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Senate Select Committee on Health
13/02/2015

CAMPBELL, Associate Professor David, Censor-in-Chief, Australian College of Rural and Remote Medicine

CHAIR: Welcome. Thank you very much for joining us. If you would like to give us an opening statement that would be very helpful.

Prof. Campbell : Thank you for the opportunity to present to this committee. Firstly, I would like to acknowledge the traditional owners of the land on which we meet and pay my respects to their elders past and present. I will say at the outset that my comments will relate particularly to health care in rural communities. I understand that the focus today is on Aboriginal health and Aboriginal health services, and I am very happy to take questions about that topic and how our college relates to that following my submission.

The Australian College of Rural and Remote Medicine is devoted to the advancement of medical care in rural and remote communities. It progresses this through the provision of quality vocational training and professional development programs, setting and upholding practice standards, and through the provision of support and advocacy services for rural medical students, rural registrars and vocationally registered rural doctors. The college is one of two colleges providing vocational training towards fellowship in the specialty of general practice. Its programs are specifically designed to prepare fellows in the special skills required to provide the highest quality care in rural and remote communities.

The college would like to make the following key points to the committee. Firstly, the development of national health policies must include a dedicated process of consideration of how they will impact in the distinct circumstances of rural and remote communities—in other words, some form of rural proofing of health policy. Rural medical services cannot make use of the economies of scale available to metropolitan hospitals, and rural patients are geographically prevented from having simple access to the same suite of health and medical services as their urban counterparts.

Secondly, special consideration must be given to the significant potential impact of proposed Medicare reforms on rural communities. The proposed introduction of the Medicare co-payment and a freeze on Medicare rebates may have negative consequences in the metropolitan context but it is likely to have devastating impacts on rural health services. These impacts need to be given special consideration.

Firstly, the reforms may dissuade rural patients from receiving needed care. Rural communities have a lower socioeconomic profile than urban communities. Farmers and rural small businesses are typically asset rich and cash poor, particularly in the current economic circumstances, and in the event that their local doctor increases their fees, rural patients have few if any alternative doctors available in their community. As such, the proposed changes, which are likely to force rural doctors to increase their fees, will in turn create a much greater barrier to accessing health care for rural people and may potentially lead to them foregoing needed medical services. This is particularly concerning as the evidence shows that rural people are already using Medicare far less than their metropolitan counterparts.

Restricting access to primary care is also disproportionally detrimental in the rural and remote context as rural GPs are often the only readily available doctors and commonly take on the roles ordinarily preserved for specialists in the cities. So if there is a barrier to access to community practice, often if there is an emergency department in the town it would be the same doctors that are providing that care. Rural people also see far fewer specialists than their urban counterparts. The reforms may lead to loss of rural general practitioners as unviable businesses and jeopardise the comprehensiveness of local systems of care. In contrast to urban general practise clinic, the general practice business model in the small rural town involves a discrete potential patient base, and making healthcare costs prohibitive to these patients threatens their viability as businesses.

The loss of rural general practices will undermine the rural training framework and may lead to the demise of rural doctor skills base for the next generation, and the majority of rural practices currently are involved in training the next generation of rural practitioners. A streamlined national rural generalist training program must be established to ensure a sustainable, proficient and cost-effective rural medical workforce for the future. The other budget initiative or announcement of the removal of the pre-vocational general practice placement program, which was originally commenced in rural practice as the Rural and Remote Area Placement Program, will potentially have a major impact on the career decisions of junior doctors.

The rural training pathway should provide and support a clearly articulated training experience from medical school through to fellowship. It needs to focus on selecting the right students most likely to become proficient rural doctors and should provide the skills needed to meet the broad range of rural community needs. These skills should extend to those ordinarily the province of specialists in the city—such as advanced procedural care, emergency care, Aboriginal health care and mental health care.

