PUBLIC ACCOUNTS COMMITTEE

INQUIRY INTO THE USE OF VISITING MEDICAL PRACTITIONERS IN THE WA PUBLIC HOSPITAL SYSTEM

TRANSCRIPT OF EVIDENCE TAKEN AT ON WEDNESDAY, 13 MARCH 2002

Members

Mr D’Orazio (Chairman) Mr House (Deputy Chairman) Mr Bradshaw Mr Dean Mr Whitely Publ c Accounts Wednesday, 13 March 2002 Page 1

Committee met at 9.36 am

CLARKE, MR GRAEME, General Surgeon, examined:

The CHAIRMAN: Welcome to the hearing. The committee hearing is a proceeding of the Parliament and warrants the same respect that proceedings of the House itself demand. Even though you are not required to give evidence on oath any deliberate misleading of the committee may be regarded as contempt of Parliament. Have you completed the “Details of Witness” form? Mr Clarke: Yes, I have. The CHAIRMAN: Do you understand the notes attached to it? Mr Clarke: I do. The CHAIRMAN: Did you receive and read an information for witnesses briefing sheet regarding giving evidence before a parliamentary committee? Mr Clarke: I did. The CHAIRMAN: Have you made a submission ? Mr Clarke: I have. The CHAIRMAN: Has the committee received your submission? Mr Clarke: Yes, it has. The CHAIRMAN: Do you wish to propose any amendments to it? Mr Clarke: No. The CHAIRMAN: Is it your wish that your submission be incorporated as part of the transcript of evidence? Mr Clarke: Yes. The CHAIRMAN: Before we ask any questions, do you wish to make any statement in addition to the submission? Mr Clarke: I will let the committee ask the questions first, and, at the end, if there are areas that I consider have not been attended to, I will make a statement. The CHAIRMAN: Could you provide us with a background on where you work, the type of work you do and how long you have been involved in the visiting medical practitioner system? Mr Clarke: I have the advantage of being both a teaching and a non-teaching hospital consultant. I work at Sir Charles Gairdner Hospital and Swan District Hospital. I have been a consultant surgeon since September 1992 and have worked as a VMP at Swan District Hospital since then. The CHAIRMAN: How many hours do you work at Sir Charles Gairdner Hospital? Mr Clarke: I have a three sessions a week appointment, of which each session is three and a half hours. I work there 10.5 hours per week. The CHAIRMAN: How many hours do you work at Swan District Hospital? Mr Clarke: Perhaps 30 hours a week. Publ c Accounts Wednesday, 13 March 2002 Page 2

The CHAIRMAN: In relation to the VMP services, can you explain to the committee how you operate as a dual consultant to Swan District Hospital? Do you refer your patients to the hospital for it to operate on them, or does Swan District Hospital employ you as a general surgeon? Mr Clarke: I am a visiting medical practitioner. I am an independent person who provides a service to Swan District Hospital on behalf of the Government. I will take the committee through the process of a patient having surgery done by me as an elective patient as distinct from as an emergency patient. An elective patient who is having his gall bladder removed will see his local doctor and have his tests done. The doctor will then ring my secretary and make an appointment for that person to see me in my office. The patient is then seen, assessed and put on my waiting list at Swan District Hospital to have his surgery done by me. The stage at which the patient is seen by me in my office is purely and totally funded by me. There is no outpatient clinic; nothing is provided by the hospital. The CHAIRMAN: You are saying that it is funded by you, but who is it charged to? Mr Clarke: It is charged to the patient. The patient will then get some money back from Medicare, and some of the money the patient will contribute. The CHAIRMAN: Is your surgery time therefore paid for by Medicare and the patient? Mr Clarke: Correct. The costs are borne by me and not by the Government. That is in contradistinction to my time in the outpatient clinic at Sir Charles Gairdner Hospital, where the costs include the secretaries, the nurses, the orderlies to get the patients, the people who provide the notes, and the added infrastructure, let alone the equipment and the facilities. All of that is provided by the hospital while I see patients there. Mr BRADSHAW: Do you provide for all the costs at Swan District Hospital? Mr Clarke: No. It is all done in my office. There are no facilities at Swan District Hospital to see elective patients. There is no outpatient clinic per se, and there is no room at the hospital to see people. The CHAIRMAN: Therefore, this is the propriety work to your operating at Swan District Hospital? Mr Clarke: That is right. That is where I make the assessment as to whether somebody needs to have surgery or further investigations, or needs to see somebody else. They then go on my waiting list. At the moment it takes around six months to be seen for the equivalent of gall bladder and hernia operations. It is much longer for minor cases. The patients are then admitted to hospital when their turn comes up. When thinking about hospitals like Swan District, a phrase that comes to mind is “work house”. It has a high throughput, the patients are managed by consultant surgeons and anaesthetists, and it is virtually like a private hospital in that patients have me as their surgeon, they have a consultant anaesthetist and they are looked after purely by specialists. They are admitted, they have their operation, they get better and they then go home. The non-teaching hospital arrangement is, as you know, on a fee-for-service basis. This is financial encouragement for surgeons and anaesthetists in that the more they do, the more they will earn and the more patients they can treat. Swan District Hospital is smaller than the larger hospitals, and because of that there is more team work and the nurses are encouraged to feel part of the team. Most of us know the orderlies and the people who work at the desk by their first names. There is an ethic in the hospital to get the work done quickly. Patients are treated in their community, and it is like treating the neighbours. We are providing surgery to a socially less advantaged area than Sir Charles Gairdner Hospital, which is centred in Nedlands. After the patients have finished their operation and have gone home, they then come back to my office for their follow-up care. The CHAIRMAN: Does the follow-up get charged to Medicare? Mr Clarke: Yes. Publ c Accounts Wednesday, 13 March 2002 Page 3

