Transcript of Q&A - National Press Club, Federal President of the AMA

18 Jul 2001

Transcript of Q&A, National Press Club, Federal President of the AMA, Dr Kerryn Phelps

Wednesday 18 July 2001, Canberra

QUESTION: You did not mention the issue that has caused a bit of friction between yourself and the government in recent times, and that is cholesterol-lowering drugs.

Dr PHELPS: Apart from the low fat seafood meal at the meeting.

QUESTION: The new guidelines for the prescription of cholesterol lowering drugs have now been formalised, which seem to put more obligation on the doctor to ensure that patients are at least making an attempt to lower cholesterol levels through diet, et cetera. Do you think the average doctor will go with that; and how successful are such guidelines likely to be in reducing prescription of Statin?

Dr PHELPS: There is an old saying about teaching grandma to suck eggs and teaching doctors to give lifestyle advice about diet and exercise when somebody comes back with their first signal of high cholesterol is like teaching doctors how to suck eggs, because cholesterol and managing cholesterol is something that doctors do in their day-to-day work all the time. There is a problem with compliance, with the Statin drugs particularly, when you have somebody who basically has no symptoms yet they are told they have a number they have to treat. It is very difficult to get people to take those medications which do cost them money, there is an effort in taking a pill every day and there is sometimes side effects. You do always try to give people the advice to manage their cholesterol with diet and exercise first. Then, obviously, if that is not working you will prescribe medication because of the health implications of an untreated high cholesterol.

The other issue that we would be concerned about and we need clarification about is whether this applies to people who have been in hospital and have a history of heart disease, because this would be contrary to international guidelines. People who have had a heart attack or who have a history of heart disease should not have to wait six weeks to qualify for their Statin drugs.

QUESTION: On a broader issue, when you took up the post as President of the AMA, you indicated you wanted to move away from the former close relationship with the government. By your own admission you have achieved that. I wonder if you could describe how you will be approaching the relationship with the government in the remainder of your term and if it will still need be as combative.

Dr PHELPS: It is a little simplistic to say that I wanted to move away from a close relationship with government. What I was saying was where we had problems with government policy that I would not be afraid to take that up to government and to state that publicly, if there were problems and if the diplomatic approach did not work. I make no apologies for being prepared to fight for what is right for the health system and not just roll over and play dead.

It is important that a strong advocate is in place for the health system of Australia because, as I have said, we are on the knife's edge for a lot of these issues and crunch time is here.

That does take sometimes a 'not nice' approach to politics. You cannot always be friendly and be nice about health policy. Where there are significant departures from what the medical profession feels is right in the system, then I am obliged to make that clear. In the future, we will be doing exactly what we have been doing, and that is advocating to government, to whoever portfolio is appropriate, what we believe is best for the health system and also making sure that the public -- who own the health system after all -- are aware of these issues.

QUESTION: I want to pick up on your introductory theme of your tag of a militant trade unionist. In Western Australia the new health minister has accused doctors of turning hospitals in an industrial battleground. I just want to know your opinion on his performance in his first five months and that of the new Labor government on health issues.

Dr PHELPS: In Western Australia we have a new government in place, we have a new minister, and I think they are still coming to terms with the enormity of the health portfolio and the system in that state. I think the first good thing that they did was to get rid of the Metropolitan Health Services Board, which was an extra layer of bureaucracy that the Western Australian health system did not need.

But it is important that the doctors in that state have been able to express that the public system has been allowed to run down. They are having tremendous difficulty recruiting doctors to Western Australia, and in particular there is now a brain drain of specialists from Western Australia who are being recruited over to Queensland. So Western Australia is not only having trouble recruiting but also having great difficulty retaining doctors.

The Western Australian government is going to have to bite the bullet and pay market rates for doctors to ensure that they stay there. They might even have to pay above market rates to attract doctors to Western Australia, particularly into the public system. But it is early days yet for the health minister and for the Western Australian government.

I think the big mistake they are making at the moment is not talking to the medical profession.

I think that is a sure recipe for disaster. If they are able to sit down and talk to the Western Australian AMA and the medical profession, I think they will find they will get a lot further in getting practical solutions. The AMA was told in Western Australia that, if they called off the industrial action, the premier and the minister would sit down and talk with them. They have called off the industrial action, and the second part of the equation has not fallen into place yet. I would encourage the premier and the health minister Bob Kucera in Western Australia to do exactly that: sit down and talk to the medical profession.

QUESTION: Can I refer to a quote in your speech:

"It is the patients and the doctors who are best placed to advise on health policy when the bureaucracies and the politicians are often removed from the everyday realities."

That is a reflection on Dr Wooldridge, isn't it?

Dr PHELPS: I think you have to work day to day in a system to understand the frustrations. If you are in a general practice and you have a patient sitting across the table from you and you are saying to them, 'I am going to try to get you a bed in a private hospital,' and it takes you six or seven phone calls in three days to get them a bed, you know there is a problem in the private system. If you have a patient who urgently needs admission to a public hospital and you have to make phone calls to three different emergency departments to find one that is not closed, you know there is a problem. You do not have to wait for it to be filtered through; you are right there at the front line.