Recent government funding approaches which stipulate the withdrawal of funding from programs run jointly with state and local government jurisdictions need to be reconsidered in the context of rural health care. A number of recent government decisions have reflected a Treasury driven approach of quarantining a community's Commonwealth support only to programs run entirely and discretely by the Commonwealth. This is incompatible with the nature of rural health service provision and associated rural training programs. I refer particularly to the decision made around the pre-vocational general practice placement program and the rationale for removing that program. Finally, rural training programs need to incorporate registrars moving across a range of work settings in both state-funded and Commonwealth-funded services, and funding of rural medical training needs to facilitate an easy movement of registrars in and out of these throughout their training years.

Thank you for the opportunity to present to the committee.

CHAIR: Thank you very much. I want to go to some of the comments you have made in your opening statement, particularly the first one in which you used the words 'devastating impact' if Medicare co-payments go ahead. You alluded to care-seeking behaviours being interrupted and I think you said that a fee increase would see people foregoing needed medical services. Can you expand on why you think that is the case and also on the government's management decisions around policy that have brought us to this precipice?

Prof. Campbell : The key underpinning of Medicare, as it has existed in Australia for as long as it has, is that it has ensured access to healthcare services. Any change to that arrangement will reduce access to services. The so-called price signal will logically reduce access to care and we know that reduced access to care leads to reduced health status. The evidence demonstrates that worldwide: good health status and improved health status directly relates to access to care. When we introduce barriers to access to care, we reduce health status.

CHAIR: You are saying that quite definitively and you echo the expert evidence of many health professionals throughout the course of our inquiries to date. I noticed you were here this morning when Senator Cameron fed back to our witnesses evidence that we received last week from the Department of Health saying that, basically, the jury is out on this or we do not have sufficient evidence. Why do you and doctors who are at the coalface and other health professionals who work alongside you continue to assert, in contrast to the government's articulation, that a price signal will lead to lower engagement with health and unhelpful health outcomes? Why do you keep saying that when they keep saying the evidence is not there?

Prof. Campbell : From an evidence perspective, it is the wrong question being asked. There is overwhelming international evidence around the importance of a good primary care service and access to good primary care and the direct relationship of that to health status and health outcomes. The environment in which I work is linkages to rural doctor movements across the world, but also the World Health Organization research shows overwhelmingly that any barrier to access to services, particularly primary healthcare services, is related to reduced health status of a community or a population.

CHAIR: So the World Health Organization is pretty clear on this?

Prof. Campbell : Absolutely. The most recent World Health Organization documents around primary care state this time and time again. Much of the work done by experts such as Barbara Starfield in this area has demonstrated this on a population basis, from a population health study perspective, time and time again. To use the one issue of a price signal or a co-payment to try and say that there is not any evidence is really asking the wrong question. What we know overwhelmingly is that, if you do produce a barrier to access, you will reduce health status.

CHAIR: You are here representing particularly the rural, regional and remote areas. The focus of today is particularly on the Indigenous community. You talked about training with regard to having specialist general practitioners. You talked about the selection of students and also the proper skilling up of what we would have to say might need to be the very best students to be able to do the higher level of almost specialist care that is required in those contexts when there are fewer specialists around. I ask you to speak to the prevocational placement program that you mentioned. Give us a bit more background as to how things were tracking, when decisions were made and the status at this point in time?

Prof. Campbell : The precursor in a policy sense to the Prevocational General Practice Placement Program was a program called the Rural and Remote Area Placement Program. This was designed for essentially the rural sector or the rural context. We had rural clinical schools in place, we had some of the other rural initiatives around improving training in rural environments at the undergraduate level and we had some initiatives in place to support doctors for vocational training to be attracted to rural practice, but we were not addressing the area of recent graduates who, by and large, had to undertake their intern placements and their junior doctor placements in metropolitan hospitals. We were finding that that experience was leading to those doctors choosing specialist careers or, more recently, sub-specialist careers. This was highlighted by the Health workforce Australia 2025 document from two years ago.

The Rural and Remote Area Placement Program was introduced to give junior doctors the opportunity to experience rural general practice at that level of their training, so in their intern year or in their second post-graduate year. It was so successful that it was expanded to include outer metropolitan areas and then metropolitan areas, and the numbers of doctors experiencing that program increased dramatically. It got to a point where, I think, roughly 25 per cent of all doctors at that level of training had the opportunity to undertake a community-based term. This was particularly directed at a time of their lives and their education where they were making decisions about their careers, and if I think about my own practice, which was involved in this program from the start—so 12 years ago—we have had more than 50 doctors at that level of their training come through. More than half of those doctors have chosen general practice, and more than half of that cohort have chosen rural general practice, and we think that is largely because of that experience.