The CHAIRMAN: What sort of work do you do in the three sessions a week that you do at Sir Charles Gairdner Hospital? Mr Clarke: I try to get all of my three and a half hour sessions done on the Monday. I go to the hospital at 8.00 am on Monday and teach medical students. My operating list starts at 8.30 am. By the time I have finished teaching the students, I get to the theatre at around 9.00 am and the registrar has started on the operating list. I arrive in the theatre and complete the surgery, and at 12.30 pm we have a department of surgery meeting. At 2.00 pm the outpatient clinic starts, and at 5.00 pm I attend the Colorectal Medical and Surgical Society meeting. At 6.30 pm I leave the hospital. That accounts for the 10.5 hours that I get paid for. Every third Friday and fifteenth weekend I am on call. I am paid the trivial amount of $92 to be on call for a night and about the same for a weekend. If I need to go back at night or at other times, it is in addition to the 10.5 hours a week that I work. The CHAIRMAN: In relation to your surgery at Sir Charles Gairdner Hospital, how many patients would you operate on in the three and a half hour session? Mr Clarke: My last registrar told me that in the six-month period he was working with me I was present in the theatre for 30 major cases and 15 minor cases. The CHAIRMAN: You were only operating for three and a half hours each week. Therefore, over six months that is three and a half times 25. Did you see 45 patients? Mr Clarke: Absolutely. The CHAIRMAN: Are the major cases different from the type of work that you do at Swan District Hospital? Mr Clarke: No. A small percentage are critically unwell - not surgically unwell because I am the same surgeon - in that they may have heart or lung disease and require intensive care, or they may be obese or something just a bit out of the ordinary that means they require the facilities of a teaching hospital and, more importantly, the facilities of having somebody on-site 24 hours a day. However, in terms of major cases the answer is no. I do as many bowel cancer operations as Sir Charles Gairdner as I do at Swan District Hospital. The CHAIRMAN: Would you do them as quickly? Mr Clarke: No. I have an abstract printed off the Internet from the British Medical Journal of a study that was done in Edinburgh by one of my colleagues, who now works at Sir Charles Gairdner Hospital. It shows that when trainees are operating they take 50 to 75 per cent more time than consultants. That is just for the surgeon. By the time you have added the anaesthetist onto that, one can add another 50 to 75 per cent. By the time one adds on all the other bits and pieces that go along with working in a teaching hospital, it makes for a very slow process to do one case. The CHAIRMAN: As an operating surgeon, would you work any differently at Sir Charles Gairdner Hospital as compared with Swan District Hospital? Mr Clarke: Absolutely. Sir Charles Gairdner Hospital is a teaching hospital. As I mentioned before, I did not necessarily operate in all of the 45 cases that I was present in. My aim as a teaching hospital consultant is to get my registrar to operate on every case if possible. There are some cases that the registrars are not up to because they are more junior in their training. However, I would endeavour to get the registrars to do every single case if I could. Mr BRADSHAW: Therefore, we are not comparing apples with apples in this case. In other sessional cases - not necessarily referring to yourself - would other medicos in that situation go in and perform the operation rather than go through the teaching process? [9.50 am] Publ c Accounts Wednesday, 13 March 2002 Page 4

Mr Clarke: You should not be at a teaching hospital unless you are teaching. That is the number one priority, and it is why we call them teaching hospitals. At teaching hospitals we teach the next generation of surgeons, physicians, and so on for when we get sick in the future. The CHAIRMAN: In Victoria, which has done away with fee for service in metropolitan hospitals, the argument is that having fee-for-service surgeons and/or specialists means that they come in, do the operations as quickly as possible, and then leave. They do not teach those in the professions any skills. In other words, the only component they provide is carrying out the procedure. How do you see that operating at Swan District Hospital? Would it not be better if we were able to use your skills as a teacher to impart your knowledge to other associated professionals at other hospitals? Mr Clarke: Will the member run his question past me again? The CHAIRMAN: Victoria changed from fee for service to sessional arrangements, and the argument is that if fee for service exists then the only input the doctor has is the straight procedure. In other words, the doctor will do what has to be done and will then go, or move on to the next procedure. The idea is that surgeons impart their skills not just at the operating stage but also in discussions with nurses and other health professionals. In that way, they are providing a total health care package. That will improve the status and the ability of the hospital to provide health services. You are obviously in a prime position because you are providing the teaching at Sir Charles Gairdner Hospital. How would you see that operating at Swan District? Mr Clarke: It could operate if there were sufficient manpower, and by that I mean consultants and juniors. The CHAIRMAN: Would that remove some of the pressure that exists at this point in time because there are not enough doctors and specialists? We seem to be screaming at every location because of a lack of specialists and doctors. Could we solve some of those problems by using people like yourself? Mr Clarke: There are quite a lot of doctors in Western Australia. At the moment Swan District has two general surgeons. Why is that so? Why is attending public hospitals so unattractive to surgeons? There has to be some reason. More people will be coming to a public hospital for, in my case when I work at Sir Charles Gairdner, $266 a session. One would have to have rocks in his head to believe that that is attractive. At , the consultants who are full-time are leaning towards part-time so that they can go out into private practice. They are not going out to the non-teaching hospitals. There is a shortage of visiting specialists at Joondalup Private Hospital. Not many people will work on a sessional basis because they are not interested. At Sir Charles Gairdner we are having trouble filling a sessional basis position for a breast surgeon. People are no longer interested. Mr BRADSHAW: Does Joondalup operate on a sessional or a fee-for-service basis? Mr Clarke: I understand that it operates on a fee-for-service basis. Mr BRADSHAW: If it is fee for service, that refutes your argument about going out there on a sessional basis. There is still a shortage. Mr Clarke: One would still earn much less on a fee-for-service basis than in the private system. It is much, much less. The CHAIRMAN: Let us have a look at the types of figures needed, because this committee is comparing the VMP service on a fee-for-service basis with a sessional basis. Some of our people have analysed your numbers. In 2000-01, you saw 747 patients. In each session of performing surgery you saw an average of five patients and attracted a fee of $586 per patient. On the sample tested - it was a fairly large sample so we could get a statistical balance - it took about 27 minutes to do a procedure. If you saw seven patients that works out to be $5 180 per session. That seems to be Publ c Accounts Wednesday, 13 March 2002 Page 5 a helluva lot of money for someone on a sessional basis when you have just told us that at Charles Gairdner you are paid $286 for a three and a half hour session. On the surface that appears to be the reason why no one will work on a sessional basis. Why would you work for $286 for three and a half hours when you can earn $5 180 per session working on a fee-for-service basis? Mr Clarke: There would be very few operating this way or doing that much per operating list. If one is accumulating and amalgamating cases at night and at weekends and bunching them all together, that may be the case. However, I think your statistics are in error. The CHAIRMAN: These are just samples of your operations. I do not want to look at your total pay package. I am doing this on a statistical basis - Mr Clarke: I think you will have to check your statistics because I can honestly say that I cannot ever remember an operating list that has earned that much money. That is like doing about four large bowel resections. The CHAIRMAN: If we take the number of your patients and divide that by your income, you are generating $585 per patient. That is indisputable, because they are the numbers. Therefore, if we look at it on the basis of the number of patients seen and the time it takes, it works out to these numbers. That means that you are basically working 15 weeks a year. The numbers are huge, but they are not the problem. This committee is looking at the system. We are not having a go at you as an individual, nor the amount of money that you are getting per visit. We are asking if the system can afford these types of figures. Can we afford to be paying anybody in the health system these types of figures? It is only going to get worse, and the shortage of specialists dictates that you can basically charge whatever you like because if you do not do it, there is no one else to do it. Mr Clarke: If you are going to compare apples with apples, then yes, for me at Charles Gairdner there is my income, and my registrar’s income, which is seven days a week, 24 hours a day. You would then have to add intern cover of seven days a week, 24 hours a day. Then holiday leave, sick leave, superannuation and all the rest of it has to be added in. You will find that it will not be significantly different. The CHAIRMAN: Even if we were to multiply your fee by 10 - it is $2 000, yours at $5 000 is double that - it is not even within cooee of being equivalent. That is the problem in the system. The fee for service appears to generate abnormally high individual incomes and individual payments. In itself, that may not necessarily be wrong. However, as a system there must be a better way of doing this. What types of numbers would we need to provide if we were to do this on a sessional basis? Have you ever thought of working on a sessional basis in the public health system? Mr Clarke: I do. This is what I consider my pro bono. The equivalent of legal pro bono is to work in a teaching hospital. I do it to teach the students and the registrars. I do it because somebody put hours and hours into me when I was a trainee, and that is why I have reached the standard that I am at today. I want to give on to the next group of people. I like the education facilities that I get in the meetings at Charles Gairdner. I do it at one place and at one place only. I will not do it elsewhere because it is not economically worthwhile. The CHAIRMAN: What type of figure would we need to provide if we were to recommend an alternative at the non-teaching hospitals? What type of figure would attract someone such as yourself to work on a sessional basis at one of those hospitals? Mr Clarke: I do not think you can, because a sessional basis means that one just turns up. Who will do the after-hours work? I wish I could have brought my daughter along today to talk to the committee. Unfortunately, she is in year 11 and had to go to school to sit a test. The committee should talk to the wives and children of doctors who work at night. They will tell you that such doctors are always late for birthdays, parties and all sorts of things, because they are called out to do Publ c Accounts Wednesday, 13 March 2002 Page 6 the emergency cases. The whole package is more than the nice day-time work. It also includes the unpleasant, disruptive after-hours work. The CHAIRMAN: How much of your work at Swan District is after-hours work? Mr Clarke: I do a one in two on call. Essentially, every second night I am available at Swan District Hospital at no cost to the community, unless I get called in. Last week was a nice week. On Wednesday night, between 8.00 pm and 10.00 pm, I was doing a man with an obstructive cancer of the colon. He is a very sick man, and requires daily visits. Thursday night was quiet, and Friday night I did nothing. On Saturday, there was a case of appendicitis and a strangulated hernia that required a bowel resection. In the late afternoon on Sunday I attended a kid who had come off a motorbike and lacerated his leg. Another person came in with appendicitis. That was my weekend. My weekend and my evenings are spent out there. So, the committee might say to me what will it take to get sessional workers. I do not need to do that type of work. In fact, I earned a lot of money out of doing that work. I probably earned $5 000 or so for doing that work. However, there comes a time when one would have to say that it comes at a huge personal and social cost. The CHAIRMAN: Is the problem that there are not enough surgeons? Why are you working so hard to provide all this care? Would it not be better if we had two, three or four of you who could provide you with some relief so that you could work reasonable hours and still get a reasonable income? Mr Clarke: Until recently, we had three surgeons on call at Swan District. One of them left because he did not want to do it anymore. He is still young enough and fit enough to do the on call, but it was getting too much for him and he has stopped working at the hospital. [10.00 am] The CHAIRMAN: So he does his private work. Mr Clarke: Yes. The CHAIRMAN: That is what I am saying. Because there is so much competition and so much demand for your services, the lack of specialists is creating this huge workload for you guys and a huge cost to the system, and there seems to be no way out, unless we provide more specialists and more doctors, and then look at the system. Mr Clarke: I think loads more doctors would have to be provided to work as salaried surgeons. We are talking about a heck of a lot of people to be able to provide the cover that each of us individually provides the hospital. Mr BRADSHAW: Are sufficient doctors being trained to become specialists? You said that is done at the teaching hospitals. Is the capacity sufficient for Western Australia, and is there a waiting list of people who want to get into the system to become specialists? Mr Clarke: There has been a problem with getting the training numbers. To get onto the training program for surgery these days, it is done nationally to fit in with the anticompetitive business, so that everyone has a fair chance, wherever they are, to get onto the general surgical training program, for example, or the cardiac program, or whatever surgical or specialty training program. It is a complex process. A number of people who have come to Western Australia to be trained in my area of general surgery have gone back interstate or elsewhere after they have been trained, or got part-way through their training and finished it off elsewhere, or changed to other disciplines. Mr BRADSHAW: Is that because not enough locals want to do it, or is it a process that - Mr Clarke: It is just a process whereby there are four times as many people in New South Wales and three times as many people in Victoria, and they are all competing for positions. Publ c Accounts Wednesday, 13 March 2002 Page 7

