Transcript of Q&A - Speech to the National Press Club - AMA President, Dr Bill Glasson "Where Have All The Doctors Gone"?

CHAIR: Thank you very much Dr Glasson.  As usual, we have a period of questions from our media members.  The first one today is from John Millard.

QUESTION: Thank you Ken.  John Millard, Dr Glasson.  Last week here in Canberra I went to a specialist and was charged the scheduled fee.  I was so surprised that I sent him a card thanking him.  Usually it's far in excess, especially if you're a specialist.  And here I'm not having a go at the hard working GPs who are getting $50 a consultation - I'm talking about some of your colleagues - especially procedural specialists whose fees are even described by some, some of your colleagues, as being greedy.

Do you think that some of the exploding costs - costs in some areas, I won't mention, but you know what they are - could be contained by some of your colleagues, perhaps cutting down, you know, when it comes to two or three or four times the salary of the Prime Minister?

DR GLASSON: Thank you for that question.  The reality is that practices these days are small businesses, and I suppose to try and provide the high quality service that we're trained to do, that our patients expect, it is a major capital investment.  And all I can say is that, that we try and work within, I suppose, the confines of, or the costs of the system we operate in. 

And the reality is that the specialist fees - for most of them out there - I do fairly, I do feel fairly reflect the costs of providing high quality care.  And I think it's unfair to judge sort of specialists, or any person's income, as they are a small business - in other words trying to judge an income on a pre-taxed situation, before expenses are taken out - is rather unfair and unjust.

And so the reality is, is in order to provide a high quality practice, we often have to charge a fee that is appropriate to meet the cost of servicing that practice.  With ever increasing medical indemnity, with ever increasing accreditation costs, and the difficulty is that these days the amount of equipment needed in practices and the costs of that equipment is rising all the time, and so we feel we need to have it, but obviously we need to charge accordingly to try and pay for it.

But, but I can reassure you that 99% of doctors out there understand the predicament patients are in, and can I suggest to you that as you were rebated sir, I and all my, a lot of my, all my specialists have the same philosophy - if I feel my patient is in need and cannot afford any sort of gap at all, I'm very, very happy to rebate them, if that means rebating everybody for the day - which I often do when I go west - then so be it.

But my role is to make sure that person gets the best quality care they can, the highest quality care that's available, and I suppose in doing that I have to charge a certain level of fee to make sure that I can continue to provide that service.

The other point I will make is that there is enough fat in the system - and I reiterate, there is enough fat in system that allows me and my other colleagues to go out and do work in other areas that we wouldn't be able to do.  In other words, to work in often indigenous, remote areas, to go and give time in East Timor and other areas of the Pacific who need it, and we go out there and give that at no charge, because we feel that's our responsibility to do that.

But to do that, we need to have enough fat in the system to actually continue to pay our overheads while we're away.  Thank you.

QUESTION: Mark Metherell from The Sydney Morning Herald.  Can I ask you two questions?  One - all things being equal, given the shortage of GPs is likely to deteriorate over the next decade, are you prepared to make a stab at what the average patient's out of pocket cost is likely to be for a standard consultation, say in five years?

And secondly - now that you've had a bit of a chance to talk to your colleagues, do you have a sense of what proportion of doctors would be prepared to sign up to the Fairer Medicare deal?

DR GLASSON: Thanks, Mark, out of pocket expenses as you know, we did spend quite a bit of money investing into an independent study called the Relative Value Study which actually put a Level B consultation in a general practice around about $50.  In reality, that was done some years ago, and that's probably even higher, particularly as indemnity costs rise.

So at the moment Mark, as you know, the Medicare rebate's $25, so at the moment the doctor who's rebating or bulkbilling is giving a 50% discount - compassionate discount we prefer to use - and a lot of us do that and continue to do that because we've got the interest of our patients at heart.

But the reality is that we cannot continue to do that for an ever increasing group of the population - particularly the card-holders, which I think often account in many practices up to 60% of patients that are seen - they can't wear that load financially and continue to provide high quality medicine.

