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Senate Select Committee on Health

ALEXANDER, Dr Graeme, General Practitioner, Claremont Village Medical Centre

BONNEY, Professor Andrew Drummond, Roberta Williams Chair of General Practice, Graduate School of Medicine, University of Wollongong

KAMERMAN, Dr Ian, Private capacity

PEARCE, Dr Colin James, Clinical Director, Charlestown Square Medical Centre

TERRY, Dr Richard, Practice Principal, Whitebridge Medical Centre

VAN LEEUWEN, Dr Fiona Joy, Vice Chair, Hunter General Practitioners Association

Evidence from Dr Alexander was taken via teleconference—

CHAIR: I am very glad to welcome GPs who have kindly given up their valuable time to speak to us today. Your experience at the patient coalface is very valuable to the conversation that we need to have at this time. We are delighted that you are able to join us and we have an hour allocated for this conversation. We will have many, many questions for you.

I would like to offer you the opportunity to make a one- or two-minute opening statement to get perspectives across the range and then we will go to questions. I will commence with Dr Alexander and ask you to be very mindful of the time: one to two minutes.

Dr Alexander : I will be very mindful of the time. I sent in a submission which I think covers this. I work in a large general practice which I run in a low-socioeconomic area with 12 other doctors. We add up to six full-time equivalents. We have a practice we are very proud of. There isn't anyone in the room there—and I am sorry I am not in that room but it was a bit short notice. As a GP, I would rather talk to people face to face.

I am not going to talk for long, because I have tried to educate politicians, journalists—you name it—over the last decade. The most effective thing I find we do as GPs is to have politicians and therefore decision makers asking questions of us rather than us telling them.

I commend the committee's decision to listen to grassroots general practice. There is no better example of the consequences of the failure to do this than the policy fiasco of the past few months. I encourage questions and questions about solutions.

CHAIR: Thank you very much, Dr Alexander.

Senator McLUCAS: Dr Alexander, I remember sitting in your surgery about 10 years ago and you explaining how Medicare worked to me. It is nice to be back with you again.

CHAIR: Professor Bonney, would you like to make an opening statement?

Prof. Bonney : It is really two statements, one as an academic and the second as a GP.

CHAIR: Thank you.

Prof. Bonney : The first is that internationally we know, and there is no doubt, that jurisdictions with strong primary care also have lower costs and reduced rates of health expenditure increase. At worst, in comparisons among countries in Europe, strong primary care is associated with lower levels of health expenditure increase even if the baseline healthcare costs were higher in the first place. So there is no conflict between seeking to contain costs and improve health outcome, providing that it is recognised that serious policy investment in primary care is the vehicle.

Seeking to contain costs by providing price signals via increased co-payments will not achieve either cost containment or health outcome goals, especially where such measures disproportionately weaken primary care. The current evidence and my experience anticipate that the result of increased co-payments will be reduced access for those most in need of care, later presentations of illness, and unplanned admissions to hospitals with ensuing higher healthcare costs. In the longer term, the disinvestment in primary care, in my belief, risks creating structural weaknesses in the health system which could take a decade to reverse.

In my own experience in a town of 3½ thousand, where I bulk-bill 80 per cent of my patients because they are either unemployed or on sickness benefit, I know full well what the outcome will be if, over the next four years, there is a freeze on Medicare and our practice is unable to sustain that level of bulk-billing. It will be that those patients do not present to us when they need care; they will present 20 kilometres away at the local hospital and have higher healthcare costs as a result and poorer health outcomes for the community.

CHAIR: Thanks very much, Professor Bonney. Dr Kamerman?

Dr Kamerman : As doctors, we are very aware that the human body is a complex system. Changes brought about by disease or injury can often bring about both predictable and unintended outcomes. So as a doctor it is certainly no surprise to me and certainly my colleagues that small changes to Australia's health system that are designed to bring about an outcome will also produce multiple significant unintended and adverse outcomes. In essence, you cannot just make one or two changes. The whole system may well come crashing down.

The recent mooted changes to Medicare payments for general practice were introduced without any consultation with the profession by the government or by the department. As a doctor who believes in evidence based medical practice, I believe it would be logical to fund Australia's health system on the basis of the evidence that exists that will provide the best health outcomes for the health of Australians: the triple aim of efficient, effective and better care for individuals. Given that general practice in primary care has an overwhelming degree of evidence behind all of the above, it is highly illogical for the government to seek to remove billions of dollars of Medicare funds from general practice over the course of the next few years and to do it selectively to general practice.

I would like to talk further about the aspects of the business of general practice. To cut the talk short, I suppose it is a concern to me as a business owner and operator as well as a GP that there is no funding now, essentially, to support the actual practice of general practice. Certainly it is marginal at the moment, and, with the changes to indexation, the gap between expenses and income is going to increase from marginal to about $100,000 a year that I am going to need to make up in costs and income in my practice. Either I am going to have to put staff off or I am going to have to increase patient fees to do that over a period of time. Currently, my non-concessional patients pay a $35 gap. That gap is going to increase to about $60 or $65 if I am going to stay afloat as a business. It is certainly much more than what has been talked about as the cost of a latte. Either that or I am going to need to cut out bulk-billing altogether.

The last short point I would make is that I am really concerned about the effects on GP training. I think this is all going to be a huge disincentive to doctors wanting to do general practice. I do not think, though, that the government and the department have looked at funding for GP training. Certainly these Medicare changes will impact on training practices significantly. And I do not think anyone has actually surveyed the Australian public as to whether they are prepared to pay a co-payment for the cost of training a GP in my practice.

CHAIR: Thank you very much. Dr Van Leeuwen?

Dr Van Leeuwen : It is my honour and privilege today to represent the newly formed Hunter General Practitioners Association as its vice-chair. Many thanks for the opportunity to address this inquiry. I wish to apologise on behalf of our chair, Dr Tony Isaac, as he could not attend today. I also wish to acknowledge Dr Lee Fong, who, as our secretary, has contributed in a major way to our submission and papers.

I and my colleagues Dr Colin Pearce and Dr Richard Terry represent three of the major practice styles that deliver the majority of care in this country—that is, solo GPs, corporate groups and small to medium-sized GP owned practices. We in the Hunter region have a history of involvement in innovative solutions to the wicked problems that health service delivery throws up at us. We have a gold standard after-hours service. We have been instrumental in bringing integrated, clinician led health pathways to Australia from our colleagues in New Zealand. And we have formed an alliance framework between the local health district, the Little Company of Mary Mater Hospital and the Medicare Local, to name a few.