Mr BRADSHAW: Surely, that is their problem in those States; we should be looking after our own situation here in Western Australia, because there is a good chance that if they come from the east, they will go back to the east. Mr Clarke: That is absolutely right. The Royal Australasian College of Surgeons is currently trying to justify - and justify it well - that it is the appropriate group to train surgeons. I think it has cost the college about $250 000 or $500 000 to try to defend the claim made against it by the Australian Competition and Consumer Commission that it is running an anticompetitive practice at the moment. Therefore, part of that must be national selection. Mr BRADSHAW: If Western Australia is paying for it, surely it has the right to decide whom it puts through the system. Mr Clarke: Western Australia has been pretty slack in paying for some of its positions. I think last year Joondalup requested extra funding for a second trainee in general surgery, and funds were not forthcoming. The CHAIRMAN: In the training of specialists, what do you think about what is happening now whereby the States actually fund the training of these specialists, who, as soon as they finish, appear to chuff off into private practice and earn big dollars? Should there not be some sort of call on some of the specialists who are trained by the State to give back to the hospitals a period of service? Mr Clarke: Compulsion is not the way to go. It should be made attractive for them to return and seek those appointments, and to become a teaching hospital consultant and do some public work. The CHAIRMAN: However, when a private practitioner can earn over $1 million, why would anybody want to go back and work for the state health system and train other specialists to provide health services, when in private practice the sums currently available are huge? Why would anybody want to go back? As the State has trained these specialists and paid for their training and costs, as well as all the on-costs, should there not be some commitment to the health system that has trained them, at least to provide one, two, three, four or five years of service? I remember that teachers used to be compelled to provide back to the system two years service in the country before they could do what they liked. Therefore, why should specialists be any different when the State pays for their training? Mr Clarke: Because they are not employees. Teachers become government employees. I accept my role as an employee at Sir Charles Gairdner Hospital, but I am not an employee at Swan District Hospital; I am a contractor who comes in and provides the services that the Government wants to provide to the public. Therefore, it is a different situation. The CHAIRMAN: We are saying that for people to become specialists, they need to be trained in the teaching hospitals, which is paid for and worked up by the State, with all the on-costs associated with that - the 75 per cent slowness in procedures and all the rest of it. Should there not be some giving back to the State for the training it has given to those people? Should there not be a period during which they provide specialist services back to the State? Mr Clarke: Not compulsorily, no. I cannot see that that would necessarily attract people to put in and give anything. The CHAIRMAN: To become specialists, people obviously need to be trained, and if the only place they can do the training is in the state health system, do you not think that the State should at least get some reward for training them? Mr Clarke: They do, because surgeons are providing health care to Western Australian society. The CHAIRMAN: At a cost of $1 million - the amounts are horrific. Mr Clarke: One individual earns $1 million. Publ c Accounts Wednesday, 13 March 2002 Page 8

