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Senate Select Committee on Health

BURGESS, Dr Zena, Chief Executive Officer, Royal Australian College of General Practitioners

JONES, Dr Frank R, President, Royal Australian College of General Practitioners


CHAIR: Welcome. Thank you very much for joining us this morning. I invite you to make a brief opening statement and then we will continue with questions.

Dr Jones : Thank you for asking us to contribute to today's discussion. Thank you, again, behalf of my college for the opportunity to appear before the committee to outline our views on the proposed changes to Medicare. I think my colleague Dr Bastian Seidel, who you met through your inquiry when you were in Tasmania, informed the committee about the role of the college when he appeared before you last November. So I will proceed with sharing our perspectives regarding the current situation.

It is quite clear, to state the obvious yet again, that a strong primary care section in general practice has better overall health outcomes. A regular place for medical care is associated with a fourfold reduction in hospitalisation. Increased continuity of care leads to higher patient satisfaction and almost halves emergency presentations. When an admission does occur, the length of the stay is halved. General practitioners are clinical experts in providing personalised, high-quality care. General practice is a medical specialty in its own right and the only specialty with continuation of care at its core.

Australian general practice patient services have been unfairly targeted by the government to find savings within the health budget. GPs and practices are now faced with an ethical dilemma of providing ongoing quality care balanced against practice business imperatives. Please remember that most general practices in Australia operate as small businesses.

The government's changes in December lead to an unprecedented protest from GPs. Thousands of GPs contacted the RACGP with concerns regarding the changes and requested advice on how to implement them. Nearly 47,000 patients, GPs and other medical specialists signed our petition to the health minister. Others wrote to their MPs and displayed posters in their waiting rooms informing their patients of the impending changes. We do not often mount campaigns. We are an academic college. But this situation warranted an immediate response.

Needless to say, the college and its members do not support the changes. We have provided a submission that provides more detail on our issues with the model and the process used by the government to arrive at their budget measures. I would be happy to take questions on that submission. But first I would like to address the area for real reform and real areas for savings that do not threaten the sustainability of the primary health care sector or target the most cost-effective part of the health system.

There has been absolutely no debate about the cost of specialist services or hospital based care. Further health savings could easily be achieved through improved chronic disease management, amendments to the prescribing authority hotline, reducing hospital admissions through better investment in primary care and addressing duplication and inefficiencies in the current system. Quality can be promoted by reconfiguring the GP MBS attendance items to encourage in-depth consultations about diagnosis, therapeutics and prevention—the three areas that GPs are experts on. Voluntary patient registration as part of an implementation of the medical home will transform the way GPs practice and result in better health outcomes for all Australians.

We are operating in a very complex health environment. Life expectancy is increasing. The population is ageing. Chronic diseases are becoming more prevalent. New technologies are increasing the effectiveness of care but also increasing costs. Short-sighted changes will not respond to these challenges constructively. Our recommendation to this committee is that the government needs to take the time needed to undertake comprehensive consultation with the profession through the GP college, our colleagues and our patients.

Our college represents 29,000 GPs. We have recommended to government that it place a six-month moratorium on the proposed changes and establish a GP health reform expert group with representatives that include GPs, patients and representatives from the government. While I have had brief discussions with the minister since she took charge, the changes to the time for consultation went off the table. I understand that consultation will end in a couple of weeks, and this is simply not enough time to analyse and identify the serious implications of these changes and will likely result in more budget measures that damage the most effective part of Australia's health system. I have appreciated the opportunity to talk to you. I am happy to take any questions, thank you.

CHAIR: Dr Burgess, do you want to add any comments at this point?

Dr Burgess : No.

CHAIR: Dr Jones, there were a number of very important issues that you raised there, but can I take you to the final comment that you just made. We have heard this morning from the AMA, and it has been on the record on multiple occasions around the country, that consultation has been the thing that has been missing that has led to the most egregious decision making, which has everything to do with dollars and nothing to do with health policy. In your closing comments, you just said that you expect the consultation to go for only a matter of a couple more weeks prior to the government firming up, once again, another position, having already declared that they continue to remain committed to a price signal. Is that correct, and could you expand on that?