We recognise that our current systems are flawed. We are not here today purely to criticise and bemoan the status quo but to engage collaboratively to seek improvement and, to this end, efficiency, care provision that leads to good health outcomes for our patients, and a healthy, sustainable workforce. These initiatives must include targeted education and continuous quality improvement to be a part of our business as usual.

Redesigning health is like building an aeroplane in the sky. Our patients, our community, are our passengers. They rely on us to build it well and, as crew, to keep the plane in the air and to land it safely. We do not have all the answers, but, if we are the crew and our passengers, our community, our patients, collaborate strongly, we are a highly skilled force to be reckoned with, full of hope, passion, commitment and possibility. The plane we build together will do the long-haul flight and land our patients safely. The risk of getting this wrong is real, but the risk of not embracing innovation and collaboration is much greater and the cost much higher.

In conclusion, we urge against any further erosion of what is an essential part of the Australian healthcare system—that is, general practice. We urge against proceeding with both the GP co-payment and the freeze on MBS rebates. Limit the damage with regard to both financial and human currency. Instead, use our collective knowledge and experience to help to begin to craft a health system that can improve the patient experience and improve the health of all Australians. We want your help to rebuild the trust. Please let us use this opportunity to take the first step towards working in partnership with grassroots general practice for a health system that will meet both the healthcare needs and the financial challenges of Australia for generations to come. Please find our submissions as tabled.

CHAIR: Thank you very much, Dr Van Leeuwen. Can I say for all of us that we are very impressed with the quality of the submissions, and we sincerely thank you for the effort that you went to in preparing them and getting them to us. Dr Terry?

Dr Terry : Just to get my statements in perspective: my other two interests apart from being a solo GP of some 32 years standing are that I teach medical students within the practice, and I have a particular interest in targeted educational programs for GPs. I commend the members of the Senate have a look at one of the programs I have developed about preventing hospital admissions in a primary care setting, which is a 10-week program. That is a good example of what GPs on the ground do, not in liaison particularly with the college; it is just something we do ourselves.

I would like to thank the commission for their excellent interim summary that they put out. It was interesting to read that, seeing that they listed a large number of peak bodies who had not been consulted around these health changes.

CHAIR: Dr Terry, are you referring to our interim report that we tabled?

Dr Terry : To your own interim report, yes. I thought it was an excellent summary.

CHAIR: Thank you.

Dr Terry : And I think that, in the same way as the science of climate change is in, the science of general practice and primary care is in. Anyone who has spent more than a couple of dozen—or at least a couple of dozen—hours actually taking the time to read the various submissions by the various health institutes around the country would quite clearly say that not only was general practice not overfunded but it is probably underfunded, and it should be the major part of the solution.

What interested me in solo general practice was how many practices in Australia are actually represented by solo GPs. Numbers are really hard to find, and I will give you some stats that I did find. The total number of GPs in Australia, as far as I can see, is about 43,000. It is interesting that the RACGP, who presented here earlier today, say they have a membership of 28,000 GPs and, by their own admission, they are an educational body. That leaves at least 15,000 GPs in the community. Essentially, taking both of those numbers into account, there are 43,000 grassroots GPs who represent thousands of patients who have not been consulted on these healthcare changes.

From the Primary Health Care Research and Information Service coming from Flinders University, I was able to drag out figures from 2010-11, and it is interesting when you do the math. It seems in 2011 that 35 per cent of the total practices—that is, the bricks and mortar we walk into, the buildings—were actually inhabited by solo GPs. Even if that data has dropped now, which I suspect it has, it could still be 20 to 25 per cent of practices which are solo GPs.

I would just like to draw attention to the financial vulnerability of solo practice. I have been in solo practice for a long, long time, and for the last 10 to 15 years we have suffered a lack of indexation medical rebates—10c a year on some rebates. Many of us in solo practice have stayed in practice for the love of our patients, because our actual remuneration, which is the money left in the pot at the end of the day, has been going down as the cost has increased. It is hard to gauge. Certainly if that Medicare level B fiasco had gone through, you would have seen practices dropping by their thousands, because you simply would have had to close the door because you could not afford to keep it open. I think that the co-payment and the lack of indexation again have the similar effect.

CHAIR: Dr Terry, I might just interrupt you there. We will get some more evidence from you as we go, but I just want to go to Dr Pearce, and then we will come back to a more fulsome conversation.

Dr Pearce : Madam Chair, thank you for the opportunity to address this inquiry. I have submitted my opening address really as a document. It has very similar messages to the other submissions that you have heard summaries of.

In summary, the doctors who I represent all believe that the proposals of no indexation and the $5.00 co-payment suggested to keep Medicare sustainable will in fact do the very opposite: they will make Medicare unsustainable. They need to be taken off the agenda. And we are here as a panel today to discuss the reasons why that should happen and to come up with ways for health funding and better solutions.

Having said that, on my 4½ hour drive here last night I came up with a little answer to a question that has been going around in my head since chairing a meeting, which is: why do GPs feel so insulted and undervalued by being given this legislation to cope with? And I thought of a big company analogy, and most people involved in any big company will understand this. The company is called 'Health'. We have a huge number of consumers—probably 20 million; I am not sure of the population in Australia now. They have a very high expectation of what health they want delivered. That starts a preconception in this country, and it goes to the last breath.

The executive of the company, Health—the CFO, the CEO and the chief operations officer, who would probably equate to the Treasurer, the Prime Minister and the health minister—decided that Health is not sustainable. They need to reduce the spend on Health, or it is all going to fail. They decided to attack GPs without consultation and simply just offer them the legislation, saying: 'As of this date we are going to do this; as of this date we are going to do that.'

How did GPs react to that? It is like a performance review without the opportunity to speak for yourself. On one hand, they say: 'You're doing a great job—you spend $5.1 billion of $62 billion health expenditure, and that expenditure has not gone up in 10 years. We really respect how efficient you are. But do you know what? Our hospitals are bleeding—they are bleeding money. You have only got to look at the graph presented by the RACGP to realise that. So what we have to do is get you to work harder. You need to be more efficient and you need to collect money from your patients on our behalf to try and make this sustainable.'

In response to that the GPs said at the meeting, 'We have three options. It is like any bad relationship—we can absorb the pain and just try and put up with it and hope that we survive and get what we can out of the relationship while we are still in it; we can leave the relationship'—and leaving the relationship will be to retire early if you are an elderly GP—'move sideways and retrain or forget Medicare completely and just charge what you think what you are worth, which is going to create huge barriers, or not join the profession in the first place'—and we are all going to have workforce issues with that; 'and the third option is to negotiate and try to save the relationship, which is worth saving.' Really, I think that is why we are all here today.

CHAIR: Thank you very much for a well-articulated summary of the situation which we find.

