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Doctors Action Speech

Dr Adrian Sheen,
President, Doctor's Action
Penrith Panthers NSW
9th November2009

Good morning and welcome.

My name is Adrian Sheen and it is really is a fantastic pleasure to welcome you all here today, this important day for us as doctors as we come together to learn about and express our views on the Health Reforms that are proposed and in some case have already commenced for the health service and in particular general practice.

At the outset I would like to thank you for your tremendous support in being here. I thank the many GPs nationally who have taken the day off in support and I thank those who are watching this meeting via the internet.

I have been in solo general practice locally for nearly 30 years. I am delighted to be able to tell you that I have been totally satisfied with my work and I see it as a privilege to be part of patents lives, to be part of the community and part of this noble profession.

I also see on the not too distant horizon the extinction of the family doctor.

I read nothing in the Health Reform document to allay my fears.

To quote Prof Michael Kidd a former President of the College of GPs "The value of comprehensive, whole-person care delivered over time by general practice is not well acknowledged". I would go further and say it was not acknowledged at all.

Let me say at the outset that the main question for today is whether Australians want to have a family GP for if they do they had better speak up now. If they do not then silence will ensure that that family doctor is thing of the past.

I will give you 10 good reasons for being here:

1) My first reason is clear I like to believe that there is for the future for the family doctor.

2) Secondly we need today to learn about the draft Health reform proposals.

The Health Minister said recently - and I quote - "We are on the verge of some of the most wide-ranging reforms to the health system since the introduction of Medicare 25 years ago."

Anything that comes between the doctor and their patient must not be allowed.

We have unique relations with our patients. We know their foibles, their oddities, their temperament.

We need to decide whether these proposals are good for our patients - they would expect you to be aware of any proposal which may adversely affect their health and adversely affect their relationship with their doctor.

3) Dealing with Bureaucracy

We are over governed in all aspect of our lives. We now have more health bureaucrats than doctors.

Bureaucrats love to measure things - their targets are your future. HbA1C, cholesterol levels, BMIs.

But the most important things in your practices are not measurable.

Can you measure the relationship that you have with your patients?

Can you measure how important you are in their lives?

Can you measure their body language which tells you so much in the consultation? These are all the very essence of medicine.

Such basics - in the care you provide your patients - are never mentioned in the report.

Patient are individuals.

They are not bits of their conditions which fit beautifully into " guidelines".

It takes a lot of knowledge, experience, hard work, sensitivity and above all love of humanity to be the family doctor. We need to maintain the human element in care.

Family medicine, in particular, is an art as well as a science. We forget this at our peril.

4) Health costs and life expectancy

On the slide (This slide is taken from the Draft Reform Report page 20 showing Australians have a life expectancy of 81years just behind Spain - also 81 years- and Japan, 82 year. The Health expenditure for Australia is 9% GDP. Comparative figures for UK are life expectancy 79 years, expenditure 8% and USA life expectancy 77 years, expenditure 15%) for life expectancy and health costs and taken from the report it is shows that Australia has a health system which delivers a life expectancy, the 3rd highest in OECD countries at mid range cost. This is evidence based medicine - we deliver effective care for out patients.

There are two specific things to note:

The health costs in the USA are double that of Australia. Do they live in America longer than us? No, their life expectancy is 3 year less than ours.

I ask you to consider to what extent is our good result because of the strength of our general practice and the referral system from GP to specialist. This is under threat from the Government. Under these reforms care will be increasingly fragmented.

Secondly, this graph shows that our system is provides better results than the NHS in the UK.

Perhaps they should be looking here for advice as to how to improve their health system not us looking to them.

5) Nurses

I have no doubt that the concept will be raised by you all today. There are already about 370 nurse practitioners but they mostly work in the hospital environment.

Practice nurses are vital to our work.

Having independent nurse practitioners will inevitably result in increased fragmentation of care.

Just 4 days ago the Minister issued a press release stating that she will " simply clarify in legislation that collaborative arrangements with medical practitioners will be required to access the new arrangements."

The details of these requirements will be specified in, I quote, subordinate legislation following the ongoing consultation with the professional groups.

We all know now what the Minister means by collaborative care. We know what it means but having to define and put it in legislation only illustrates the tenuous relationship between all parties

Indeed, the need to define such a basic term sounds like organising a pre-nuptial agreement in a marriage that is bound to fail.

If nurses make the diagnosis, interpret the tests, prescribe the treatment - they are totally responsible for outcome.

GPs cannot take responsibility without leading the care. GP lead care has delivered excellent care with undeniably excellent results. This must not be dismantled.

6) Item numbers We are now in a time when patients will sit down and tell you they would like a 721, a 723 and 2710

We have a plethora of new items - and some just disappear such as joint injections. We are told just part of a normal consultation.

A Medicare rebate for GPs to refer for an MRI scan would be good for patients. It would save them having to pay for the total MRI or seeing a specialist who sends then sends them to have the scan.

Likewise it is way past time for an item to enable a GP to send a patient for a screening mammogram.

Having a screening mammogram ordered by their own doctor would encourage continuity of care.

An item for a screening mammogram would, at a stroke, enable you to add a further service to your patients which provides enhances the continuity of your care.

7) "Voluntary" Patient Registration

The Health Reforms want a trial of voluntary patient registration.

GPs will be paid to look after various categories of patients.

I hardly need mention the bureaucracy and administration costs of such a scheme both for the government and your practice - money which would be better spent on actually looking after patients.

This concept has not been thought through.