And so the message is that unless we can increase the Medicare rebate to an acceptable level that allows the doctors to continue to provide high quality medicine, then essentially the gaps will force patients out of the system.  Where they are forced, they are forced into the public system.

So, how much will fees rise?  Obviously depends on how the costs of, medical costs rise, how much, how well we control medical indemnity, etcetera, etcetera.

But I can see ever increasing gaps unless the governments of the day become serious about funding your and my insurance arm - and that's Medicare.

Your second question Mark, just remind me.

QUESTION:    does, obviously need to make sure we reflect the needs of the community I suppose.  So we are trying to modify our stand to reflect the views.

I've had a lot of pressure from AMA members too, saying, you know, get off your high horse and come back, come down to the real world and just see what's happening out there.

So as an ophthalmologist we don't see much of that, so I need to resort to my GP colleagues.

QUESTION: G'day Dr Glasson, Morgan Mellish from The Financial Review.  I was just listening to your speech, and you said, you accused the government of attacking doctors, said that was unhelpful, and then you said that the government descends into name calling often, but during much of your speech you appeared to attack the government back, and then also descended into name calling - referring to Patterson's curse.

You know, the AMA has obviously had a rocky relationship with the government in the past, and I'm just wondering whether you're confident of having a better relationship with the federal government than your predecessor did - who had numerous stoushes with them.

DR GLASSON: Thanks, Morgan.  Thanks for that question.  Look I am happy to work with anybody out there who's willing to listen, and I try and understand the point that we're coming from.

The AMA, really, is the voice for patients, and when we stand up and make an issue over something, I try to make it from the perspective of me being the patient, what I want.

I'm not out there to make a stoush with Senator Kay Patterson, the government, the Opposition, or anybody else.  I'm very happy to work with them, and I'm very happy to talk to them any time of the day.

Kerryn Phelps was a strong leader who I admire, and if I can have half of her sort of energies and drive, then I'll, you know I'd feel as though I've at least gone some way of doing the job.

I feel that we have to stand up and make a noise about it.  If things are wrong you speak about it.  You don't sit there under the bed and sort of murmur and grumble and whatever.  You stand out in front of the public and say this is wrong.

And so I think that what you'll get from me is hopefully honesty.  I am not party political - I don't care what party they come from - but if they've got good ideas, I'll certainly get behind them, and you know if it's out there supporting good patient care, if it's out there supporting the clinical independence of the doctor patient relationship, and the independence of my doctors to run their own business according to what they feel that the appropriate clinical standards are, and not being told by government how to treat asthma or how to treat diabetes, or how to whatever, then essentially I will get behind them.

And I think the government will listen, and I think the government hopefully will come back with some policies before the next election that reflect the views of the community at large, because what will happen at the ballot box, I can tell you what, is gonna bite and bite hard, if we don't solve these before the next election.

QUESTION: Jason Frankel from The Herald Sun, Dr Glasson.  The Health Minister has written to doctors' organisations - including the AMA - urging them to, well to tell your constituents to cease the queue-jumping, bulkbilling, billing practices, which have, which have sprung up.  Are you going to pass that advice on to your members, and what do you see happening with that kind of billing procedure in the future?

DR GLASSON: Well, thanks very much.  I suppose, first of all, I think the practice whereby you have two lots, two patients in the one room and you say to one patient 'well listen you're paying a co-payment and you're not', and the other one's saying 'I'm not paying anything at all' - and by the way, the one that pays only gets in front.  That sends a wrong signal.  I personally don't support it at all, and I don't think any doctors would.

But what it tells you is, is this is a symptom of the system.  The system's failing.  And why doctors are trying, what the doctors are trying to do, they're trying to preserve some level of bulkbilling, yet at the other end is saying 'listen I can't bulkbill everybody because I can't provide the quality of service I need to'.  So they're saying 'we're going to privately bill a group of them and we're going to bulkbill the rest'.  So they are trying to attempt to continue to bulkbill.