The CHAIRMAN: No, I am saying that the salaries can be so large on a fee-for-service basis that it makes it difficult to provide specialist services in a public health system. Mr Clarke: Is it better for one man to provide services at $1 million or for 10 men to provide those services at $100 000? I do not know. Mr WHITELY: I have a problem. The arguments you present sound reasonable, but I come back to the figures and I struggle, frankly. You described your pro bono work as the work you do at Sir Charles Gairdner Hospital. On my reckoning, you would earn about $900 a day. Even if you worked only 200 days a year, that is a salary of about $180 000. Mr Clarke: At Sir Charles Gairdner Hospital I earned $40 000 last year. Mr WHITELY: You worked one day a week there, did you not? Mr Clarke: Yes. Mr WHITELY: That is pro bono work. If that is multiplied by five, that is $200 000 a year. This is where I am struggling. It seems to me that you get paid a rate that is about 10 times that when you work at Swan District Hospital as a visiting medical practitioner. I accept some of your arguments, but I struggle with those figures. What is enough of an incentive? Your argument seems to be based on the fact that adequate incentives need to be provided for surgeons to work in the public system. Obviously, you regard a salary that is equivalent to about $200 000 a year as pro bono work. Mr Clarke: No. Mr WHITELY: That is what you called it. Mr Clarke: No. I consider the $40 000 a year that I earn for working one day a week at Sir Charles Gairdner Hospital as pro bono. Would you like to know why? Let me just say that if I sell Rolls Royces, for example, at $100 000 each, and I sell 20 of them a year, what is my income? Mr BRADSHAW: You cannot compare that, because if you sell Rolls Royces, you must have stock. Mr Clarke: Of course, one must pay for the stock. I am a surgeon. I have to provide my office five days a week. Therefore, it costs me in overheads somewhere between $250 000 and $300 000 a year to run my office. Per day, per year, that is about $5 000 to $6 000 a day. I lose money essentially. I am cash flow negative by going to Sir Charles Gairdner Hospital. If that is not pro bono, tell me what is. Mr WHITELY: Let us go back to the issue of incentive for working at Swan District Hospital. The rate is approximately 10 times the rate that you are earning. If you were to work full time at Swan District Hospital, and if that rate is multiplied by about 10, it would work out to be in the order of $2 million a year for working there continuously. Mr Clarke: Even Gary Hastwell did not earn that much. The CHAIRMAN: You are working for the state health system, and being paid for it, for basically 15 five-day weeks. Mr Clarke: Twenty-four hours a day, seven days a week. The CHAIRMAN: We understand that that is on call. However, the actual work that you did was 27 minutes times 747 patients, which works out at 15 weeks a year. I understand that you see people in your private practice, and that you have Medicare charges as well for those patients in your practice, which are obviously all additions. However, the period for which the public health system pays you works out at 15 weeks a year. If that were expanded over a full 52 weeks, the income you would get would work out at over $2 million. Mr Clarke: Somebody like Gary Hastwell works 100 hours a week for $1 million. Publ c Accounts Wednesday, 13 March 2002 Page 9

The CHAIRMAN: The committee did that exercise in Gary’s case as well. He works for the public health system for 15 hours a week. He does not work 100 hours a week for the money he gets from the public health system; he works 100 hours a week doing his private work, his Medicare work and all the rest of it. The actual hours that he worked for the money that he got from the public health system were 15 hours a week, not 100 hours a week. Mr Clarke: I think a lot of sitting-around hours are actually work but are obviously not picked up - time waiting for deliveries, time in between cases and time waiting when one books a case for six o’clock, and somebody else is waiting and one will not get to that person until seven o’clock. There are many things. The committee can hone it down to the period from skin to skin - from knife in till last stitch out - if it wants to, but it would have to look at its figures carefully to make sure that it is being fair with its comparisons of numbers and statistics. The CHAIRMAN: We are trying to do that. Mr WHITELY: What is your typical day? We are faced with those sorts of statistics. If you can tell us that you do not actually line up operations one after the other - you do not have the capacity to do that - obviously the figure will come down, but it is difficult to get a picture of what sort of remuneration you are getting for the sort of workload that you have. You have talked in general terms, but can you be more specific about how your surgery roster is organised? Mr Clarke: If the committee wants me to, I will go through my typical week. On Mondays I am at Sir Charles Gairdner Hospital. On Tuesdays I start consulting at about 7.30 am. One week I consult all day, and one week I operate privately. On Wednesday morning I consult, and on Wednesday afternoons I operate at Kalamunda District Community Hospital from one o’clock till about 4.30 pm. Mr WHITELY: Typically, how many patients would you see in that period from one o’clock to 4.30 pm? Mr Clarke: This afternoon, four. Mr WHITELY: What is the average remuneration for those four patients? Mr Clarke: I can tell you exactly what I will get. Somebody is having a gall bladder operation - that is about $700. There is a carpel tunnel operation, which is $200. There is a pilonidal sinus operation, which is about $300. The fourth case was something small too, but maybe another $300 can be added. Mr WHITELY: Therefore, it would be round about $1 500. Mr Clarke: Yes. Mr WHITELY: That session is from 1 pm to 4.30 pm, is it? Mr Clarke: Yes. Mr WHITELY: What after-sales service - pardon the lack of technical terminology - do you provide? Mr Clarke: I go back tomorrow to review those patients to make sure they are fine. I discharge those who are ready to be discharged and see how they are. Most of them will go home tomorrow. Mr WHITELY: For how long would you be at the hospital providing that sort of after-operative care? Mr Clarke: Half an hour. Mr WHITELY: Are you on call in the evening if one of the patients has a complication? Mr Clarke: Absolutely. Mr WHITELY: How rare would it be for you to be called in on those occasions? Publ c Accounts Wednesday, 13 March 2002 Page 10