Senator DI NATALE: You are a marriage counsellor now, aren't you?

CHAIR: I think the funding for marriage counselling has been withdrawn, hasn't it?

Senator DI NATALE: That is true.

CHAIR: So we are in all sorts of bother at a whole lot of levels. Some of the language that we heard in your opening submissions was about feeling insulted, the break of trust and about illogical action not based on evidence. All of these are things that we heard in our 15 inquiries prior to the interim report—which I am very pleased that you have acknowledged. It is a very good record of the perspectives across the country. Despite the fact that it is on the record, though, we still have a government that continues to say that we must send a price signal. So today we are particularly keen to hear what it means on the ground. We have heard some commentary on the business impact, but I would like to ask a really basic question. Has the current uncertainty around policy had impacts already on the health outcomes of your patients? Have you seen reticence to seek help? Have you seen concerns amongst people? Have you already seen an impact of flow to emergency? Would someone like to take that question? I see Dr Van Leeuwen is nodding and then we will hear from Dr Pearce.

Dr Van Leeuwen : Interestingly, the week after the budget announcement we had a 20 per cent reduction in patient attendances. This quite possibly has started to return back to baseline but it has taken a long time and it probably has not completely resumed where it was.

CHAIR: Is that of concern to you and why?

Dr Van Leeuwen : It is of concern to me because, even though we know that we can gain further efficiencies from our consultations, healthcare is now so complex we need to supervise patients regularly—their managements and their treatments—and treat them opportunistically and preventatively.

Dr Pearce : I would concur with that. There were actually three periods of reduced demand on appointments. Probably the government thought, 'This is great; this is working.' But in actual fact it means that people are avoiding care because of price points. People do not really fully understand announcements. The budget announcement in May said that there was going to be a $7 co-payment. We were inundated. Our secretary spent seven or eight phone calls each day explaining that had not come in yet. There was a drop in appointments. My appointment times went from about a one- to two-week wait down to about a three- or four-day wait.

CHAIR: As you say, though, the government thinks that is good. What we want to understand from you is why you think it is bad.

Dr Pearce : Take a simple example of a child with an ear infection. You have a new parent and they have a one-year-old child with an extreme fever. Those kids look sick, they do not want to eat, they are pale and they are very hot—and the parents are extremely anxious. I think the people who are being least acknowledged in all of these debates are actually middle-income earners who do not have a healthcare card. So they are new parents and they have got lots of costs. If they come and see me I am going to charge them. Co-payments have existed for years. They were $10 about 10 years ago and they are now $35. So we get a 50 per cent rebate. If they come and see me, my general policy would be—unless I feel very sorry for them and I can see their financial distress—to charge them a gap of $35. So for a standard visit it would be $70. In about eight or nine minutes, I could very adequately assess that child, work out that they did not have meningitis or urinary tract infection, find the focus for the infection, treat that appropriately, and reassure the parents and prevent them from presenting to hospital.

Now, if you take it on the other side, they say: 'I don't actually need to see Dr Pearce today. The kid's really sick. Maybe we should go to the emergency department.' In their mind, they are doing the mental arithmetic: 'Well, that's $35 to see the doctor. He's going to prescribe some antibiotics, because the child's under two and is septic or very sick from the ear infection, so that'll be another $15. Then we've got to get some Panadol or some Nurofen; there's about another $20.' These are parents earning a middle income, with no other subsidy, and they are faced with a bill of $120, out of their pocket, when they pay tax, and they expect some form of medical insurance for that tax. So, they present to the emergency department, where it is all free. But, in reality, as we have heard earlier, it costs $500 for that encounter. So, you are looking at a cost to the government of $37 to pay me to assess that child efficiently versus $400 for them to present to the emergency department. Of course that $120 or so that those people are going to have to pay to see me becomes a price barrier. There is no other way to look at it.

Prof. Bonney : Perhaps I might add to that. The premise of the price signal is that people are unnecessarily seeking health care and that it was for trivial reasons and therefore it was a waste of the taxpayer's money. We know health-policy-wise that the things that improve overall health outcomes are four components of primary care. The first is access to care, and following on from that, once they are in the primary care system, is continuity, comprehensiveness and coordination.

But perhaps I could just illustrate two cases from my own practice within the last fortnight. We are in a small town, and we are under-doctored, so my waiting time is two or three weeks, or longer. And to try to improve access, because we are dealing with so much chronic disease, we have an hour walk-in clinic in the morning. So, if there is an acute problem, you can just turn up and we will see you. That might take only three or four or five minutes, particularly if it is for a work certificate or something, where we can usually knock it off pretty quickly. But, of course, people just turn up because people do not go to university to learn medicine just so that they can manage their families. So, within that walk-in clinic, the people turning up just for things like, 'I'm a bit worried about this, Doc' included two patients who had lost sight in an eye because of diabetic haemorrhages and a fellow who had a lump in his groin, which turned out to be lymphoma. They are all things that obviously are going to take longer than five minutes. But just having a walk-in clinic so that people can access care when they need to means that people with very significant, serious things can have those picked up and dealt with quickly. Now, if we had just standard appointments at standard rates, I am not quite sure when those folk would have turned up. But by improving access to care—because patients do not understand sometimes when they truly are ill—you can prevent an awful lot of grief and mortality down the track.

The other thing is that about 10 per cent of my patients are Aboriginal. Those folk do it very tough, and a copayment for my Aboriginal patients would significantly restrict their access to our care. And I know just from prescribing and medication that the Close the Gap incentive, such that Aboriginal patients do not have a copayment for their medications, has made a huge difference. But, prior to that, we would just keep a stock of medication, because the next question I would ask after trying to sort out what was the problem would be: 'Have you got the cash for the medication? And, if you haven't, then let's sort out some samples for you until you have the cash to be able to do it.' It is a very, very real need.

CHAIR: I want to ask some questions about turning the GP into the financial counsellor as well as the doctor, but I am mindful that Dr Alexander is sitting there at the end of the phone, and I am very aware of the demographic of large sections of the Tasmanian community. I just want to invite you to make comments in light of what has just been said.

Dr Alexander : We have seen a massive impact from these changes that were overturned and the changes still being threatened down the track. I work in Tasmania, in a lower-socioeconomic area. Tasmania has the worst-performing health system in the country, full stop—probably with the exception of some of the Aboriginal areas. We have the worst performing public hospital. We have the oldest population and the most diseased population. So the rest of Australia should be looking to Tasmania to see what the future problems are that we are going to face in health care.