We know that the others who have made career decisions about specialist practice know what the context is like, because they have worked in our practice for a three-month period. They know the difficulties that we have with referring people to specialist care and they understand the expectations of rural communities and rural people. In their specialist practice, when they have those people referred to them, they will remember their experience as a junior doctor, understand the context and have a far better commitment to the communication back to the referring doctor.

The program had many, many benefits and many, many spin offs. There was absolutely no communication with the profession that this program was going to be removed in the last budget. It is having a huge impact and a potential downstream impact not only on training, but also on the career direction that junior doctors are taking.

CHAIR: Can I just be clear that there was no consultation with your peak body about removing this program?

Prof. Campbell : No, none at all. It was a major surprise to the whole sector when that program was removed.

CHAIR: Shock or surprise?

Prof. Campbell : Shock. It had been such a successful program, and there is well-documented evidence about how successful it was and has been. The rationale for the removal of the program was that the Commonwealth was no longer going to pay for junior doctors, who are the responsibility of the states, to undertake community practice. That was the rationale for the decision.

CHAIR: You would hardly call it evidence-based or outcome-based policy making in the health department, would you?

Prof. Campbell : It was certainly part of the decision that was made about general practice training generally—that there has been an increase in the number of positions for general practice training to 1,500 this year in the intake—and it was within the Australian General Practice Training program province that this program was delivered, but a line was put through it because there was a need for savings in general practice training.

CHAIR: In your opening statement you indicated that the long-term impact of that was going to be the loss of a generation of a capacity to provide general practice in the bush for whoever, whether it is Indigenous people or the entire community. Could you expand on why you think this is such a critical and bad policy decision by the government?

Prof. Campbell : The combination of that decision and the decision about Medicare co-payments or a reduction in the Medicare rebate creates not only issues around the viability of rural general practice as a small business, but it also creates major disincentives within the training system, particularly when we have graduates who may be, if we have the changes to tertiary education structures that are being promoted, emerging with a $100,000 debt that they have to pay back once they graduate as doctors. With that level of debt they are going to be more attracted to the high income sub-specialities. They are not going to be interested in rural practice, which the evidence shows generates a lower income, and particularly rural general practice.

We are going to see, despite the fact that we have had the data pointed out to us by the Health Workforce Australia 2025 document, that the system is going to need more generalists, not more sub-specialists. We are going to see the next generation of graduates being attracted to sub-specialisation and sub-specialist careers because of the remuneration and because of their HECS debts. There are built-in disincentives which are going to backfire on the community and the population in 10 years time.

CHAIR: In the health policy space we have got a perfect storm going on here. We have got the defunding of Health Workforce Australia and health workforce planning through that agency. We have got $100,000 degrees, or more than that, in estimates that have been put forward with regard to medical degrees. We have got a complete halt to the placement of trainees, graduates, in the community.

Prof. Campbell : In the junior doctor years, yes.

CHAIR: And we have got doctors who are sole practitioners, many of them, out in the bush at a point where their business model for maintaining their business is so under threat by the government that they may indeed walk away from their practices or have to start charging to survive out there and not be able to continue the training.

Prof. Campbell : The other concerning data is that more 50 per cent of rural doctors are now over the age of 50 and are considering their retirement decisions. So how are we going to replace those doctors when they do retire over the next decade to 15 years when we are not steering the increased number of graduates? We have increased the number of medical school places, but we are not incentivising the system to encourage those doctors to undertake rural practice and rural careers.

CHAIR: Before I go to Senator McLucas, could you expand on the particular implications of this perfect storm for Aboriginal and Torres Strait Islander people?

Prof. Campbell : If we look at the issues around access for rural communities, they are compounded tenfold when we look at the issues around access for Aboriginal and Torres Strait Islander people and the resultant health status. In my own community we have an Aboriginal-controlled community health service which obviously is serviced by rural doctors. They are having huge funding constraints. They are unable to employ doctors because of the changes and the reduction in their funding. I heard earlier about the submissions that are currently with the Department of the Prime Minister and Cabinet, and I am aware of those submissions, that funding is going to run out at the end of June.