Mr Clarke: In my practice it is fairly rare - at Kalamunda anyhow - because I try to select the cases that are low risk, because that hospital has very limited resources and no backup - nothing. On Thursday morning, however, I am removing a bowel cancer from somebody. Mr WHITELY: This is at Swan District Hospital? Mr Clarke: Yes. Then I have a hernia operation and a gall bladder operation. It will be about $1 500 for the bowel cancer operation, about $700 for the gall bladder operation and $400 or so for the hernia operation; so that is $2 600. The man with bowel cancer will be in hospital for two weeks. He will be seen daily for two weeks. Mr WHITELY: By whom? Mr Clarke: By me. He will be seen by me on Sundays, and his family will be seen by me. He will have all the emotional support that needs to be given to somebody who has just had a bowel cancer operation. [10.15 am] If he runs into complications at night, bleeding or feeling sick, I will either go out to see him or preferably it can be dealt with over the phone and the nurses can attend to it. Friday will be much the same. The CHAIRMAN: Do you do any private practice? Mr Clarke: Of course. The CHAIRMAN: Which hospital do you use? Mr Clarke: Mercy Hospital, Hollywood Private Hospital and Westminster Surgery Centre. The CHAIRMAN: How many sessions a week do you do at those hospitals? Mr Clarke: Tonight, after I finish operating at Kalamunda, I am going to Mercy Hospital to operate on a bowel cancer and other patients. The CHAIRMAN: You said you received $1 500 to operate on a bowel cancer at Swan District Hospital. How much do you get at a private hospital? Mr Clarke: The Medibank Private fee is around $2 000. Mr BRADSHAW: Not all doctors or specialists charge the rebate? Mr Clarke: Let us get CMBS bedded down. Virtually nobody charges CMBS fees in surgery. That is not a fee. It is something that the federal Government says it will rebate, and previously it and health insurance funds would rebate patients. The federal Government did not tell me, ever, what I as a private surgeon was going to charge. Mr BRADSHAW: That is what I am trying to get at. You are saying you get a Medibank Private fee. Mr Clarke: Medibank Private will rebate its members for my surgery. The CHAIRMAN: Do you charge the Medibank Private fee or do you charge above that rate? Mr Clarke: I charge around that level. Mr BRADSHAW: But a lot do not? Mr Clarke: Of course not. You charge what you believe your fee is worth in the marketplace. Mr BRADSHAW: You charge what you feel you can get? Mr Clarke: Let us say that back in 1975 or thereabouts there was a common fee. Thanks to Medibank there is a sharp difference in the elevation in Medicare rebates. For example, there was a very generous increase of 1.4 per cent last November, compared with medical inflation which is running at between four and five per cent. There is a progressive gap between what Governments Publ c Accounts Wednesday, 13 March 2002 Page 11 will naturally pay and what is relative to where we are and where our costs have gone. That is what this gap is about. Mr BRADSHAW: You said earlier that you do not think specialists will go to the public hospitals because the private hospitals offer a bigger sweetener. I can understand that. If you get paid more in that system people will be attracted to it. Do you feel that people are getting due rewards in the private system, or do you feel that because the private system rewards people better they will be attracted there? Do you understand what I am trying to say? The reasonable fee may be the amount being paid for fee-for-service at the public hospital, but because the sweetener is in the private hospitals, specialists are moving to them. Mr Clarke: Income is an important factor for all of us. Mr BRADSHAW: The more you can make the happier everyone is, but you also have to be reasonable. The health system is bursting at the seams because of the demands on it, and those costs are contributing. Mr Clarke: That is but one of the costs. The percentage of the health budget that goes to VMP payments is not 90 per cent, 80, 70 or 60 per cent; it is a smallish percentage of the total cost. The CHAIRMAN: It is about 33 per cent. Mr Clarke: A big saving there will make a little saving in the total budget. Mr DEAN: Referring to your negative cash flow, you said you dealt with 747 patients last year in the public system. How many of those would you work up in your surgery beforehand? I assume you charge the standard Medicare fee, which would not be the usual fee of $40 that is paid to a general practitioner. Do you work up any of your private patients in your surgery and can you attribute any of that cost back to the private system? You said a while ago that you had a negative cash flow in your office set-up. My calculations indicate that if you saw close to 100 per cent of those patients - let us say 50 per cent - then Medicare is contributing at least, say, $60 000 to your office costs. I want to explore the negative cash flow in your surgery or office. Mr Clarke: First of all, as a monetary unit, I charge people $92 for an initial consultation, and they get back about $57.55 from the Government. There is a $34 or $35 gap for them to pay for their initial consultation. I charge them $52 for subsequent consultations and they get back $27.90. There are out-of-pocket costs for most patients, except for aged pensioners. Mr DEAN: How many follow-up consultations would you have? Mr Clarke: Let us say a typical patient with gallstones comes along - Mr DEAN: Would you see him again before the operation? Mr Clarke: No. I see him first to assess him, make sure the symptoms are right for the procedure, discuss the procedure, tell him what he is in for, and do the surgery at Swan District. He comes back to see me a few weeks after surgery to make sure everything has gone satisfactorily. I answer questions, check their pathology, make sure their wounds are fine and write back to their doctor. Mr DEAN: Is that in your surgery? Mr Clarke: Yes. Mr DEAN: Is that billed to Medicare? Mr Clarke: Those two consultations are done in my surgery. Mr DEAN: That is about $140 in income? Mr Clarke: Yes. Last week in emergency I saw about eight through the hospital who needed surgery and some who did not. Maybe 20 or 30 per cent of patients fall into the emergency category. Of that 740, 500 have come through my office and the remainder would have been seen because they have come in via the emergency department. Publ c Accounts Wednesday, 13 March 2002 Page 12