The impact of what the Minister has done - and I indicated this to one of her staffers - if she makes a huge amount of noise about this, then what will happen is bulkbilling will completely disappear altogether.  The doctors will say, well okay, well I'm not going to bulkbill anybody, they'll all be privately billed.

So the impact could be that we're gonna lose more and more bulkbilling.

But I agree with you that it sends the wrong signal, however, and I think if doctors are going to bill patients or make appointments based on, on the nature of the bill, then somehow those patients should be separated or whatever.  But I'm not, I wouldn't in any way advocate they be kept in the one room or the patient feels in some way inferior because they can't afford to pay the gap.

So it is the wrong message, and certainly we have indicated that to our membership.  But we've also similarly indicated to the government is if you increase the Medicare rebate the problem will go away.  You won't have a problem.

QUESTION: Sue Dunlevy, Daily Telegraph, Dr Glasson.  You've been big on describing the problems here today, but short on describing the solutions.  If you were health minister, how many extra students would you put through medical school next year, and by how much would you increase the Medicare rebate?

DR GLASSON: Sue, thanks for that question.  Firstly in relation to the medical school numbers, essentially, looking at our workforce participation, which is about seventy per cent, and I suppose looking at, what have we got, about 1,500 students Australia-wide, I would suggest to you that we're going to have to increase the numbers probably in the order of - I mean, anything from up to a thousand students to probably make - to have any sort of impact in the long-term.

I obviously would have to do a more detailed analysis to decide on - on - on the appropriate - the absolute number.  But given the shortfall that we have at the moment, I think that's probably being fairly conservative, to be honest with you.

Because the reality is that what we're training at the moment is not enough, full stop.  

Now, what would I do as a health minister?  Well, I think the first principle I would do, I would say that as a health minister here, I'm here to fund Medicare.  Medicare is our insurance arm for my constituents out there. 

Medicare is not there to fund doctors.  It's there to fund my constituents, my patients.  At the moment, I know, the cost of providing a level B consultation is in the order of $50.  Can I, as a Government, afford to pay $50 on any consultation, you know, a level B, seen by a general practitioner?

And if the reality is as a - as a Government I'm satisfied I can't do that, then I have to decide to what level I can fund it. 

Now that may be $30, $35, $40, or whatever.  And then - and then you may even decide - I'm not recommending this - you may even decide you're going to give a higher rebate to one group over another group.  But I suppose our philosophy is that unless you fund that, Sue, to a level that is - that is - comes, you know, at least close to the $50 mark, or something that the doctors will accept, and if it's - if it's funded, you know, reasonably close, doctors will do the hard work for you.

The doctors will rebate the patients that need to be rebated, and they'll accept that as the full payment, and the reality is that we don't need governments telling us how to practise medicine.  That's what's happened.

There's a huge amount of bureaucracy and red tape.  If you took all that money out of red tape and bureaucracy, put it back into patient rebates, you'd probably find you'd get a huge number of savings.  So what we say is get away from this business of trying to fund doctors - this concept of funding doctors. 

Fund your patients.  And then the system, essentially, will work itself out.  Does that answer your question, Sue?

QUESTION: Misha Schubert from The Australian newspaper.  Hi, Dr Glasson.  You've had a couple of months in the job now, and a chance to sort of survey the landscape, and make some assessments about the capabilities of other key players in the sector. 

I was just wondering if you could share with us your analysis of how effective you think Kay Patterson has been as a Federal Health Minister and maybe give her a mark out of ten for her job so far.

DR GLASSON: Misha, Misha - how could you do that to me?  Look, the job of the health minister, whether it be at a state level or a Federal level, is an extremely difficult job.  And I think that - you know, I'm sure if John Howard said to the ministry out there now who'd like the new job as a health minister, put your hand up, I'm sure there wouldn't be very many people wanting to put their hand up.