The issues around rural are compounded tenfold when we look at the issues of access to health services for Aboriginal people. Inserting a price barrier or a price signal for that part of the community is just ridiculous. They are just not going to attend health services. They are just not going to receive health care. Therefore, their burden of disease will increase dramatically.

Dr Boffa's comments about the need for funding of public hospitals as well as the primary care sector is perhaps more relevant in a town like Alice Springs because of the burden of disease of that population. If you look at a population of 90,000 perhaps in Alice Springs, the burden of disease in that community is about five times that of the rest of the community. So you are looking after a population of about 450,000 equivalent because of the burden of disease in that community. So you definitely do need a public hospital that is going to provide that level of care as well as the primary care services.

CHAIR: There is so much more I would like to ask you, but we will now go to Senator McLucas.

Senator McLUCAS: Thank you very much, Professor, for your evidence and also for attending. I am glad you put that evidence down on the PGPPP. In particular, I wrote down 'ask him why'. If that is the rationale that the Commonwealth has no role in training rural GPs, I think that is a fairly flimsy answer.

Prof. Campbell : It also translates to the negotiations that the college is currently having with the department around the new training arrangements for general practice. The minister, in the press release at the time of the budget, also stated that the Australian General Practice Training program will no longer support placements in the public hospital system as part of the training. That is a major issue for our college because we expect the vast majority of all of our trainees to undertake some of their training in a public hospital system. If the expectation is that the Commonwealth-funded program is no longer going to support that as part of the training, we are going to have to negotiate with the state jurisdictions to support that level of their training. That is a major issue for our registrars.

Senator McLUCAS: It is a simple cost shift to the state governments, in my view.

Prof. Campbell : Definitely.

Senator McLUCAS: We are now in the third iteration of some sort of 'price signal' to general practice. The intent of this is to reduce the number of attendances at general practice. That is the intention of the policy. Can you talk to us about the business model of a small rural practice, probably a one or two-GP practice? What will it mean for the ability of that small business to be viable into the future and, particularly, what will it do to the pricing arrangements and, therefore, patient attendances?

Prof. Campbell : I suppose the first thing to say is that the initial concept of a co-payment was directed at the price signal for the community. What we are left with now, which is a reduction in the Medicare rebate, potentially, and also a freeze on indexation, is directed at a price signal for doctors. That is the change in approach that has been taken.

A small rural practice of one or two doctors, even three doctors, from a business model perspective is unable to absorb such reduction in income. As a larger practice in a rural area—we have eight or nine doctors in our practice, depending on the number of registrars we have at any one time—we are still in the process of considering how our business model will reflect these changes and how we, frankly, need to pass on the change in reduction of income to our patients.

For instance, a patient that we are currently looking after at the moment, who is a diabetic, has a diabetic foot and requires us to look after his infected foot on a twice-daily basis with dressings et cetera, which is requiring both nursing care from our practice and also medical care from our practice. If we pass on that cost to that patient that is a huge cost to that patient personally. The costs include not just the expertise provided by the health professionals but the dressings, the radiology and the pathology related to taking swabs et cetera looking for infection and those sorts of things. All of those costs, if they were passed on to the patient, would potentially prevent that patient from seeking that care and maintaining that care. Patients like that are multiplied 10 times in our practice.

Larger practices are potentially able to absorb these changes but will not because of the need for viability and the need to recruit more doctors to their practice for succession planning et cetera. You need long-term viability within your practice to be able to recruit. Any change such as is being proposed to the business model will have a dramatic impact and will eventually be passed on to the patient, the consumer.

Senator McLUCAS: Professor, have you done any work on working out what you would have to charge a concessional or a non-concessional patient yet?

Prof. Campbell : In our practice we have, yes. Currently we offer rebate only. We bulk-bill for all children up to the age of 16 and any students over the age of 16, obviously Veterans Affairs, and concession card holders. We have a reduction in our fee for them.