Dr Jones : Sure. We have had very brief contact with the minister, purely because of timing issues. We are meeting with her next week. Briefly we met her last week at United General Practice Australia, and she was very much in the listening mode, and that was good to hear, but the indications were that there was a time limit on the consultation process. I can give you no more information than that.

CHAIR: So there is a time limit on the consultation process with the new minister, but we do not know what the time limit is.

Dr Jones : Correct.

CHAIR: But you also said in your opening evidence that you thought there should be a protracted period, a moratorium of six months. Is that correct?

Dr Jones : We have asked for six months so we can all sit down and see what the implications of all the proposals actually are.

CHAIR: What we have seen so far is policy made in a vacuum, without consultation, and this brief period to make more policy, from a government that has a pretty bad track record—let's face it—should be of some concern to you and your members.

Dr Jones : It certainly is. As I say, we think that what we need to do is be able to advise government on the implications of policy changes. Their policies seemingly have been made on the run, with no consultation. Like my colleague Professor Owler, I also received a phone call about half an hour before the announcements were made. There was no consultation with our college or our members whatsoever.

CHAIR: This government is into pretty short time limits, isn't it: no consultation prior to the budget announcements, half an hour before they gave version 2 in December, and now, again, time limits on their consultation with the experts in the field.

Dr Jones : We believe so. We believe we have some positive solutions that can help government, and we are absolutely willing to talk.

CHAIR: Thank you very much for putting that on the record. Could I just go to the opening comments that you made about the better health that is achievable. You talked about a fourfold reduction, a halving of emergency and higher satisfaction rates. Could you take me to those two particularly: the fourfold reduction and the halving of emergency accesses if we maintain a proper primary healthcare system without a price signal.

Dr Jones : Certainly. There is very good evidence within Australia and overseas. You have to pick winners. The high-cost end of the system is hospitals. The high cost is within the emergency departments. We know that if you pick the winners, reduce emergency presentations, reduce admission and reduce time in hospital then you can save money. That has been well documented. It is evidence based. We know that. The question earlier on about government was: do they actually hear what we are saying about the efficiencies of primary care? I think they maybe hear but they do not listen. This message is so strong worldwide. The literature is so strong worldwide: if you have a strong primary care system, it is going to save money downstream. There is absolutely no question.

CHAIR: But the government have ignored that to date?

Dr Jones : Seemingly, yes.

CHAIR: Would you say you are concerned that they still might not hear it, considering we have heard that they continue to be committed to a price signal?

Dr Jones : Minister Ley, in our brief discussion last week, did acknowledge that countries with strong primary care did save money down the track. I am not sure whether she has taken it on board and what she is going to do, but she has certainly heard that message loud and clear.

CHAIR: But she remains committed to a price signal?

Dr Jones : As far as I am aware.

Senator McLUCAS: Thank you very much for appearing before the committee. I also want to talk about the consultation process. Did the minister indicate why there was a two-week limit on the consultation going forward?

Dr Jones : Two weeks?

Senator McLUCAS: Sorry, you said the consultation would end in a couple of weeks.

Dr Jones : That is our impression: that there would be a time limit on the consultation.

Senator McLUCAS: Did the minister, or anyone, indicate why there would be an end to this consultation?

Dr Jones : No. As I said, we have suggested at least a six-month moratorium so we can sit down and discuss this.

Senator McLUCAS: I have a question similar to one that I posed to Professor Owler: can you give the committee an understanding of the parameters of the consultation? Is the minister saying certain things are on the table but certain things are definitely off the table? You seem to be telling us that the minister has said very clearly that a price signal needs to be conveyed. That to me is a co-payment or a tax. So that issue is still on the table. I am just trying to work out what is in and what is out at the moment in terms of the consultation.