There have been huge outcomes from these proposed changes by the government. I am just going to point out: it is disappointing that there is not a government member, as far as I can gather, there today. There should be. This should be beyond politics. We have been waiting, and Senator McLucas will probably back me up on this, for years for a non-political health policy. We need to talk more about health care than Medicare. Health care is what we are after. With this hearing coming up, I decided to look at some of the literature that backed up the value of general practice. It dawned on me, after some hours of looking through endless surveys about the value of general practice, that the decision makers—the politicians, the health departments—know our value. It has been told; it is there in black and white; it is everywhere. I did not choose in my submission to endlessly put how valuable we are as GPs because everyone knows this. The problem we have is that, despite the decision makers knowing it, we do not understand, as GPs, why the policies simply come out to undermine general practice. That is the problem this committee should be looking at. Why do we have the evidence but come up with policies in completely the other direction?

There is another devastating flow-on from what we have had to deal with over the past few months—that is, the morale of our existing workforce and particularly our young workforce. I was encouraged to go to an AMA meeting—I am not an AMA member, I am not at college member for reasons I can happily go into—and I tried to encourage young GPs to also go to this meeting. We had two doctors under the age of 45 at that meeting, and the average age was over my age and over 60. The damage this is doing to our workforce is an ongoing damage while we do not get these issues resolved. Hopefully the government will particularly withdraw the two policies we should be looking at, which are the fixed rebate and the $5 co-payment. It is so easy to explain the damage they will do; it is just the basics of health care. It is affecting the morale of our workforce and we do not understand—I would like to ask the four senators, if I am allowed to ask a question: we do not understand why there is this disparity between the evidence and the policies that come from all parties—

Senator McLUCAS: That is our question, Graeme!

CHAIR: We have the same question. We are getting the evidence and we are hearing you loud and clear, and we keep asking why the government continues to move in this direction. I also note that there have been a few comments here about the department and their role in consultation, which seems to have been absent as well. The department will be joining us later this afternoon and we might have some questions about that. I will go now to Senator McLucas with some questions to follow on.

Senator McLUCAS: Graeme, that is our question as well. We have had evidence from the AMA and from the RACGP, and everyone who has come before this committee makes the case that we actually do not—there is this 'problem', this 'dreadful unsustainability' that they are asserting. I think that every witness who has come before us has said that there is no problem. Dr Van Leeuwen, you said the system might be flawed but it is not unsustainable. All of our witnesses have said we can do things to fix this, to fix the system we have that we call Medicare, but that essentially it is a good system. Dr Terry, can you talk to me about a concern I have about the disproportionate effect on small practices? I was very interested in your comment that 35 per cent of GPs are operating in single practices. That is much higher than I thought it would be.

Dr Terry : It surprised me—that is from 2011—but as I said I suspect that is a lot lower now because of the fact that more people have been forced out of practice. There are a lot of people my age, in their early 60s, who could walk away from general practice now—and may have to because of the cost of general practice. In my practice, I could have four or five doctors working in my building as it is big enough; it is totally equipped in all of the surgery rooms. But the amount of money, proportionally, that it takes for me to run my surgery, being a sole practitioner, is much higher. Again, the rural doctor people talked about this earlier on; it is particularly hard in the country.

If I could just read one little email—I moderate an email mailing list from GPs as well as being on the national doctors email list, and there has been massive debate among the list, massive debate, about this—one of the GPs said: 'The Senate needs to know that, if the current trend to freeze Medicare rebates and remove the item numbers continues, there will be a point reached where there will be a massive exodus from bulk-billing patients. GPs are now close to that point.'

The point I would like to make is that we do not want to be forced down this road to a user-pays system such as exists in America, where 'user pays' is synonymous with 'medicine for the rich', and the disadvantaged and the poor do not get access to health care. One of the powerful things about Medicare, I think—and it is a cherished institution in our society, by both doctors and patients—is that it already has the infrastructure set up; it is a manageable thing. The people within it have to be accountable, and it is actually equitable. But we do not want to be pushed to the point where we have to charge people to survive.

Senator McLUCAS: I find it quite extraordinary that, at the moment, America is trying to establish something that looks a little bit like Medicare, whereas our government is actually trying to—

Dr Terry : Trying to dismantle it.

Senator McLUCAS: move us toward something that looks a lot like America's system.

Dr Terry : Yes.

Senator McLUCAS: Professor Bonney, you made a very clear statement. You said that you know that, if there is a co-payment, people will not come—it was a very unambiguous statement—and that they will go to the hospital 20 kilometres away. How do you know that?

Prof. Bonney : From 23 years practising in my town and understanding the demographics of my town. The town, proportionally, is of significant socioeconomic disadvantage.

Senator CAMERON: Excuse me, Professor Bonney, what is your town?

Prof. Bonney : Culburra Beach, which has a population of about 3½ thousand, just out from Nowra, on the New South Wales South Coast.

CHAIR: It is a typical sea-change town on the eastern coast, and many such towns have large, ageing populations.

Prof. Bonney : Yes, that is completely correct—and a high Indigenous population. Also, rent is cheaper than it is in Sydney, so if you are really doing it tough in Sydney then it is a bit of a bolthole. So we just know that folk will not turn up. People ask if we bulk-bill. We know that from the folk who do not get their medications made up because they do not have the money, for example, or the people who do not attend specialist appointments—and that is huge problem for us, getting people to see specialists, because a significant number of specialists do not bulk-bill, although an honourable minority do, and I congratulate them on that. But co-payments make a big difference to access to care.

Senator McLUCAS: Yes. Going to that other issue, about attendance, Dr Van Leeuwen, you said there was a 20 per cent reduction in attendance, but I think a lot of the other doctors said that it just meant that the time to attend was shortened. We asked this question of the department and the Department of Human Services, and they produced data that said that there had been no reduction in attendance over the month following the May budget last year. But I think that now explains it: people just did not have to wait so long. Instead of waiting three weeks to see the doctor, you could get in in 1½ weeks or something like that. So I appreciate the other evidence but I appreciate yours as well, Dr Van Leeuwen.

Dr Van Leeuwen : From a small-business perspective in that setting, the fixed costs remain fixed; the income changes. We have been encouraged to employ nurses to work in a team-care environment. Then income is drastically changed, so small businesses are left with responsibilities to our employees and staff.

Senator McLUCAS: Yes. Thank you.

Senator DI NATALE: I just want to thank you all for attending. We do not do enough of this, talking to people who are at the coalface, whose lives are affected by this and who are in direct contact with patients. Well done to the secretariat and to Senator O'Neill for making sure that we actually heard from GPs. It is terrific that you were able to come. I want to put to you a couple of arguments for why these changes are necessary—arguments that I do not support. One of them is, of course, that people who have the means should pay for their health care. Why is it that a millionaire should not be faced with an additional co-payment? I just want to hear a response.