It's just about the curse. And it's the curse because it's a very difficult portfolio in the sense we have ever increasing demands on health, and we've got limited resources, unless we want to be taxed more and more, and I think most of the constituents out there wouldn't say they want to be.

So I admire Kay Patterson.  I think Kay Patterson has a difficult job.  And I think she's done a good job. And I think it's for me to stand up here and say that if Kay Patterson listens to the medical organisations, listens to her constituents, and acts accordingly, then I think that's what - you know, that's what we want our Minister to do.

And also, keep the door open so we can talk and communicate.  We won't - we won't agree all the time.  But at least we can, you know, openly communicate about issues.  So, any health minister in this country I admire and congratulate, and certainly at the Federal level, Kay Patterson's got a difficult job, and I commend her for taking it on, and she may have received certain amounts of criticism, but I think anybody in that job will get similar criticism.

So I'm happy to work with her, support her, and in whatever initiatives she would, you know, like to pursue.

QUESTION: And a mark out of ten?

DR GLASSON: A mark out of ten . Well, I suppose - that's unfair, Misha.  I think it depends what you're marking.

CHAIR: The next question's from Frank Cassidy.

QUESTION: Dr Glasson, Frank Cassidy from the Canberra Times.  I hope you'll forgive me to be a bit parochial, but Canberra is suffering a major crisis in GP services, and numbers are going down.  As a result the cost of going to the doctor here is higher than anywhere else in the country, and in its Fairer Medicare package, the Federal Government has lumped the ACT in with the other capital cities.

Now, the ACT Government has complained that really we should be classed as something special - we have this particular problem.  The Federal Government is yet to respond.

But I'm wondering, from your experience in dealing with the Federal Government, are they fair dinkum about solving this GP problem?  Or is this another example, using Canberra's case, of the economic imperative triumphing over the health needs?

DR GLASSON: Thanks very much.  I mean, I think that - can I just make one point about the ACT Government.  The ACT Government fees are going to go up if they don't get their tort law, or state law reforms in place appropriately. 

If there's one state around this country that is dragging the chain in relation to tort law reform, it's the ACT.  And what will happen is that the medical defence organisations, when they raised their premium - when they sort of sent out their premiums to the doctors - they're going to recognise, or look at those states where there's higher claims and higher payouts, and our concern is that the ACT will be one of those states where in fact the doctors will in fact be forced to pay a higher premium because they are considered a higher risk.

So my message to the ACT Government is for goodness sake get your tort law reform in place, acceptable to at least the New South Wales standards, and you'll find that the workforce that you have will stay here.  But what's going to happen, the workforce is going to continue to leave, because they're not going to want to pay higher premiums because their state government refuses to, you know, put in the appropriate tort laws or state law reforms in relation to medical indemnity.

I think the Government is - are they serious?  Well, I think they do recognise the problem, and I think they have come out and acknowledged that.  Now, whether they're really serious - I think they're not quite sure where they should be heading is the trouble.  They're not quite sure what the solution is. 

But in reality I think that if - I don't believe in disparate rebates on geographical grounds, if you mean - me to answer that question. Other words, I don't think - somebody sitting in Canberra should get a higher rebate than somebody sitting in Sydney or Perth.

I think you can have - if you're talking about disparate rebates, you may look- talk about in relation to economic grounds, but certainly not on geography.

And so I think that essentially government has to become serious about funding Medicare to an appropriate level, as I keep saying.  And what that level is up to the Government to decide, and then it's up for the community to decide what - whether that level's appropriate for them to be re-elected.

CHAIR: Mr Glasson, thank you very much.

Thank you very much for this last hour.  After just a couple of  months in the job I can imagine that some of those questions are not all that easily asked, and some of the issues on both the consumer and demand side are yet to be defined.  But I'm sure we'll see you back in the not-too-distant future to add the next chapter.  Thank you very much .

DR GLASSON: Thank you very much.  Much appreciated.  Thank you very much, everybody.  Appreciate it.

Ends