If you are working as a politician or as a bureaucrat, this is not an insult to these people; it is stating a reality that, unless you talk to the people who spend every day sitting with patients and dealing with frustrations in the system, then by definition you will be removed from the everyday realities of the health system. It takes a while for these things to filter through. Unless they are actually going and sitting in hospitals and sitting in practices and seeing what the problems are, then they are only ever going to get filtered evidence. The point I was making was that doctors and health professionals must be consulted on health policy because that is where you will get the practical solutions.

QUESTION: Comrade Phelps, you have talked in the past a fair bit about your country obstetric comrades leaving obstetric work because of soaring medical indemnity costs, and my question is about general practitioners. Are doctors also leaving general practice work because they are dissatisfied about their incomes; and what do you think of the level of general practice incomes today?

Dr PHELPS: The AMA has been very concerned about the situation in general practice for a long time, and I am very much on the record regarding those issues. We have just completed a survey of GPs around Australia where we had 7,000 detailed responses. We were looking at the work force in Australian general practice. One of the things becoming clear is that, while we might have numbers of doctors registered and working in general practice, there is a difference between different groups as to who is actually spending consulting time working face to face with patients. A lot of GPs are working some of their time in consulting and some of their time doing other work such as divisions or education or driving a taxi -- for all I know -- but they are working at things outside of medical practice as well.

Just last week in the Medical Journal of Australia we saw a survey released which showed that 50 per cent of Australia's GPs are not happy and are not satisfied with their work. This is tragic because general practice has the potential to be most satisfying medical career that there is. It is the frustration of increased bureaucracy, increased administration and decreased viability of their practices because the Medical Benefits Schedule has not kept up that is creating a lot of problems for general practice and, yes, many of them are giving up and doing something else.

I think that is tragic because we are losing a lot of very good people from this specialty. We do need to see urgent action. The action will come on two fronts: on one front it will be the government having to take account of the relative values study and do something really constructive for general practice in terms of remuneration for patients' rebates. On the other hand, we are going to see those doctors who remain in practice increasing their fees and abandoning bulk-billing because they simply cannot practice quality medicine in that way. So we are once again, in general practice, at crunch time.

QUESTION: You mentioned it several times, and in this room probably most people do understand what the relative values study was about, but would you like to spend couple of seconds telling the rest of the audience what it is about?

Dr PHELPS: I will clarify the relative values study. This was a six- or seven-year study, which was a joint effort by the AMA and the Commonwealth government, which was looking at the real value of medical services comparing with professions other than medicine and comparing with the medical profession in other countries. The AMA has done some preliminary modelling and it came to the conclusion that Medicare benefit fees, which is the schedule that governs all medical fees public and private, is about $1.5 billion per year short. In terms of patient rebates as an insurer, Medicare is paying $1.2 billion less than it should be for the real value of medical services. This is creating the problem of, No. 1, gaps which are being picked up by household incomes and, No. 2, GPs that are being picked up now by the private health insurance funds.

QUESTION: During your long running and very public dispute with the health minister, is a reason that he found it difficult to work with you that, no matter what he did, you were always criticising him. You have had lunch and made up, since then I know that some of your press releases have continued to criticise him and I think you described the insurance policy last week as 'confusing crap'. Can you today say three positive things about the federal government and its health care policy? (part of this question inaudible)

Dr PHELPS: If I could just clarify that was not my verbiage. As you can tell from my speech those would not be the words that I would use. We simply quoted somebody else as saying that the health fund brochures were 'confusing crap'. What we did say was there was a double standard operating by the health funds. On the one hand, they are saying that doctors should provide informed financial consent for everything that they could possibly dream of doing to a patient or with a patient in a hospital; and, on the other hand, the health funds have been trying to back away from -- in fact, completely sabotage --efforts to put the costs of their products and the services that they provide for their product into an information brochure for patients. You cannot on the other hand say doctors have to be completely up front about predicting what their costs are going to be when the health funds are not prepared to put their costs up front. That is what I was saying there. I think we do need to put some pressure on the health funds to make sure their brochures are not confusing crap.

QUESTION: But can you say three positive things about the federal government?

Dr PHELPS: Yes, I can. I think the federal government has made a tremendous effort in immunisation and we not have unprecedented levels of immunisation in this country. I am on the record also as saying that the private health insurance initiatives undertaken by the federal government were an absolute necessity and have been effective. Let us think of a third thing -- the government is talking to us again.

QUESTION: Double beds in nursing homes, I was wondering if you could tell me if this is a sign that baby boomers are well and truly preparing for their autumn years and whether you had any other ideas about how to make those facilities more user friendly to protect the dignity and lives of the people in them?