Dr Terry : The reality is that we already charge people who can afford it—the gap in my surgery is $37, I think—but that is a very small minority of people. Healthcare cardholders or people who are actually employed but on a low income you might charge either nothing or $15.

Dr Pearce : I was going to say the same thing, except I would like to qualify it a little bit more. I think we are all responsible GPs here. We book our time in 15-minute average appointment times. Some of those take six minutes; some of them take 15 minutes. They are all level B consultations, or standard complex consultations. We have a similar gap for people who do not have a healthcare card of about $35 or $36—thereabouts. Our policy at the moment is to bulk-bill healthcare cardholders. But, if you look at Fiona Van Leeuwen's argument there, costs remain the same. So, if I am booking four appointments per hour and I happen to see four healthcare cardholders per hour, at the moment I get about $45 per visit, which is about $180 per hour for the allotted time. Forty per cent of those billings go to the practice, to look after—

Senator DI NATALE: Overheads.

Dr Pearce : Yes. Seeing private people, it is $280—a big difference. So we are actually already discounting. Why is it that there is such a big disparity for us when we have fixed costs and we are offering the same care? What will happen if this model continues and this gap grows bigger is we will be offering people two different levels of health care, because we will not be able to give people who do not pay that $37 gap the same level of time allocation. We are going to have to see them quicker. They are not going to have as much explanation, or we are going to have to charge them a similar amount, so their costs are going to increase. Do you see my argument there?

Senator DI NATALE: Yes, sure. You do not have to convince me. I am just interested to hear how you respond to some of these arguments. The other question is about unnecessary visits. We keep hearing that we need to put a price signal in place because some people are going along to the doctor just to have a chat with them. Why should we be paying for that?

Dr Terry : There is a very small group of people who have unnecessary visits and they often have anxiety or stress related type conditions and they need to come more often. There are, paradoxically, some unnecessary visits because it is cheaper to come to the doctor to get a script for paracetamol or some other drugs on concession than it is to go and buy them from a chemist. But the vast majority of people who come to the doctor do not come very frequently. They will only come when they actually need something.

Senator DI NATALE: Getting back to your point, Professor Bonney, the whole point of having a medical degree is that you learn the capacity to distinguish between what is necessary and unnecessary. That information is not in the hands of most ordinary people.

Prof. Bonney : That is correct. In most situations, GPs have waiting times for standard appointments of several days, which really negates the whole argument of trivial visits. They are not spur of the moment decisions or for minor things. If people have to book in advance and wait, then typically that has already sorted out people who need to be at the doctor's.

Senator DI NATALE: Dr Kamerman, in your paper you highlighted the impact of some of these changes and said that the combination of the changes to the level A and level B coupled with the changes to indexation would have resulted in a gap of $250,000 per year in your practice. Can you explain to me how you got to that number?

Dr Kamerman : The A and B had the most significant effect. We figured that, if we did not make any changes to staff wages or staff numbers, we would be dropping something like $15 per consultation for the shorter ones, and we worked out the percentage of consultations which were under 10 minutes, which was about 25 per cent.

Senator DI NATALE: Which is pretty close to the average.

Dr Kamerman : So we were looking at those sorts of figures. Then we worked out the effect of the loss of indexation. We worked out that probably about seven per cent of our total income would just be frozen.

Senator DI NATALE: So you have calculated the changes to indexation. That would cost you $100,000 per year?

Dr Kamerman : Yes, by the time we get to 2018.

Senator DI NATALE: I suppose it would be worth me pointing out that the changes to indexation have had bipartisan commitment. They were introduced by the previous government—I am sorry to say to my Labor colleagues—

CHAIR: For a short period of time, not for four years.

Senator DI NATALE: That was a policy that was introduced by the previous government and has been continued now to 2018.

CHAIR: Four years.

Senator DI NATALE: What are your options in those circumstances? Indexation, it appears, is something the Senate does not have any power to change, although we are looking at that. The issue of indexation means that you have got two options. One is that you will increase the out-of-pocket gap to $60. So you are saying there that a visit to your practice will cost now $100?

Dr Kamerman : Yes. Basically, if I make no other changes at all to my costs, that is what a non-concession card holder is going to have pay if I am going to continue bulk-billing the rest of them.

Senator DI NATALE: And that is just to maintain the level of income you have got at the moment?

Dr Kamerman : Yes. That is just to break even.

Senator DI NATALE: So $100 a visit. Have any of the other practices done similar modelling looking at what, under the changes to indexation, you will need to start charging non-concessional patients?

Dr Pearce : I did a rough spreadsheet on that. I modelled it on a five-doctor practice, which is an average practice. I worked it out per doctor. With the $5 co-payment in 2015, per doctor it would be a $18,750 reduction in income based on 50 per cent bulk-billing and 50 per cent non-bulk-billing. This is per GP. The non-indexation in that year in its true sense would look at about $6,021 per GP. In a five-doctor practice in 2015 that would be a $51,000 reduction in service fees. That is the usually 40 per cent retained by the practice for service fees.

In reality though non-indexation is a double whammy because we are all going to increase our private fees by between one and three per cent. There was a very good article printed in The Conversation this morning that tried to extrapolate that. In fact, if inflation is running at two per cent, so we miss out on two per cent indexation with the Medicare levy, and increase our private fee by two per cent, in actual fact the patient is slugged by four per cent non-indexation in their rebate, if you get what I mean. I do not think that has been taken into account either. It is significant. This table I can submit as evidence. It is hard to explain.

Senator McLUCAS: Dr Kamerman, what is the tipping point in your practice? If you are going to say to a person $100 is what you are going to have to be charged to come, I suggest that that would mean that patients will just say, 'No, I can't afford it.'

Dr Kamerman : Certainly from a practice perspective my tipping point will be 1 July. We will not be able to continue to bulk-bill patients at that stage—

Senator McLUCAS: At all?

Dr Kamerman : At all.

Senator DI NATALE: What about the $5 reduction in the rebate?

Dr Kamerman : I will give you my perspective of the $5 reduction in the rebate. I currently bulk-bill the disadvantaged, who are supposed to be protected. The loss of indexation is going to hit us very quickly. Already we are marginal, so I will start going backwards from 1 July. I am going to have to stop bulk-billing and if I am going to stop bulk-billing it is not going to be a $5 gap for disadvantaged people. It is not worth me charging $5; it is not viable. It is going to be something like a $25 or $30 gap.

Senator DI NATALE: Let us just explain that. You are saying that, because of the changes to indexation that are already biting and will only get worse over the next few years, you will not be able to bulk-bill even non-concessional patients and the impact of that is that you are not going to increase it by a small amount. You have to go to the trouble of collecting a payment from patients and you have to deal with some people who will not pay, bad debts and all the stuff that goes with that—the administration costs and so on. You are suggesting that even concession card holders are going to be faced with at your practice an out-of-pocket $20 to $25.