Mr DEAN: How many office staff do you employ? Mr Clarke: Two. Mr DEAN: Full time? Mr Clarke: Yes. Mr BRADSHAW: Where are the costs for running your office? You said it was $50 000 and $60 000 a week. Mr Clarke: Yes. I do not know. I have a secretary - Mr BRADSHAW: You said you had two office staff. Mr Clarke: I happen to be one of Perth’s busiest surgeons. Mr BRADSHAW: But for two office staff, even if they get $60 000, that is $120 000 for the year. Mr Clarke: Yes. The CHAIRMAN: They are pretty highly paid office staff. Mr Clarke: I look after my people. Mr BRADSHAW: That is still a long way from $50 000 or $60 000 a week. Mr Clarke: That is the wages. Our rent is nearly $40 000 a year, there are medical defence fees, disability insurance and God only knows what else. There is office equipment and such. I know that that is what is billed. The CHAIRMAN: I will refer to your private practice again, because I am trying to contrast this so that we can look at the cost pressures in the state system. You say you can get $2 000 for a bowel cancer and $1 500 if you are doing it in the public system. Would you be doing half and half in relation to your public and private work, or is it more private work? Mr Clarke: I prefer that to be off the record. The CHAIRMAN: I commented earlier that if there were more specialists you would not have this problem of working so hard and being the busiest specialist; you would not have the cost pressures of other specialists and the ability to charge basically whatever you like. You said you charge whatever you are worth, but in relation to your private practice it is $2 000 for bowel cancer and the government rate is about $1 200. Mr Clarke: The government rate is $1 400. The CHAIRMAN: Is it not in the interests of the specialists and the Royal Australian College of Surgeons to make sure the numbers are kept low, because the fewer specialists, the more ability there is to charge fees that will make the rest of the community feel the system is ripping it off. Salaries of $1 million and $2 million are foreign to most normal people in the community, and seem astronomically high even for doctors. Can you not see that there needs to be an increase in the number of specialists so we do not have this cost pressure? Mr BRADSHAW: Surely you do not work at that rate for the rest of your life? Mr Clarke: No. I am 43. I do not want to be working at this rate for ever. I have missed a helluva lot of my daughter’s growing up. I have missed a heck of a lot of what others would consider normal life. There is the benefit economically, which is without doubt real, but the social mores of today is making me one of the dinosaurs of surgery, in contrast to the generations ahead of me. We believed that we got up early in the morning, we did our ward rounds not long after dawn, we got home well after the sun had set and we worked seven days a week and so on. That is not currently being translated to the next generation of registrars. The next generation of doctors does not view surgery as their life, as I do; it is viewed as a job. Many will want to work only 40 hours a week or less. They will want to have their afternoons off. They will not be like me and work all Publ c Accounts Wednesday, 13 March 2002 Page 13 day Saturday and do ward rounds every Sunday. Can you imagine getting up and driving all that way, doing the loop and seeing patients? Mr BRADSHAW: I suppose you could live out that way. Mr Clarke: Where do you live in an area covering Sir Charles Gairdner to Swan District, and where are you most likely to be called into quickly for the trauma case at Sir Charles Gairdner Hospital? The CHAIRMAN: The commonwealth rebates are set by the Commonwealth for the fee-for- service situation. Mr Clarke: Yes, for Medicare patients but not for VMPs at state government hospitals.. The CHAIRMAN: The fee-for-service fees that you receive from the state health system are approximately nine or 10 per cent above the commonwealth fees. In Victoria the Department of Health pays nobody above the commonwealth fees. The commonwealth fees already contain components for after hours and all those other things. Mr Clarke: I will correct you on that. I get the same fee whether I do the appendectomy at six o’clock in the evening, at two o’clock in the afternoon or at four o’clock in the morning. I get no more, not one zac. Neither is there in the commonwealth rebate any component for surgeons for after-hours attendance for surgery. The CHAIRMAN: There is a call-out fee after hours. Mr Clarke: Not for surgeons. There may be for anaesthetists and general practitioners, but there is not for surgeons. Mr WHITELY: What do you get for an appendectomy? Mr Clarke: About $400. Mr WHITELY: How long does it take? Mr Clarke: From skin to skin it takes about half an hour. The CHAIRMAN: I am trying to get a handle on these numbers - the nine or 10 per cent that we pay above the schedule fee makes a lot of difference to the bottom line. If we are talking about $5 000 for a session, it would only mean - if we paid the commonwealth fee - a difference in your case of $500, so instead of $5 000 it would be $4 500, which is still about 10 times what the a general surgeon at Royal Perth Hospital would be paid on a salary basis. Mr Clarke: I do not do any operating lists. I am a fast surgeon. I do major cases. I do not get $5 000 for an operating list. [10.30 am] I cannot make that much. I do not have the time to earn that much money from an operating list. You keep going on about my earning $5 000 a session. I can get the figures or the committee can speak with the general manager or anybody and they will say that I do not do that much work per operating list. The CHAIRMAN: Even if the figure were lower, for example, $3 000 - Mr Clarke: I have just told you. One operating list this afternoon is worth around $1 500 and one tomorrow is around $2 500. Neither of them is worth $3 000. The CHAIRMAN: The statistics I have are based on what our people have worked out from your claims over the past 12 months. Mr Clarke: That might include every after-hours case or doing a one in two or one in three on call. I do a lot of after-hours surgery and I see many cases per week. The committee might want to include the extra two-hour skin-to-skin operating time. The committee’s figures do not include the Publ c Accounts Wednesday, 13 March 2002 Page 14 sitting around time and anaesthetic time. I was asked what my operating time is. My operating time starts from when I put the knife into a patient to when I finish the operation. That is different from the length of the time of the whole operation. If this committee wants to add the two hours that it took me to operate on a patient on Wednesday night and say that that two hours has miraculously jumped into my sessional time, which statistically the committee has done, that is fine, but it is not the truth. I implore members to examine my whole operating list, not just round off the figures and ask me what I earned for my standard in-hours operating list. The CHAIRMAN: We will take those comments on board and ask our people to reassess the numbers on that basis. Using your figures of $2 000, 10 per cent of that is $200. That is still $1 800 compared with a sessional basis, which is about $200, as you said, but I think it is much higher that that. Some of the senior specialists we have examined probably earn about $400 our $500 per session. Mr Clarke: I am a senior specialist. The CHAIRMAN: I know that. Last week, committee members saw figures of about $400 or $500 for the same sessional basis for the doctors on salaries. Mr Clarke: It is different from sessional work. Full-time doctors are paid per week for their 37.5 hours, or whatever. Some so-called full-time doctors work eight sessions in four days and some sessional workers work one or one and a half days. The CHAIRMAN: I am referring to the doctors employed by the system. The doctors on salaries are getting about $400 or $500 for the same process. You get paid four or five times their salary. Why do we pay a premium on the recommended fees? Mr Clarke: Those premiums are paid because I do all the work on my own. I do not have the backup of somebody else to answer the phone calls. The CHAIRMAN: The hospitals provide you with nursing staff, backup staff for the services, and the rest of it at the operation. The only thing the hospitals do not provide is your office. Mr Clarke: They do not provide anyone to cover at night. Who gets the phone calls at 2.00, 3.00, 4.00 and 6.00 am? Which mug has to get up to drive all the way to Swan District Hospital to change a catheter, put in a drip, assess someone’s low blood pressure, or examine a patient whose heart has gone into a funny rhythm? The nurse does not do that. The surgeon looks after his patients. He gets up and drives to the patient and spends many hours trying to sort out the problem. At Sir Charles Gairdner Hospital, I do not do that. After I leave Charles Gairdner, I virtually do not hear anything more about those patients until I turn up on the following Monday. I am available on the phone and I get a few phone calls from the registrar, but I do not often hear from them at night unless there is a major catastrophe and they need a specialist, in which case I would attend. However, by and large I do not do all the nitty-gritty work; it occurs around me. Notionally, I am the consultant supervising it, but a lot goes on there about which I do not know. I am the chief executive officer and the junior doctors do the work. I do not keep track of every single detail of each patient under my care at Charles Gairdner. Mr WHITELY: I cannot remember what the operation was, but you were paid $1 500 in the public system and $2 000 in the private system. Are your office costs shared equally across those systems or - Mr Clarke: I have an open office. I see public and private patients on a random basis. On one day every patient might be insured, on another day I might see pensioners, and on another day I might see uninsured patients. Mr WHITELY: Are they apportioned at the same rate? Mr Clarke: I open my doors and let the patients in. Publ c Accounts Wednesday, 13 March 2002 Page 15