Dr PHELPS: I sometimes wonder how much older people are actually asked about what they want in an aged care facility. One of the best things you can do for yourself in thinking about aged care is to visit a few nursing home and aged care facilities. If any of you have had to go and visit a few nursing homes and plan for an elderly relative, you walk out shaking your head and thinking that you have to try to pick between the best of a bad lot. Some of them are excellent; most of them are not.

We really need to look at this with the baby boomers in mind, who perhaps are a little more vocal about what their needs might be into the future - yes, I think baby boomers starting to plan for how things might be in the next 30 or 40 years - and we do start thinking, 'How would I like to spend my retirement years?' Having double accommodation is one way of reducing the stress of going into assisted accommodation. The notion of separating people because one of them becomes unable to look after the other is just inhumane. The point I make about double accommodation is that, if people want to be able to spend their final days together, the system should facilitate that and at the moment it seems to conspire against it.

The big thing we need to do is to ask aging people and ask the baby boomers what they want for their future, how they would design the ideal nursing home and then cost it out and see if we could actually come up with a number of different models so that people have choices. At the moment the choices are rather limited.

One of the other areas we need to look at is not just in residential aged care but in aging at home, in having people in their own homes but provided with adequate community support that enables them to remain independent for as long as possible and does not put an undue burden on families. The issue of providing community based care is one that we do need to pay far more attention to so that there is not just this horrible choice between not coping at home and being dependent in a facility and being separated from your partner.

QUESTION: I was just wondering if you could expand on that last question and whether you think the provision of double beds is something that the Human Rights Commissioner should have a look at.

Dr PHELPS: Good idea, John, make some notes.

QUESTION: The other thing is that you seem to be suggesting that accreditation should be handed back to the industry rather than something that the government does. Has that approach already been tried and been found wanting? What is the thinking about that particular shift?

Dr PHELPS: The thinking behind that is to amass the expertise from the aged care sector and to have a process of accreditation which is owned and accountable by the aged care sector itself. I think government does need to have a part in this but I do not think necessarily think it should run it.

The reason we are looking at holding an aged care summit later this year is that we do need to get together all of the great minds in aged care working in aged care, including older people, and ask what they believe needs to happen in aged care into the future. Remember that we are not just planning for next year or five years time: we have to look at the next 50 years. We can project the population into 50 years; we need to be able to work out what is going to be the most appropriate way of dealing with a range of care needs and independence levels over the next 50 years.

QUESTION: It is now clear that the next election will be fought between the tax cutters and the spending increasers, to quote the Prime Minister. Given your call today for quite a large injection of funds to health and your belief that health will be the No. 1 election issues, doesn't that inexorably lead the AMA to one side of the political fence during the next campaign, to the Labor Party side of the political fence, and is that clear for you now?

Dr PHELPS: Not necessarily, and in fact the AMA is a completely non-partisan organisation. We would not endorse one party or another. What we will do is look at an issue by issue basis between now and the election. In terms of health spending, I think what we need to do is perhaps rearrange spending generally in government and ask the fundamental question as to whether we are spending enough on health of as a percentage of the GDP.

I would like to see improvements in efficiency right throughout government spending so that we can allow for spending on important areas like health. If there are other areas that can be trimmed to allow for health, then that would be my argument.

QUESTION: Would you be arguing against the government promoting tax cuts as the first use of any increased surplus?

Dr PHELPS: I would be wanting any expenditure that is available to be going into health because there is such a great amount of unmet need.

QUESTION: You have called for the major parties to take a non-partisan approach to health policy. Given their rather fractious record on health policy, along with IR and education, this does not look all that possible. Could you pinpoint particular policy areas where this non-partisan approach is crucial? Could you also briefly outline what you think the main agenda should be for a national health summit?

Dr PHELPS: The main areas are the ones I talked about today which are the too-hard basket issues, the ones where the wires are very tangled between Commonwealth and state and between the states and crossing sectors -- that is indigenous health, aged care and public hospitals. If we can elevate those three issues above party politics, then I feel there are tremendous gains to be made for the Australian health system.

In terms of a national health summit, we need to be looking at key areas of spending. We need to be looking first and foremost at those key areas where there is such a huge amount of unmet need and where there is a great deal of social injustice; for example, in the areas that I have mentioned of indigenous health and aged care in particular.

We need to look at an agenda that has a long-range vision and that looks to the future, not just the next few years. Let us have a look at what funding is available now, at what our population projections are and at what our work force, nursing and medical, is now and into the future. Let us look at whether we will be able to meet that need in the future. Let us look also at how the public hospital system is funded and at community based facilities. Should, for example, aged care come under one umbrella? Should the states or the Commonwealth take care of that issue?

These are fundamental issues that need to be asked at a health national summit to get all the people involved to raise the difficulties and to make sure that people who are running at the front line -- the clinicians, the doctors and the nurses, and the key stakeholders -- have a part in developing health policy into the future. We need to look past the next three years. That is just not far enough. We have to look to the next 50 years.

PRESENTER: Thank you, Dr Phelps. Congratulations on this past hour. You have covered an enormous amount of territories.


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