Dr Kamerman : The message we are getting from the government, very clearly, by these changes is that bulk-billing is finished as far as a source of income for general practice, if you actually—

Senator DI NATALE: Let us be clear about this: for everybody. The government keeps saying they are going to protect concessional card holders. Why is it that these changes do not protect concession card holders?

Dr Kamerman : Because the rebate is frozen. If we got indexed rebates, at least I would know that I will be able to marginally cover cost increases over time even though the inflation on medical equipment—the fall on the Aussie dollar is certainly going to blow out some of my costs. Unless there are wage presses—and I have got a big practice; I have got a 15 doctor practice, so I have got to pay payroll tax as well. Thankfully—again, I am sorry, I do not want to be political—superannuation increases have frozen, because all those things keep biting into the costs of a practice. Yes, I have got an integrated team care practice. We have got nurses, we have got dieticians and we have got psychologists in the practice, so it is not a simple operation. It is actually a reasonable sized business, and for me to have close to $1 million worth of capital invested and get no return, I would have rocks in my head being a practice owner.

CHAIR: Can I be really clear about this. Come 1 July, if I am a concession holder and I show up at practices around this country—because I am sure, Dr Kamerman, you are not on your own in this—and I am the mother of the child that we heard about earlier. I am a young parent. I have a concession card and I show up. I am going to have to pay a gap regardless that will be much bigger than $5. Is that correct?

Dr Pearce : That is correct. Unless out of our social conscience, which the government seems to be preying on, we can see that there is desperation in your eyes and we can decide to bulk-bill you. But if we do that, then we cross that point where practices are not sustainable and then the government precipitates this thing that I have written in my submissions, which is that infrastructure will just disappear—

CHAIR: That means there will not be doctors to go to—

Dr Pearce : Doctors on this panel will walk away from their practices and then the government is going to have to become involved in providing the infrastructure for which primary health care can deliver health services. At the moment we have got a huge investment in infrastructure which has got to remain viable. What everyone is saying here is that, with all of these little bites that have been happening over the last 40 years since Medicare came in, every little bite, we have reached the tipping point. This is the tipping point. Unless we change our billing procedures, unless we actually look at ways to change our business model to make our practices sustainable, the people that own infrastructure—be they GPs or corporates—will no longer be able to make any profit and, as a result, the infrastructure will be walked away from. It will be sold. It is an unsaleable item, because it is non-profitable, and the government will have to step in.

Dr Van Leeuwen : Just in terms of savings, nobody actually mentions the fact that GPs quite often choose, as do we in our practice, to charge a person less on a healthcare card for the same consultation, considerably less for the same rebate. We accept how much less per consultation?

Dr Pearce : A 50 per cent discount.

Dr Van Leeuwen : A 50 per cent discount. If we were selling a pair of jeans we would not say, 'Hang on a minute: tell me how much money you've got and I'll charge you $5 and you $25.' Medicare does have this component of relying on the goodwill of human nature to support it, and the true cost of a consultation, unfortunately, because the environment in which we work today is not the environment in which Medicare was born, is very marginal when it comes to providing service.

Dr Terry : Just one quick comment I was going to make. If you look at all the statistics about the age of general practitioners, there is a very large number of GPs who are 50 or over 60 now. Given the problem with the loss of income, there could be quite a large number of older GPs who will say, 'Well, it's just time to hang up the shingle, because it is no longer profitable.'

Senator DI NATALE: You basically charge your non-concessional patients a lot more, or you start charging your concessional patients. That is really the equation, so either way someone is going to have to—

Dr Kamerman : Or we close.

Senator DI NATALE: Or you walk away. If you are at an age where you are contemplating retirement, you might bring that on by a few years.

Dr Van Leeuwen : There is one other thing, which of course is just to reduce your staff. Instead of encouraging your clinicians to work at the top of our scope, we would have no practice nurses and very few administrative staff. So you can wind back the clock 25 years and go to one GP seeing one person for 15 minutes.

Senator DI NATALE: That might sound attractive to people who think administration is where we should not be spending our money. But let's be clear what that means. It means no recall for people who need their vaccines done, it means no regular diabetes checks and making sure people are recalled for all sorts of health conditions. That administration is not just—

Dr Van Leeuwen : It inhibits modern care.

Senator DI NATALE: When we are talking about the increasing burden of chronic disease, those staff that you are talking about are critical in terms of chronic disease management.

Dr Van Leeuwen : Absolutely.

Senator DI NATALE: I suspect you will not get much disagreement about the level of concern that we feel here in terms of the impact this is going to have on patients and, of course, doctors. But governments keep saying we want to hear alternatives. Do you think there is an appetite within the general practice community to start looking at how we better reward quality and outcomes and how we better look to reduce wasteful spending? Is that a conversation that you think people on the ground are really ready to have? Or is it just, 'We've had enough of this. Leave us alone'?

Dr Terry : We have had a lot of discussions about this. I would bring you back to that graph that the RACGP put in their submission. It shows that our costs have stayed fairly static and the cost of the hospital system has gone up. We have sat down as a group and looked at large number of areas we could help make changes in. There is the high PBS expenditure on lots of drugs—the pharmaceutical benefits cost. There have been recent articles in the press claiming that Australia is overpaying up to $1.3 billion compared to other countries and asking why we can't adjust our pharmaceutical costs. I think general practice would sit down and we would look at the areas we can actually make a difference in, such as do investigations need to be done and can we reduce pathology costs—all those sorts of areas.

Senator DI NATALE: I thank the Hunter association for the submission on that.

Senator CAMERON: I do not want to get any of the detail at the moment, but could you provide the secretariat with the details of your 10-week program?

Dr Terry : It is already in the Hunter GPA submission. It is on the back page.

Senator CAMERON: Dr Kamerman, we had some discussion previously about Tamworth in relation to bulk-billing. I received correspondence from a Tamworth resident complaining bitterly about not being able to access bulk-billing and the cost of medical treatment in general. It is not just about the cost of bulk-billing in Tamworth; they have to go to Newcastle to get a specialist, and transport costs and all of that are added on. Rural and regional health costs per individual are quite high. That is a fact, isn't it?

Dr Kamerman : Absolutely. Once you add in the distance and the travel time, it is increasingly high. In a lot of states, rural emergency departments are not funded by the state government. Consequently, doctors generally have to bill them privately or bill through Medicare, which is just bizarre. I could not imagine this happening in any city metropolitan large emergency department.

