Transcript of Dr Kerryn Phelps, AMA President and Dr. Michael Hodgson, Australian Society of Anaesthetics President, Thursday 8 February 2001, Canberra

Dr Phelps: I think it's a very difficult question. We do have limited health dollars and resources are being rationed whether we like it or not because there are not enough health dollars to go around to meet all of the need and I think what a lot of the doctors are saying is that we need to see a contribution being made by the patients in terms of optimising their chances of doing well out of a surgical procedure, and if patients are continuing to smoke and wanting to have these particular operations, that they will not do as well afterwards, so there has to be a choice made.

Choices are being made very day about which patients will get which services and this is a decision that's being made on the basis of which patients will do better after operation than others and clearly if there is a patient who is continuing to smoke up to the operation and after the operation they will not do as well with certain procedures as others and so those decisions are being made on those clinical grounds.

Question: Where do you think you draw the line though. I mean do you make the same judgements with patients who drink heavily or who use drugs?

Dr Phelps: There are decisions being made all the time about fitness for surgery and you want to be able to optimise a patient's fitness prior to surgery.

Obviously if there is an emergency situation and the patient's life depends on whether they have that operation today, tomorrow or next week, that that operation will be done, but if we're talking about elective surgery you want to be able to optimise that patient's conditions and their chances of recovery with fewer post operative complications. You don't want to put patients in a situation of having to have post operative pneumonia, needing intensive care, having some incident after the operation which could have been averted if the patient has stopped smoking or stopped drinking heavily.

Question: I think I can understand the argument about not smoking after the operation but why is it necessary to put this six months cut off point. Why not at the point of diagnosis say rather than at the point of, you know, some arbitrary date six months in advance of the operation?

Dr Phelps: We're fortunate to have an anaesthetist here with us who assess patients for operation and Michael I'll get you to answer that.

Dr Michael Hodgson: Certainly. It's very fascinating this issue is raised today because 10 years ago I was being interviewed by the media as an AMA President on this very issue of refusal by surgeons to perform elective procedures on patients who refused to have surgery, and they were talking particularly about people who were having major vascular surgery on limbs and they refused, they wouldn't stop smoking pre-operatively.

Interestingly the Minister of health of the day was Neal Blewett, and he came out publicly saying that doctors had the right to refuse to perform services on patients where it was considered a waste of time doing the surgery when they wouldn't comply with the request that they stop smoking. So that's a side issue.

The anaesthetic issue is that to get the benefits from stopping smoking you have to stop smoking for a matter of weeks to months. You can't just stop today and have the anaesthetic tomorrow and have no risk. The risk is still there for weeks to probably a couple of months later.

So from a pure anaesthetic point of view you've got to stop smoking for a period of time before the surgery.

The incidence of post operative pneumonia in somebody who smokes having major surgery is six times that of a non-smoker, and those are figures.

The incidence of people who have major vascular surgery in having poor results from that surgery if they continue to smoke - I can't give you figures but they're poor.

Question: If you like your smokes at the door and …

Dr Phelps: I think that the task of the PBAC is a difficult one. There are enormous pressures on the members of the committee to satisfy government, the public, the drug companies, and they have to be able to make an objective decision based on what they see as the facts on scientific basis and based on clinical imperatives - what drugs are necessary, how much they cost, whether they're affordable to the public.

In terms of whether the committee was stodgy, I think that that is actually an excuse for culling as many members of the committee as was possible.

Back in December the government tried to push through legislation which would have effectively gotten rid of the most experienced members of that committee. In effect that's happened by resignation of members in protest at Mr Clear's appointment.

I think we need to have experience on that committee. I'm saying nothing against the qualifications of the other members of the committee who have now been appointed but I think it will take them a little while to come up to speed.

One thing you can say is that committee will come under scrutiny like it has never seen before.

Question: You say you're perplexed about, puzzled by the appointment of Mr Clear, but what do you make of the Opposition's accusations that there can be really no other explanation than that the Government is in the pocket of the international drug companies?

Dr Phelps: I'd like to see some other explanation, if there is one.

Question: Do you think there could be one?

Question: Do you fear for the PBS itself? That that might be the …

Dr Phelps: I'm concerned that there will be increasing load placed on private health insurance premiums because the drugs that are not listed on the PBS will have to be subsidised by private health insurance.

Now I don't want to see a situation where private health insurance companies start acting like managed care organisations and deciding which drugs they will and will not subsidise for members.

Question: I wondered if I can ask you about the ACCC and MBF. What is your reaction to Mr Fels taking the MBF to task over these advertisements?

Dr Phelps: I think members of health insurance companies need to have all the information possible to understand what they are buying, and what they have purchased.

There's a lot of people have had their insurance for a long period of time and you know, they pay their premiums and they don't really understand until they're in a situation of needing an operation, needing to go into hospital of understanding what they're actually covered for and quite often people have been getting nasty surprises.

What we've been saying, particularly since last July, when we had a big influx of new members was that it was incumbent upon the insurance companies to make sure that there was absolute honesty and absolute clarity in their representations to their members.

Now particularly with attracting new members I think it's vitally important that people understand exactly what the nature of their product is, what they're waiting time will be, what their exclusions might be.

I think it will be up to the courts to decide whether MBF has acted in good faith on this particular issue, but as a broad principle I think fully informed members is the way to go.

Question: So there is a danger is there that accusations of these kind, of this kind, if found to be true by the courts could jeopardise the integrity of the private health insurance system?

Dr Phelps: I think if accusations hypothetically …

Question: Credibility.

Dr Phelps: Yes. I think if hypothetically accusations such as this are found to have been proven then it will be a great impetus for the health insurance companies that their members are fully informed and that there is great clarity in their promotions.

Question: What impact, by the way, if any, do these problems over disclosure or non-disclosure and what people are entitled to or not, what impact does that have on doctors specifically when they're dealing with patients?

Dr Phelps: It's created an enormous amount of paper work. I mean I talk to a lot of my specialist colleagues who say they are spending increasing amounts of time on the phone to insurance companies trying to find out if people are covered or not so that they can give informed financial consent before people have operations.

I mean you've got to understand that when people are proposed for elective or other surgery they're under tremendous stress. I mean they've got to worry about the operation, they've got to worry about what it means for looking after their kids, the family pet, you know, what happens to their finances and so forth, and you know doctors are trying to take some load off patients as much as they can.

We also are committed to providing fully informed financial consent but we can't necessarily stretch that to finding out exactly what the patient's covered for depending what table they're in, and which fund they're in, people need to understand, patients need to understand before they're in that situation exactly what they're going to be covered for and make sure that they have the cover that they need.

But it is having a tremendous administrative impact on specialist practice.

Thanks all very much.