Senator McLUCAS: You do not bulk-bill those?

Prof. Campbell : A large proportion of those we bulk-bill. If we look at that proportion of concession card holders, because we understand their financial situation our bulk-billing rates for that proportion of our patient load is about 75 per cent. That is individually negotiated between the doctor and the patient and we understand that. We have a compact with our community in that regard and there is an expectation that we will provide them with adequate care and 24-hour care. We understand the nature of their lives and their economic situation et cetera. We make those decisions because we do not want to create a barrier to access to services. That is why we bulk-bill all children because, particularly in paediatrics, there are certain conditions which, if they are not diagnosed early, can lead to devastating consequences. So we do not want to have a price signal to prevent families bringing in their children for emergency care when their children are unwell.

Senator McLUCAS: In terms of billing arrangements, what will happen if the current arrangements are proceeded with? Would you like to share that with the committee?

Prof. Campbell : If I could refer back to your original concept of a one- or two-doctor practice, the potential for that practice is that it would become unviable because there are not the economies of scale in being able to absorb the changes. In a larger practice there would be changes made to the business model and, logically, these costs would be passed on to the patient. It will mean that those patients who can afford to pay will probably be paying more because we will continue to adopt the philosophy that we do not want to have a price barrier for patients who cannot afford the care. We want to be able to continue to provide that care. We do not have a hospital in our town, so we provide emergency care to the community as well. So, from that perspective, our business model includes the whole provision of emergency care, defibrillators, airway management et cetera, which we have to provide for the community because the nearest hospital is 40 minutes away. But we have taken the view that we think it is important to provide that care. From our perspective, that is expensive. So there are other costs we have to absorb into our business model, which will mean that probably those who can afford to pay will be subsidising those who can't.

Senator McLUCAS: That is my view as well. I grew up in a town of 1,000 people and there was a doctor there. You made the point that people who live in rural communities are poorer. It will mean that if a single-doctor practice has got to remain viable, there are a group of people that you cannot charge; they do not have the money in their pocket. So that group of people who do have money in their pocket will then have to cross-subsidise within that practice which, to me, goes against the fundamental of Medicare. Medicare is population wide. It is about providing health care for Australians, not putting the onus on you as a GP to make decisions about who can and who cannot pay. I agree with you: it is going to be terrible for urban areas but devastating for those little GP practices in rural areas. It is shocking.

Prof. Campbell : I get back to my original point: it will reduce access. It becomes a barrier to access and therefore the community will be experiencing an expanded burden of disease and a reduced health status in rural Australia.

CHAIR: Senator Cameron, are you there?

Senator CAMERON: Yes. What is the sound quality like?

CHAIR: It is excellent.

Senator CAMERON: That is good.

CHAIR: We have not been able to get rid of your Scottish accent, but otherwise we can hear you well!

Senator CAMERON: Professor, what you have described is an impending crisis in rural health, have you not?

Prof. Campbell : Yes, and of course many of the policy decisions that the rural doctors have negotiated with government over the last 15 to 20 years have averted that crisis. I think we have already discussed how two or three of the decisions made in this most recent budget have the potential to not just recreate that crisis immediately but have a significant impact on the health of rural communities in the next decade and beyond because of the disincentives in the system to discourage people, junior doctors, to undertake rural careers.

Senator CAMERON: If junior doctors do not undertake rural careers, those who are left will not be able to provide the quality or the quantum of health care that is required to keep up standards, will they?

Prof. Campbell : That is the most immediate impact. And, as I pointed out, many of those are already of retirement age and, if they have to close their practice because of these decisions, I suspect that that is one of the things we are going to be seeing.

Senator CAMERON: So you will get a demographic time bomb and a policy crisis; that is what you are facing.

Prof. Campbell : Yes.

Senator CAMERON: What is the implication for bulk-billing of these recent changes?

Prof. Campbell : We are going to see a reduction in bulk-billing. That is quite clear. If rural practice is to remain viable as a small business, the business models will change. The reduced cost from the reduced income from Medicare, which is generated through bulk-billing, will naturally be passed on to the patient as much as possible. Otherwise, the practices will no longer be viable.