Senator CAMERON: Professor Seidel, who has given evidence to the committee, came back with the results of some investigation he has done in Tamworth. There is one area that bulk-bills everyone, and that is the Aboriginal medical service. There are three that do not routinely bulk-bill. However, they offer pensioner rates. One is in the process of changing its policies so that a selected number of GPs will bulk-bill. Three others do not bulk-bill but will do it with discretion. One other did not respond but, on their website, they say that all consultations have to be paid for at the time. These changes are going to make that even worse.

Dr Kamerman : Currently, our practice is one of the largest practices in town. We have got a policy. We used to routinely bulk-bill concession card holders. Some of the doctors stopped doing it, so it was only half our doctors and all the registrars that were bulk-billing concession card holders. Come July 1, we will be stopping it altogether and that will only leave the Aboriginal medical service. I do not know how they are going to continue to operate with a frozen rebate for 2018.

Senator CAMERON: So Indigenous health could suffer. Your local member is Barnaby Joyce.

Dr Kamerman : Correct.

Senator CAMERON: You are not doing a 'Barnaby' on us, are you? You are not saying there is going to be a $100 lamb roast and there is absolutely no chance of that ever happening. This $100 co-payment is a real issue, isn't it?

Dr Kamerman : It will not be a $100 co-payment; it will be a $100 fee. If these changes are not reversed, I just do not know how to make ends meet or I am going to have to close the doors and that is not really good for anyone. I would rather keep trying to get the business up and running and continue to operate.

Senator CAMERON: And you have got one of the biggest practices in Tamworth, so this may even be a bigger problem for some of the single practitioner doctors that do not have economies of scale.

Dr Kamerman : That is right. There is certainly lots of evidence that you get economies of scale around a five- or six-doctor size. Smaller than that you tend to run into trouble with costs: staff and infrastructure. If I was in my former practice, which was in Bingara, a town of 1200, 150 kays north of Tamworth—

Senator CAMERON: I have been there.

Dr Kamerman : a great town—I would have closed my practice and just walked down to the hospital and opened my practice from there and just used the state government rates and seen everyone through the emergency department. It would be the only viable way of keeping on operating in the long term.

Senator CAMERON: Have you had any discussions with Mr Barnaby Joyce about this?

Dr Kamerman : No. I must admit I have been that busy trying to organise my practice, I have not got around to organising an appointment with him. It is just as much my fault for not getting together with him. My staff are organising an appointment to meet with him and go through—

Senator CAMERON: So you are trying to organise a meeting with Barnaby Joyce. As a cabinet minister, he is going to be very influential in how this operates. Have any of the doctors had any feedback that any of the coalition MPs that you have engaged with have any understanding about this relationship between running a business and providing health care?

Dr Kamerman : Actually, I think Barnaby Joyce would be a good example. One of my colleagues had him visit their practice at length, and my discussion with them was that, yes, he took note of what was happening and the decision was made to go from the $7 to the $5 and protect the disadvantaged after that meeting. The message—

Senator CAMERON: Barnaby saved the patients, did he?

Dr Kamerman : I am not sure about that at all but that was certainly the message the practice was sending to him. Cabinet did meet after that, and my understanding was that, yes, from the profession's point of view—and this practice's point of view—it was very strongly put that the disadvantaged need to be looked after with a form of protection as far as continuing to get the full rebate rather than a co-payment.

Senator CAMERON: That is interesting.

CHAIR: But Dr Kamerman, you have said—just to be clear—that when we hear $5 rebate, a concessional holder as of July 1 should actually hear a $100 fee.

Dr Kamerman : I do not know that I would be charging $100 to a concession card holder.

CHAIR: What would you be charging, Dr Kamerman?

Dr Kamerman : I would probably be charging in the vicinity of $60 or $65.

CHAIR: So when they hear $5, they need to really hear $60, because that is what it really means.

Dr Kamerman : Correct.

CHAIR: Thank you.

Senator CAMERON: Tamworth is not the poorest place in regional Australia but it is certainly not the richest, is it?

Dr Kamerman : That is correct. There are a whole lot of disadvantaged people and disadvantaged areas. I am a methadone prescriber in town. I am going to have to make the decision whether I stop bulk-billing those people. If there is a reduction to access to opiate substitution therapy in town, because I am the only private prescriber—

Senator DI NATALE: You are the only private prescriber of methadone in Tamworth?

Dr Kamerman : I have a registrar who does it as well, so there are two of us who do it.

CHAIR: Within the one practice?

Dr Kamerman : In one practice.

Senator DI NATALE: A methadone patient is not going to pay 60 bucks to get their methadone.

Dr Kamerman : A lot of them will not.

Senator DI NATALE: Sorry—you are right. Many will not; most, I would suggest. I was a methadone prescriber as well. So what does that mean?

Dr Kamerman : It means crime rates will go up in Tamworth and around Australia, I presume, or the public system will be overwhelmed. Waiting time for methadone in Tamworth in the public system is about four to six months.

Senator CAMERON: We have engaged on this issue, about the social implications of these changes to Medicare in that it will create these social problems, where drug dependency cannot be dealt with effectively and that means more violence, more break-ins and more criminality. Do you agree with that proposition?

Dr Kamerman : Absolutely.

Senator CAMERON: And that is as a direct link to people not being able to access medical care—is that right?

Dr Kamerman : Correct.

Senator CAMERON: In the New England-Tamworth area, the last time I was up there I went to one of the suburbs in Tamworth that had a nurse practitioner operation.

Dr Kamerman : Coledale.

Senator CAMERON: It looked to me to be in one of the lower socioeconomic areas in Tamworth. Many people were telling me that this was the only way they could access health care, because at the moment they could not pay the fee to see a doctor. Do you think we will see more reliance on these types of operations if the $5 comes in?

Dr Kamerman : I totally agree. I think you are going to get a whole lot of diversion into alternative means of accessing care. Some of that might well be through NGOs picking up some of the costs. Organisations in our area, such as Centrecare and the Richmond Fellowship, bring patients along and pay fees on their behalf.

Senator CAMERON: Charity. So we move from a Medicare system to a charity system, do we?

Dr Kamerman : Yes.

Senator CAMERON: So we go back 100 years in this country.

Dr Kamerman : At the moment, if you think about it, what I am doing in practice and what most GPs do is provide a form of charity. We reduce our rates for people who are doing it tough. The trouble is that, in the economy at the moment, there are a lot of people doing it tough.

Senator CAMERON: But what I think you are arguing is that there is a limit to your capacity to make a 'charitable donation' to patients. It will now fall back to the charity groups, the non-government organisations.

Dr Kamerman : From memory, wasn't one of the principles of Medicare such that doctors were not having to provide charitable and honorary care for patients?