Dr Jones : At United General Practice Australia last week she said the same words—that Medicare was not sustainable, and the way they felt that they could do it was with their price signal. Now, that needs to be debated and discussed. I have just tried to outline the implications to you, as Professor Owler has. It will have huge implications for general practice. GPs will be faced with the ethical dilemma of whether they take a cut in their fees—especially after 1 July with the indexation.

By the way, the indexation for General Practice has been frozen for the last 18 months, as is. And now we have another three years ahead. This will put enormous pressure on general practices to provide quality care. It is about quality care. It is not about the numbers coming through; it is about the quality that we provide for our patients. And we know that if you invest in general practice, and prevention particularly, we will save money. People's outcomes are better; their health lifestyle is better. We know this.

Prevention is often forgotten in this discussion. When I see a patient I do three things. I make a diagnosis, I decide on therapeutics—that may be medication or it may be referral elsewhere—but also embedded in my consultation is prevention. Every single patient I see—every presentation—has prevention as a part of the consultation.

Senator McLUCAS: Coming back to the parameters of the consultation, the minister is saying that she is of the view that Medicare is unsustainable. That flies in the face of the evidence that we have heard from yourselves, from the AMA and, frankly, from almost every witness that we have spoken with. How do we make it plain to this government, or are they just not listening?

Dr Jones : It comes down to your ethical and philosophical point of view. Countries like Australia are relatively well off. It really reflects that fact that we have to have compassion and look after the more disadvantaged patients—people in our society. There is no question about that. We also know that if you invest in health—the social determinants of health are really important—you have a healthier population and a healthier workforce. So it flows on; it is an economic no-brainer.

Senator McLUCAS: I agree. Thank you.

Senator DI NATALE: Thank you very much for your submission. I want to go to a couple of things that were announced. I will go to changes to levels A and B—the short consultation change. I will be honest—possibly to my detriment. When the change was first announced my reaction was not, immediately, that this is a terrible proposal. It was that we want to encourage quality in general practice and we need to think carefully about ways of doing that. And at least we are opening up a debate. The position I came to was that, while the debate was being framed in terms of quality, it was really about cost saving. But at least we have opened up the space to talk about quality. Can you see any merit in a proposal that does change the way we incentivise quality—if, for example, we made changes to short consultations but we reinvested that in, perhaps, rewarding for longer consultations or other parts of general practice to reward quality, there might have been some merit to that proposal?

Dr Jones : I think, like yourself, that many colleagues did not realise the repercussions when the first announcement came out. But on the next day, very much there were repercussions.

Senator DI NATALE: I learnt very quickly, from my general practice colleagues, that they were not enamoured of the proposal.

Dr Jones : I think the evidence that time based consultations improve quality is relatively poor. It is not good but there is some evidence. In our modelling for government—this is one of the discussions we wish to have with them—we wish to remodel the ABC system. We have some ideas and we have done some financial modelling as well. Tagged on to that—very importantly—is improving the quality of care.

We have a proposal whereby the items of service would be reframed, if you like, and it would encourage longer consultations and disincentivise superficial consultations. Tagged onto that—very importantly—are payments for practitioners to provide quality care, for practices to be able to enable practitioners to do that, and, thirdly, reflecting the complexity of the local demography. We have modelling along those lines. So I think that we do have some potential solutions (a) to improve the health of the population, which is by far the most important thing, and (b) to help this government out of the dilemma that it is in.

Senator DI NATALE: The temptation for me is to focus on how ridiculous some of these proposals are, but I would like to explore perhaps a more constructive line of questioning. When you talk about remodelling to reward quality—we do have practice incentive payments, for example, which attempt to do that, and we have some item numbers around care planning and so on that are an attempt to move away from just fee-for-service to look at rewarding quality in general practice—are you talking about an expansion of practice incentive payments? Are you talking about changing the way we do our care plans? Do you want to perhaps elaborate a little bit more on that?