Senator CAMERON: Dr Kamerman, from Tamworth, who is part of a 15-doctor practice, indicated that he believed that for the practice to remain viable they would have to charge non-concession holders $100 and concession card holders $65. Do you have any comment about that?

Prof. Campbell : That is certainly the modelling that we have been looking at in our practice. It is not as big as Ian Kamerman's practice. But, as I say, we have eight or nine doctors in our practice. It is certainly the model that we have been looking at and, as we discussed previously, the cost will be passed on to those who can afford to pay if we want to continue providing care to those who can't.

Senator CAMERON: Where is your practice?

Prof. Campbell : In Lakes Entrance, in Victoria.

Senator CAMERON: So this is not just a New South Wales rural problem; it is a problem that will be systemic across rural and regional Australia?

Prof. Campbell : The information from the Rural Doctors Association of Australia is that these discussions are going on right across the country.

Senator CAMERON: Have you had any reasoning in your discussions, either with the minister or the junior minister, as to how they see this as being a reform—and I use the word 'reform' in the context of making things better?

Prof. Campbell : Our college has had discussions with the assistant minister and the previous minister around the changes to the training arrangements for general practice, but I am not aware of any discussions that we have had about the Medicare changes.

Senator CAMERON: Why have you not had discussions on this policy crisis?

Prof. Campbell : I do not think we have had that invitation.

Senator CAMERON: Do you think you should wait any longer?

Prof. Campbell : Through the general practice groups, such as the Rural Doctors Association and United General Practice Australia, this issue has been discussed with the minister. We have had representation on those groups through the Rural Doctors Association. But I am not aware of the response.

Senator CAMERON: So it is highly feasible and quite likely that, to remain viable, you would have to charge $100 for a non-concession card holder and about $65 for a concession card holder?

Prof. Campbell : That is highly possible. If by 30 June the $5 reduction in the rebate for a consultation is introduced, it is highly possible that that is the business model that we will be adopting.

Senator CAMERON: The departmental officers who attended the hearing in Canberra on the fifth of this month were downplaying these figures quite significantly and were basically saying, 'It's only $5.' How could they be so wrong in their assessment?

Prof. Campbell : I suppose it is a matter of how you look at health and the health of the community. Much of my involvement in supporting the workforce for rural practice et cetera has been based on the fundamental understanding that good medical care relates to access. As soon as you create a barrier to access, you will reduce health status. We do not need to be doing more research into that piece of evidence. In fact, that was the underpinning of Medicare in the first place; it was the reason why the policy was introduced 25 years ago.

CHAIR: Senator Cameron, we are going to wind up now.

Senator CAMERON: Okay. Thank you, Professor.

CHAIR: Professor, do you think the community understands this? Do you think the government's communication with the community has led to an understanding that when they say $5 as a co-payment, it will actually mean $100 has to come out of their pockets or their wallet or off their bank card if they are a non-concession holder, or $60 to $65 if they are a concession holder? Do you think the community that you serve, those who you think can afford to pay, understand that and will they continue to be able to pay?

Prof. Campbell : It is a complex system. The funding of general practice services is complex. I think a small percentage of our patients would understand it, would understand the nature of how Medicare rebates the cost of the service, but many would not. In particular, those who we do decide to accept the rebate only for have no understanding of this. To all intents and purposes, our services to them are free. The level of understanding in the community for this is probably in the minority. They are not going to understand the changes that we have to make unless we are able to have a very detailed dialogue with them about that.

CHAIR: We can always hope that the government might see the error of its ways and not implement the policy and that you will be able to continue as you are, which seems to be a sustainable and enabling practice.

Prof. Campbell : Thank you.

CHAIR: Thank you very much for being here today. We really appreciate your evidence and your coming to see us here in Canberra.

Prof. Campbell : Thank you very much for the opportunity for the college to attend; thank you.

CHAIR: You can send us anything in addition that you think you want to put on the record as of today. I acknowledge that we have been joined in this session by the shadow assistant minister for health, Stephen Jones, the member for Throsby. I also ask the senator to allow for any photography to be undertaken by those who are present.

Senator McLUCAS: Certainly.