Mr WHITELY: You are a visiting medical practitioner, you treat private patients and you do sessional work. I take the point you made about the pro bono work. Although you have a salary of $500 000, you work there five days a week because you have to meet the costs of running your office. Effectively, it works out as a negative cash flow. What sort of salary would attract someone with your skills to provide one service in one area, or even in the public sector, on a decent salary if that doctor had to work 50 or 60 hours a week rather than 80 or 100 hours a week? What is a reasonable return for a reasonable day’s work? Would there be a downside to operating in that way? In the end, this committee must consider the value for money. If you told me that you would have to earn a salary of $600 000 a year and that you would not have any office costs associated with that, but the downside is that you would not work as fast, I would accept that. It does not matter how much you get paid; this committee is trying to determine the value for money. Mr Clarke: There is an exodus of doctors from Western Australia to the eastern States because the full-time rates of pay in Queensland are about 30 per cent - Mr WHITELY: What would someone with your experience be paid in Queensland? Mr Clarke: They would be paid about $250 000 or $260 000 if they worked full-time without junior support. Mr WHITELY: Would the medical insurance be met by the hospital or would some costs come out of your own pocket? Mr Clarke: I am not sure. Notionally, Charles Gairdner covers my indemnity for work I do there. However, a doctor who worked full-time at that hospital might, if he trusted his employer, accept crown indemnity. An obstetrician would certainly accept it. If doctors were paid $250 000 a year, had no overheads, did not have to do private practice, worked only 36 hours a week and were provided with junior staff, some doctors would consider that to be a relatively attractive offer. The CHAIRMANr: If the Government offered you that package, would you accept it? Mr Clarke: No, I do not want to work at just one campus. What experience do the doctors at Joondalup have? Would doctors work only in a place like Joondalup, for example, where there are problems with the operating lists and management? They would not. To get into bed in one place would not sit well with me. I prefer to be independent and be my own boss. Mr WHITELY: You must then accept some of the inherent inefficiencies of being independent. You are spreading the cost of running your office across the four days that you work. For someone so skilled, you spend a lot of time driving in your car. Those things are all inefficiencies and must be paid for somewhere. Are you the norm, or would other doctors who were equally skilled be prepared to work in one place? I accept the point that the hospitals would probably want doctors with your skills to work more than 37 hours, but for larger remuneration in places like Swan District Hospital even if the doctors were shared equally between Swan District Hospital and the teaching hospitals. Mr Clarke: Doctors do not want to work like that. Currently there is a semi-parallel at Swan District Hospital with its general medical unit. That hospital has had trouble employing doctors because it wanted a joint appointment at Royal Perth Hospital and Swan District Hospital. It is not attractive to work at Swan District Hospital. Some doctors say that it is a pokey little hospital that has no backup and any problems there will be transferred to the teaching hospitals. Doctors there do not do much and there are not sufficient associated specialists. The hospital is without a lot of infrastructure. However, if it were made into a decent hospital - Mr WHITELY: The committee heard similar comments when we travelled around the State. However, some doctors regard working in a community hospital as an attraction. Is there a different culture among the doctors in the metropolitan area? Publ c Accounts Wednesday, 13 March 2002 Page 16

Mr Clarke: Everyone is different. Some doctors wish to be academic; others like the committee structure of public hospitals and like being on the drugs and therapeutic committee. They like to mix and match with the CEOs and have morning and afternoon tea and lunch. They like that position of powerbrokers in hospitals. Other doctors just do the work. Mr WHITELY: Do only a few doctors in Perth like to work at Swan District Hospital or Armadale-Kelmscott Memorial Hospital? Mr Clarke: Committee members know that and have seen what must be done to attract people to Armadale-Kelmscott Memorial Hospital. It is a long way away. The CHAIRMAN: That situation exists because there is a shortage of doctors. If there were not a shortage of doctors, there would not be this problem. You get a 25 per cent increase in fees for working in the private sector. Why do you work in only private practice and forget about working for the public system? Why do you work for the public system? Mr Clarke: I try to give something back to the community. All doctors have a practice. My office is in Midland, not Subiaco or Nedlands. To be a general surgeon and provide a service to the community, a doctor must have some access to the local hospital. That is why I do it. To be honest, I could walk away from it and live comfortably, stop working on Saturdays and have a day or two off a week. Mr DEAN: How many years before you can do that? Mr Clarke: Tomorrow. I earn a lot of money. My private practice is sufficiently robust - Mr DEAN: Is it in the back of your mind? Mr Clarke: No, it is not. The CHAIRMAN: This committee is trying to improve the health system and get value for money. What should this committee consider to improve the service delivery that would take the workload off you and, more importantly, provide better value for money and improve the system? Mr Clarke: Fee-for-service hospitals provide extremely good value for money. Without wishing to stereotype any of them, the patients at Midland who go to Swan District Hospital are not socially advantaged. A lot of pensioners and people who have had a rough time in life live in Midland. They get care from consultant surgeons and consultant anaesthetists and good facilities in a relatively friendly, happy working environment. I enjoy working there. The staff and other people with whom I work are nice, friendly people. It is a pleasure to go to Swan District Hospital. The patients get the same pleasure. Mr WHITELY: Armadale is not a long way out. It takes only 40 minutes to drive out there. It is not far at all. It seems there is a certain mind-set among the doctors. Mr Clarke: It seemed a hell of a long way when I went to Albany last weekend. The CHAIRMAN: You must forgive our country members here. Mr Clarke: For me, it provides that kind of environment. It is a long way from other things. If a doctor’s private practice is based in Hollywood, St John of God Health Care in Subiaco, and the Mount Hospital, then Swan District Hospital is a fair way out from those other hospitals. There are no private hospitals beyond Mercy Hospital on Guildford Road. That would involve a lot of travelling time. In the Midland area there are probably around 30 per cent of private patients. A much greater percentage than 30 per cent will be private patients in colleagues’ rooms in Subiaco, where they will be serviced by St John’s and other private hospitals. The CHAIRMAN: Do you not have any suggestions on how to improve the system? Do you think it is fine? Publ c Accounts Wednesday, 13 March 2002 Page 17