Dr Jones : Yes, I could certainly provide detail if the Senate are interested down the track, but, basically, certainly the Practice Incentives Program needs to be looked at very carefully. There are certainly some efficiencies and changes that could be made there. We would see the PIP thing continue within our new model but again reflecting the actual payments to practices, not just the practitioner, because the systems need to be in place. General practice is complex. We have to have appropriate recall systems. We have to have nurse practitioners. We have to have our nurses involved in all this. So it is not just straightforward A-B-C-D medicine. We have embraced teamwork in general practice. We do believe that the general practitioner is central to that, obviously. One of the things that disincentivises doctors from employing nurses is, for example, the nurse payment. It is very difficult to employ nurses with the change in some of the governments—in recent times, the Practice Nurse Incentive Program, for example. That has gone. There are lots of ideas that we have on which we would love to sit down with government and give them some solutions.

Senator DI NATALE: Let me ask you about a submission we received from the Hunter General Practice Association. They focus on unnecessary spending on pharmaceuticals, investigations and so on—what some people will call medical waste. Do you have a view on whether there is scope to achieve savings in those areas—

Dr Jones : I do indeed.

Senator DI NATALE: and what sort of framework would enable us to achieve that?

Dr Jones : I think there is a whole scope of efficiencies there, if we are talking money. For example, if I refer a patient to the emergency department and I have actually worked up a patient already with various blood tests, they are usually repeated.

Senator DI NATALE: Yes.

Dr Jones : That is one simple example.

Senator DI NATALE: Yes.

Dr Jones : General practice can also do things so much cheaper. There is a four- or fivefold difference. For example, if you take a skin biopsy in general practice, it is about $62. In hospital it is about $290. It is the same procedure. So there are huge opportunities for us to look at the whole system.

Senator DI NATALE: We keep hearing about that. There are countless examples of where we can get those efficiencies, but we are not doing anything about them just yet. We can have a conversation about it, and I know that in other settings there have been initiatives set up to try and do that. But how do we go from talking about the problem to actually starting to put some of this into practice?

Dr Jones : I guess it is a little bit like when I teach my registrars. I teach my registrars to have a conversation with patients, not just a consultation, so I think maybe now we need to have a consultation with government so that there is actually an outcome and not just a conversation. There are multiple examples that we as a college can provide to government where there are cost efficiencies. Again, I say that reducing disincentive via general practice is really not the answer to Australia's healthcare problems.

Senator DI NATALE: Let me ask you the same question I asked the AMA president. We could have a new Prime Minister next week. If you had one thing to say to an incoming Prime Minister about health care, what would it be?

Dr Jones : Countries with a strong primary healthcare system have better health outcomes.

Senator DI NATALE: They would argue they are strengthening our primary health system at the moment.

Dr Jones : Well, unfortunately, by the looks of the dollars and cents, they are not. There are multiple examples we have just given you.

Senator DI NATALE: Thank you.

CHAIR: So the core message is: don't touch Medicare. It is sustainable; leave it alone—at the very least. Don't break what's not broken.

Dr Jones : Absolutely.

Senator CAMERON: Welcome, Dr Jones. I think you have been a bit diplomatic this morning in some of your responses, where you said the government have 'seemingly' ignored the importance of primary care. All of the submissions we have are that there is no 'seemingly' about it. They have ignored it. Have you got a different view? Are you being diplomatic?

Dr Jones : As I say, we are an academic college at heart, but I believe that the College of GPs now has to be involved in anything that impacts on the quality of care that I can provide for my patients. There is no question that the proposed changes will cut general practice and its services and quality. Really, that is from my point of view as a GP. I have been a GP in my town for 30 years. On the quality I will be able to provide for my patients with these rebate cuts, we will have to have a serious look at our numbers in my practice and how we actually charge patients. The day of the announcement of the change in the A and B, when I received the phone call from the minister, we were having a practice meeting about how much we were going to have to charge our patients to continue. That is how close it was: three hours.

