say that I'm not going to vaccinate my children and do my bit for the rest of society. But I'm there, the AMA's there to help.

SARAH MARTIN: Let's conclude on that note.

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