As with so much of the Health Reform proposals little detail has been given.

What happens if the patient wants to change doctor in the middle of the year?

How do patients get a "second opinion"?

Can doctors decide that they want nothing to do with patient registration? Do patients then have to go to one doctor about some symptoms but return to their family GP for other problems?

Figures quoted in the report from the Commonwealth Fund show that 9 out 10 Australians use one or two doctors a year. In other words the vast majority of people are quite capable of deciding who they want to look after them. They do not need a top heavy bureaucratic system telling them who should care for them - they have already decided.

Patient registration is just another arm of Government control.

It is expected that 32% of the population would be eligible to register with a doctor.

The Health Reforms talks about "bundled payments" which over the "course of care" are no more expensive to the government.

They also state that there will be redirection of indexation and growth.

In other words this heralds the end of indexation of the rebates.

Put it simply patients will be paying more for their care.

8) Super Clinics

The Health Reforms want the Super Clinic concept to be extended beyond the current 36 so that by 2020 there 10 times this number. 300 in all.

Each will have 15 GPs servicing a population of 17000 people. It is estimated that 25% of the population will be cared for in a Super Clinic.

To give you some idea what this means for every 2 McDonalds restaurants there will be one Super Clinic

You can imagine it can't you. The big "M" will stand for medical centre.

The Government are struggling to open the current 36.

Does anyone really believe that they will open one of these Super Clinics every 2 weeks for the next ten years. Why is the Minister so silent on this? These Super Clinics will be a major election issue and I believe they will the Governments Achilles heel.

The Super Clinic program will involve well over 4500 GPs.

There will be no incentive for young doctors to take the business risk of starting their own practice as they will have to compete with taxpayer funded Super Clinics.

And yet there is no greater incentive to provide long term care to your patients - the very essence of family care - than to have committed yourself to the infrastructure of your practice.

For an example let me show you the new Townsville Super Clinic

Here set in amongst 8 practices within 5kms is the new clinic.

In a letter from the Governments Super Clinic Branch - and that is an official name for the Department - such a clinic in this location would - and I quote - "it is the expectation of the Government that GP Super Clinics will build on existing primary health care services - that is enhance rather than compete with these services." "The Department will monitor the progress of the Super Clinics to ensure they provide ongoing integrated primary health care services in line with the GP Super Clinics Program Objectives for the next 20 years".

What happens if they fail - does the taxpayer just pick up the bill?

There would be a perception in the public arena that if you, say, had a headache you would ring up and see a doctor at 9 am who will send you to the physiotherapist down the corridor and then you could see the psychologist and perhaps it is work related so you go next door to the occupational therapist, check in to have you your feet looked at by the podiatrist - pick up your pills from the Pharmacist and by 5 o'clock you will be home and feeling much better.

The reality will be very different. You will go to the one stop shop the nurse who will decide whether you need to see a doctor. You will wait 3 hours to see him and if you need physiotherapy you will have an appointment with the one stop shop physiotherapist, not because he is the best physiotherapist for you, not because they suit your personality but because that is the physiotherapist that it there.

You won't be able to get an appointment for 3 weeks because there are limited government finances. The story will go on for all the other specialties.

Most importantly you will have to travel to the one stop shop by bus, by train community transport or neighbours car to get to the Super Clinic there will be a significant cost for the transport.

When you want to go back to your family GP - you wont be able to - he's gone.

9) Medical students - the future

These are the future of the profession and the most vulnerable. It behoves us to ensure that they have a future - even it is that for the selfish reason that I would like a family GP to care for my family and myself when I retire.

These students have an extremely tough life ahead. The rapid increase in numbers mean that there is no guarantee that they will ever be registered, their postgraduate training will be difficult to obtain and they will be obvious target to staff the Super Clinics.

We hear about the "doctor shortage" but we have 114 GPs per 100,000 this is nearly twice as many as there are in the NHS in the United Kingdom.

The problem is that GPs prefer to work in skin clinics, travel medicine, psychological medicine executive checks occupational health rather than do General Practice.

The rules, regulations red tape combined with the hours and expectations of the Government makes general practice an unattractive career choice for many.

10) Our patients

This is really the reason that we are here today. It is certainly the message that I wish the public - that is our patients - to understand.

This reason is bigger than all the other reasons put together.

As doctors we cannot be reassured that the Government tells us, and I quote from the Sydney Morning Herald: GPs have "nothing to fear" but do our patients?

Do patients have nothing to fear from the disappearance of their local doctor Do they have nothing to fear from the disappearing choices they have? Do they have nothing to fear from rationing of their health care, from the wastage of taxpayers funds use to create this alternative primary care system, from losing their family doctor who is part of their social structure, their friend and confident? I believe our patients have much to fear.

We must ensure that there is no Government or Opposition policy which puts a barrier between you and you patients. It is a simple message.

There will be an election within 12 months.

Do not underestimate the effect you can have with you patients.

On average you see them 4 times a year.

They are our greatest allay.

We need tell them on every visit that at no time in Australian medical history is the local family doctor under such threat. Under these reforms, extinction is a certainty within a few short years.

Doctors Action needs to be united in purpose and ensure that the public realise that reforms that do not put them, the patients, first are bad. Reforms that put a bureaucrat between them and their doctor are bad and reforms that do not recognize that value of the relationship between them and their doctor are bad.

It is a simple clear message and one which we must tell each and everyone of our patients at each and every visit.

Thank you, each and every one of you for being here today. It is better for our patients to have a day without their family doctor than a lifetime.