Senator CAMERON: We have not spoken about another issue. The whole system is very complex, and it is not just GPs; it is the hospital system and it is the university system that supplies the doctors into the system. What are the implications of these cuts to income for GPs coupled with an increase in costs to be educated to become a doctor? Has there been a discussion about that?

Dr Jones : This discussion is not about income; however, I can tell you that general practitioners are the lowest paid speciality in Australia. With these proposed cuts again threatening the viability of practices, why would a young doctor choose to be a general practitioner? It is going to make it very unattractive. You might as well go and be a salaried doctor in an emergency department, where you know what your income is. Who is going to want to come into general practice with all this uncertainty? So it will definitely have an impact, and we certainly have feedback from younger doctors about—

Senator DI NATALE: Do you mind me interrupting? Have you got any data on what this is doing for young doctors going into training at the moment?

Dr Jones : I can take that on notice. Certainly we have verbal responses from young GPs saying, 'Why would I bother?' We can certainly take that on notice.

Senator CAMERON: Dr Jones, you said that when you see a patient you do a diagnosis. That is the first thing, I think, and then you do therapeutics, and then prevention underpins. Is that correct?

Dr Jones : Yes, absolutely.

Senator CAMERON: If you look at this in the context of the political task to deal with Medicare, would you agree that the government's diagnosis is wrong and that the therapeutics they are using are the wrong therapeutics—

Senator McLUCAS: This is too poetic.

Senator CAMERON: and that prevention is not being done, surely?

Dr Jones : Generically I would say that is probably correct.

Senator CAMERON: Yes. So they are just not being professional about this?

Dr Jones : I do not think I should comment on that.

Senator CAMERON: Why not?

Dr Jones : Well, I think that their job is to govern the country. They have been elected by the people. That is what their imprimatur is.

Senator CAMERON: Okay. The Newcastle GPs have given very good and detailed practical submissions—not to say that all the submissions have not been practical, but these are the guys and women at the front line. They say in their submissions that the proposals for no indexation and the $5 co-payment are ill considered and have not been modelled. They say they will make Medicare unsustainable and in the long run will increase government costs, create barriers to care, create workforce shortages, put patients at risk and reduce infrastructure in the primary healthcare system. Have you got any difference on any of that analysis?

Dr Jones : No, I would agree with all of that.

Senator CAMERON: If you agree with that, what are the implications of Medicare being unsustainable?

Dr Jones : The implications are that you will have worse health outcomes. People will present to their doctors late, potentially more unwell, potentially requiring more investigation, potentially needing more hospital referral and emergency department presentations. The on-costs are huge. It costs $400-odd to see a patient in casualty for a semi-emergency. It costs $37 to see a general practitioner who is used to dealing with undifferentiated disease and using fewer and fewer tests.

Senator CAMERON: Senator Edwards, one of my colleagues, a Liberal politician from South Australia, says basically that if people are sick they will find the $5—it is a cup of coffee. But it is more complex than that and it is not just $5, is it?

Dr Jones : It depends on the maturity of our society—whether we believe we should have universal access to health care or not. We should have absolute equity to everybody, for sure. As a college of GPs, we have never been opposed to the fact that GPs can charge what they feel is fit. That is their own professional prerogative. Certainly, we have to protect our disadvantaged. We are altruistic. That is what we do. That is why we are doctors—we care for people.

Senator CAMERON: What would be the implications in rural and regional Australia?

Dr Jones : I am a regional GP. Very, very much. I work in a very low-socioeconomic area. We have a lot of opiate abuse, for example, and methadone—

Senator CAMERON: Can I just ask you where you come from.

Dr Jones : Mandurah, in Western Australia, an hour and a half south of Perth. We have a lower socioeconomic mix—social class 4 or 5. We have a large methadone-prescribed population. There is no way in the world that those guys have money to buy their drugs, but if we do not look after their problems to keep them away from drugs, if we start charging them, there is no way in the world that we are going to reduce the opiate abuse. So we bulk-bill them. That would be a really tough call for us in our practice.