Senator CAMERON: Yes. What is the message we should take in the Senate? What should we do in the Senate in terms of all these changes? Some people are asking for a six-month moratorium to have discussions; we should not pass any legislation; we should look at whatever means we can to stop the $5 co-payment, even though that may be difficult?

CHAIR: I think Dr Alexander wants to answer that question.

Dr Alexander : I think the message that needs to go back to parliament is that, in order to sell an ideological policy, you first set up a few myths. The first myth is that there is a blow-out in the cost of Medicare. The second myth is that there is somehow a blow-out in patients accessing their GP. There is a simple message here. There has been no blow-out in patients accessing GPs or the costs in a decade, during which we have delivered better health outcomes. For every dollar of a co-payment, states and federal governments will have to find $3.35 to fund their public hospitals. There are no unnecessary or very rarely unnecessary visits to GPs. There are rarely, if any, millionaires being bulk-billed. When we use the word 'bulk-billed' it gets a bit distorted. The term 'bulk-bill' is often interpreted as meaning: are doctors charging their patients? When doctors bulk-bill, what we are actually doing is accepting half the cost of the fee. That is what we are really doing.

Senator Cameron is right. There will be a vastly inferior health system for the poor and the disadvantaged whether they access clinics or get their health care through the pharmacy. There is an interesting thing happening at the moment: as general practice comes under attack—and I point out to you that one of the few areas of general practice that will survive is the large corporate-run clinic, and people should be asking the question why. The huge void that this will fill as general practices' doors close—and that is what we are talking about; we are talking about the viability of general practice, because general practices are going to the wall as we sit here now and they are going to go to the wall with this new health policy. But we have pharmacists and the powerful pharmacy guild talking about how they want to do ear infections. It is an embarrassing grab for money. It is not about health care; it is about people grabbing little bits and cherry picking the bits that they want—even the nurse practitioner example.

The patient that we are dealing with in 2015 in Australia is complex, elderly and with multiple medical problems. As soon as we fragment that patient, it is costly to the taxpayer and hugely detrimental to that patient's health. GPs give patients a better quality of life and save the taxpayer billions. That is the message.

I understand it is difficult for committees such as this and politicians because GPs are such a diverse group of people. We have to be. We are in rural and regional Australia, in cities and in large corporates. It is interesting to know that the corporates have not been anti some of these changes. Why? Because patients accessing their GP are a very, very small part of their income. They make income from the areas that are blowing out in Medicare such as investigations, pathology and specialists. But the majority of rural and regional Australia relies often on privately run clinics such as many of those you have been talking about today. The large corporates will churn up the taxpayer dollars and survive this onslaught on general practice, but it is the smaller, privately run clinics that are going to struggle, and patients are going to suffer.

Senator CAMERON: Thanks for that, Dr Alexander. Dr Kamerman, I want to clarify the issue of the $100 payment. When would it be required for you to implement that payment to survive?

Dr Kamerman : I would imagine it would come in probably over the course of the next 12 months.

Senator CAMERON: So in 12 months in New England, in Tamworth, it will be $100 to see the doctor.

CHAIR: If you are a non-concessional claimant—

Dr Kamerman : If you are a non-concession holder, for an average consultation.

CHAIR: And, if you are a concessional holder, $60 or thereabout.

Dr Kamerman : Thereabout.

Senator CAMERON: When you indicated that Mr Joyce had taken this to cabinet and had this victory to cabinet, is this anecdotal evidence or did he tell you this?

Dr Kamerman : No, I certainly have not had any feedback from him. It was that the feedback I had from colleagues was that the message was put to him very clearly that those that were disadvantaged had to be protected in some way. I am well aware the government has made those changes to particular groups. I did notice that Indigenous people were not included in that unless they happen to have a concession card.

Senator CAMERON: So, if the price signal comes in, Mr Joyce has a lot more work to do in cabinet.

Dr Kamerman : Along with a whole lot of other politicians, I would imagine.

CHAIR: I have a final question in relation to what you said. I am almost frightened to ask this question, because it made me think that perhaps part of this ploy is to push the costs to the state governments in a very cynical way. You said that the best way for you to survive would be to pull up stumps in your practice and shift to the local hospital, delivering your service there—in a more expensive way, I understand—with the budget implication for the state government and not the federal government. Did I understand you correctly?

Dr Kamerman : That is correct. If I were working in a one- or two-doctor town with access to a hospital, the tipping point about running a practice is hitting us now. Why would I want to continue investing in a practice and maintaining all the obligations of looking after staff, the OH&S issues and the taxation accounting issues when I could close all that, walk down to the hospital and get quite a significant income with no overheads, living a much simpler life?

CHAIR: So this is not just a policy change that is going to drive patients to the local hospital; it will ultimately drive the GP practices to the local hospital as well.

Dr Kamerman : It could.

CHAIR: That is very concerning.

Finally, Dr Van Leeuwen, how do you make the decision? How do you do a financial audit of somebody when they are there to let you look in their ear? How do you make this decision about who you charge and who you do not charge? I do not know how to tell people do and do not have money by looking at them.

Dr Van Leeuwen : Of course the dilemma is that we do not really ether. The current system does not support us to identify the appropriate people and have their health subsidised.

Senator DI NATALE: You can look at whether they drive cars!

CHAIR: Yeah, check out the car park!

Dr Van Leeuwen : One other thing: I have been in general practice for 15 years now and I have never before had to sit down after each 15-minute consultation and so carefully determine in my mind how I am going to earn a reasonable income to pay my practice costs and my own wage and ensure that I am not charging the patient too much money.

CHAIR: That must be a very difficult experience for you every day.

Dr Van Leeuwen : I desperately want to focus on my clinical abilities, because that is what I am trained for.

CHAIR: But you are being forced to be a tax collector for the government.

Dr Van Leeuwen : I need to be thinking about money much more frequently than I would like to.

Dr Terry : In a smaller practice, having looked after generations within the same practice, we know their economic status very well. We know who is under financial strain because we get them in stressed about the fact that they cannot meet their obligations or there have been marriage break-ups. There have been a number of occasions where I have actually paid for the patients' medications or the girls have gone over to the chemist, got the medication, put it on our bill and come back because we know the patient is not going to actually have the money to buy it.

CHAIR: So we are at a critical point. You have certainly made that very clear.

The committee intends throughout the course of this year to continue to take evidence from real doctors like yourselves who are interacting with real patients, because there seems to be a big gap in consultation from the government and, as you pointed out, Dr Kamerman, from the health department's engagement with patients and the sector itself. Thank you very much for kicking off our consultation with doctors in such a professional, informed and generous way.