Senator CAMERON: This is an interesting point you make. Drug abuse creates other social complications, such as crime.

Dr Jones : Of course.

Senator CAMERON: So this could actually increase the incidence of crime amongst addicted Australians, because they are just not getting the proper treatment.

Dr Jones : That is quite possible. We know there are social implications of health. If you do not get the things right at the start, the whole thing roller-coasts. That is a very simple example. There are multiple others.

Senator CAMERON: I have done a lot of negotiations over my career as a union official but, when you sit down at negotiations and there are polemics and you are poles apart, you are not going to come to an agreement fairly quickly. It seems to me that the organised labour in the medical area are poles apart from the government on this issue. All of the submissions say this is bad policy and it has huge implications in a whole range of areas. If there is a time limit on the process, how do you think we are going achieve a proper outcome?

Dr Jones : I think all we can do as a medical profession is present the facts as we know them and be sure that they are evidence based. It really is up to government at the end of the day what they do with that. They are the elected government. In all the submissions you have heard we think this is bad policy, it is not good for the health of Australia and it is going to have ongoing costs. How much clearer do we have to be?

Senator CAMERON: Has either the previous Minister Dutton or Minister Ley given you any evidence of the unsustainability of Medicare?

Dr Jones : No. We have read about it, but personally, one to one, no.

Senator CAMERON: So they just make assertions, do they?

Dr Jones : It is only what I have read in the press releases that they have made about Medicare. In one-to-one conversations that has not been talked about.

Senator CAMERON: Do you agree with the AMA submissions that per capita the actual expenditure has gone down?

Dr Jones : There is certainly good data on that. We have good data on that as well. If you actually look at the graph, it is very simple. GP co-payments are there and hospital payments are up there. It is a very simple graph, and I am sure you have seen that.

Senator CAMERON: I know that some of the GPs have said that you should look at the hospital system for savings. We need to be a bit careful about that as well, so we do not create a push into the hospital system to defund aspects of the hospital system, don’t we? It is not a simple issue. It has to be evidence based, doesn't it?

Dr Jones : Health care is complex. Every country in the Western world is struggling with the fiscal responsibilities of its ageing population and its chronic disease. When I was a younger GP it was relatively straightforward. My patients are incredibly complicated now. My cohort of patients have grown older with me. Most of my patients are over 60 or 65. They have at least five to seven medical diagnoses; they are usually on about five to 10 different medications. It really is a different ball game these days. So general practitioners basically are now the expert general doctors of the 21st century. We know that if you invest in that it will actually save money in the hospital system. It is a complex discussion. The states fund their public hospitals; the federals fund Medicare. That is a political dialogue that really needs to take place about that system, because there is such a lot of duplication there. Again, it is not my brief today to discuss that with you.

Senator CAMERON: As a consumer or a patient—there are all these different things you called them—

Dr Jones : We call them patients, actually!

Senator CAMERON: As a patient you go in and you are thinking about medical issues. Do you think the population really understands that these are small businesses and they have all the pressures of small businesses, or do they see it purely in medical terms?

Dr Jones : I do not think they understand—but some do—the actual business implications. We know that intuitively patients know that GPs do a great job, and intuitive GPs do too. The problem with general practice as opposed to certain other specialities is that measuring outcomes is quite difficult. If you are a cardiologist, you know that if you put X number of stents in, you are going to get X number of good results. My patients might have seven interrelated medical conditions.

You mentioned research earlier on. In Australia, all the research funds primarily go into hospitals. Less than three per cent of medical research in Australia goes into general practice, and we see 85 to 90 per cent of the population annually. Now, if you are going to talk about research, let's talk about the money that goes into general practice. But, again, that is not our brief today.

Senator CAMERON: I want to come back to perceptions and understanding the practicalities of dealing with this issue. We have to try and deal with the issue. Have you seen any evidence that the government, the minister or the minister's staff understand the complexity of providing care while keeping a sustainable business? Has that fundamental issue been engaged with effectively by either of the two ministers we have had?

Dr Jones : I have not had that conversation with Minister Ley. We had a brief conversation with Minister Dutton. He understood the fact that health is important. He understood that putting some money into—

Senator CAMERON: Well, that is really good for a health minister—to understand that health is important!

Dr Jones : Indeed. He did understand that primary care is efficient but he also said that he wanted a price signal.

Senator CAMERON: Yes. So it is simply this ideology that you have to treat health care as a purely market-based issue.

Dr Jones : That is the impression that I was left with, yes.

Senator CAMERON: If they do that, then they do fail to understand the health, social and economic implications of what they are doing, don't they?

Dr Jones : Well, one would think so.

Senator CAMERON: Okay. Thanks.

CHAIR: Dr Jones and Dr Burgess, you would be aware of the Medical Journal of Australia article by Lourenco, Kenny, Haas and Hall, the most recent summary of concerns regarding the impact of changes to Medicare bulk-billing. It says:

… caution is needed when considering changes to GP fees and Medicare rebates because of the many possible paths by which patients' access to services could be affected.

And we have heard a little bit of that from you this morning.

I want to close with two questions. Firstly, the process by which the government was about to bring in the changes to levels A and B was by regulation, which was to get around the Senate. That should only be done in the most extraordinary circumstances and it should be done after consultation. We have established this morning there was no consultation. These processes reveal the arrogance of the government towards the profession and particularly the Senate.

Dr Jones : And patients.

CHAIR: And patients, at the core of it. Given the track record of this government and their very unusual way of manifesting their understanding of 'consultation', the concerns that you raised about only two weeks of further 'consultation', could you put on the record what it will mean, what it will look like on the ground, if the proposed changes that you have seen so far from the government go ahead? What will it look like in your practice, and how will it affect your capacity to run an effective business? This is a government that says it is the friend of small business; but, frankly, from every conversation I have had with doctors who run those small businesses, and practice managers, they have never, ever experienced such a tsunami of change as that foreshadowed prior to this last backflip by the government. So there are two angles there: the business angle and the impact on patients.

Dr Jones : I think it will be gradual. If it goes ahead on 1 July, I think most practices will sit down and refashion their business models. They will actually see what impact it is going to make on their practice. I think over a period of time people who continue to accept the rebate—I would rather use that term than 'bulk bill'—will find that their income will go down by between seven and 10 per cent. That is our modelling, approximately. It is going to be an individual practice and practitioner decision whether they do that.

CHAIR: So you think some practices will just hold out and continue to look after people?

Dr Jones : They will have to monitor it, because they have got to pay their staff and their mortgages; like every other business, they have to do that. They will monitor it very carefully. I suspect that most practices will do their sums and there will be a patient contribution.

CHAIR: So that will essentially change the way that Australians interact with their doctors?

Dr Jones : Yes.

CHAIR: You will have to have money in your pocket if you are sick because you will need that to access your doctor?

Dr Jones : Yes.

CHAIR: That is your prediction if the government continues?

Dr Jones : If it continues. It may not happen straightaway; but, over a period of months, after 1 July, if practices are doing their monthly financials, they will soon find out what is actually happening from their business model, and I think they will have to change.

CHAIR: So this is a government intent on destroying businesses and health at the same time.

Dr Jones : It certainly does not bode well for the future general practice of Australia if this position is maintained.

CHAIR: Thank you very much, Dr Jones. As I indicated to Professor Owler, given the uncertainty about the status of the government at the moment and the tenuous nature of the conversations which we might hope are happening—consultations seem to be occurring—this committee would be very happy to take submissions from you about the things that you are advancing so that we keep some of this conversation in the public place rather than behind closed doors.

Dr Jones : Sure. Thank you very much for your time.

CHAIR: Thank you.