Mr Clarke: I emphasise that the fee-for-service system is efficient. The Government has no outpatient costs. We, and subsequently the patients and the federal Government, carry those outpatient costs for the State Government. To set up the infrastructure and to build an outpatient clinic and staff and man it is very expensive. At Sir Charles Gairdner Hospital there has been talk for a long time about trying to privatise the outpatient clinic to earn a few extra bucks for the hospital. It is an expensive business. I will refer to the throughput of surgery. In a year I treat about 700 patients at Swan District Hospital, whereas at Sir Charles Gairdner Hospital I treat 45 patients. It is chalk and cheese. [10.45 am.] Mr WHITELY: You are there as a teacher, are you not? Mr Clarke: Yes. That is when I am present in the theatre. I am scrubbed up, standing watching the registrar operate or doing the operation if there are problems. Mr WHITELY: You could not make that comparison if you were employed as a salaried doctor. You would obviously achieve a lot more throughput than that, because if you did not have a teaching responsibility your throughput would be much greater. Mr Clarke: Would you salary me for 37 hours a week? I work 37 hours a week and I am no different from anybody else. The CHAIRMAN: If you have 45 patients, you will have over $1 000 per patient at Sir Charles Gairdner Hospital, so the fee for service is almost the same. Mr Clarke: I cover outpatients, see people there, and do things like that. The CHAIRMAN: It is almost exactly the same amount that you are getting at Swan District Hospital, is it not? Mr Clarke: It is for me, but the Government would have the registrar’s costs for 24 hours a day, seven days a week and the resident’s costs for 24 hours a day, seven days a week. The CHAIRMAN: We would be getting your expertise as a teacher for the next generation of specialists, and that is what it is about. It is about providing the training. That is lacking at Swan District Hospital, because you are merely going there, doing the procedure and getting out, are you not? Mr Clarke: Yes. I do one day a week at Sir Charles Gairdner, but I would not do three days a week at the same rate. I would not be able to achieve the same throughput as I do at the moment. The CHAIRMAN: Are you saying that you would not want to do it because it would take much longer and it would mean hanging around with a trainee in order to do the same surgery? Mr Clarke: That is correct. Mr BRADSHAW: You said that you do one in two operations. If you or your offsider suddenly disappeared off the face of the earth, that would leave one of you to be on call 24 hours a day, seven days a week. Mr Clarke: Notionally it does, but you may have noted that at Swan District Hospital on two weekends out of four no general surgeons are available because we cannot physically cover that much. Any patients who go into the emergency department that weekend will be moved on. Mr BRADSHAW: If one of you did disappear, there would be less cover of that area, would there not? Mr Clarke: Yes. Mr BRADSHAW: There appears to be nobody to fill the gap and eventually you guys will move on and there will be a hiatus. Publ c Accounts Wednesday, 13 March 2002 Page 18

The CHAIRMAN: We need some more specialists. Mr Clarke: Absolutely. Mr BRADSHAW: What sort of remuneration would attract people there? Obviously the new generation of doctors would not work the hours that you work and be on call. There obviously must be a sessional or full-time specialist employed at those hospitals if the new generation of doctors is to be attracted to them, so that they do 37.5 hours or 40 hours and then somebody else takes their place to provide a seven days a week service. Mr Clarke: Junior staff are not required to do it. We do not need lots of junior doctors to cover the 24 hours a day. I have no interest in sitting in a hospital overnight. It costs the Armadale- Kelmscott Memorial Hospital a lot of money to have the anaesthetist sit around at night. People would not do that for nothing. The CHAIRMAN: It always comes back to the lack of specialists. If there were more specialists, people would take it up because that would be the only job available. The massive shortage of specialists creates the artificial demand. With no disrespect, it means that you guys can do whatever you like, and we can do nothing about it. Mr Clarke: That is right. There is a problem with supply. The CHAIRMAN: The Australian Competition and Consumer Commission may be correct, may it not? Mr Clarke: It has nothing to do with training. We must ask ourselves where we can train them and who will do the training. You would need to pay me twice as much per case at Swan District Hospital to train somebody if I was doing only half as much work. The CHAIRMAN: That is true, but that will only be a short-term problem. If you can train up four or five specialists, that would take care of the problem. The fees that we are paying individuals would not arise, because there would be the ability to employ people on a normal-type salary. Mr Clarke: Yes, but, as you just said, specialists get paid the same amount at Sir Charles Gairdner Hospital per case. Perhaps I should start billing Sir Charles Gairdner Hospital fees for services. The problem is that there is a manpower shortage. I understand that Mayne Nickless has advertised in the British Medical Journal and other publications for surgeons because Mayne Nickless will soon be down to two or three surgeons to cover . So far it has had no takers. Mr BRADSHAW: How many doctors are trained each year in general surgery? Mr Clarke: There are at the moment 12 training positions for general surgery. The CHAIRMAN: Is that 12 per year? Mr Clarke: No, it is 12 training positions for four years, so it is usually three per year. Mr WHITELY: How is the number determined? Is it determined on the basis of need? Mr Clarke: It is determined on the basis of the location of funded places to train people. The CHAIRMAN: Obviously there is a fundamental problem if three people are being trained a year. It means that if they all completed their training, every year three specialists would be generated. Mr Clarke: They would be general surgeons. That is quite true, but we must ask where we can train them and how we can train them. At the moment there are five general surgery training posts at Sir Charles Gairdner Hospital, four at Royal Perth Hospital and three at , which are accredited training positions. The CHAIRMAN: What process do we need to expand the accreditation? Publ c Accounts Wednesday, 13 March 2002 Page 19

Mr Clarke: They are accredited by the College of Surgeons. The CHAIRMAN: It is like a circle. Mr Clarke: If you believe in collusion, you should talk to Mr Fels. The reality of life is that if you want to train somebody, you must have the caseload and throughput and the ability to do it. Royal Perth Hospital has gone within a bee’s whisker of losing its accreditation in general surgery because of the lack of throughput at the hospital. The CHAIRMAN: You do not seem to have a problem with your throughput. Why not send your patients there? Mr Clarke: It is not a question of patients going there. They cannot go there. Patients who are on the Royal Perth Hospital waiting list are coming to see me. They have been waiting so long because they cannot get in there. Mr BRADSHAW: Is Royal Perth Hospital doing procedures other than general surgery that cause those problems? Mr Clarke: There is the question of staff, the vancomycin-resistant enterococcus scare and all sorts of other things that have occurred. There has been an appalling lack of funding to Royal Perth Hospital, which has meant that the caseload that can be dealt with is limited, and the amount of trauma and emergency work that staff get through is very large. They are getting not much elective surgery done, but mainly super-urgent work. Mr WHITELY: Presumably the College of Surgeons determines the criteria for caseloads. Therefore, the question of resources would be a fairly circular argument. I am not accusing anybody, but there is the opportunity to turn the screw and restrict the supply of surgeons, by simply upping the definition of the criteria for becoming a surgeon? Mr Clarke: You, everybody else and I want the training criteria of surgeons to be at the absolutely highest level. There is no place in this world for second rate, third rate or fourth rate surgeons. Mr WHITELY: That is true. We do not want surgeons who are extremely tired because they have been working for 100 hours a week, cannot get a decent night’s sleep and have been doing it for 10 years. That is a recipe for disaster no matter how talented they are. Mr Clarke: That is quite true, but in the end there must be a minimum standard we wish to achieve in the training of surgeons. Mr WHITELY: I am merely trying to understand the system. The minimum standard is determined by the College of Surgeons. There is no external oversight for training standards. Obviously the college’s expertise is crucial, but there is the potential for it to restrict the supply. Mr Clarke: This is the very point that is being viewed by the Australian Competition and Consumer Commission at the moment. It has looked at the amount of time surgeons devote to training, such as tutorials on Saturdays. For example, this Sunday I am spending the day in the basic skills laboratory at the centre for training education to teach trainees how to get basic skills. I get a bottle of wine for helping those young people to get through. An enormous amount of time is spent in doing that. That is all part of it. We try hard to train as many people as we can. If there are no facilities to allow us to do it, we cannot do it. Not everybody can train. The training and throughput are in many ways two ends of the spectrum. You have put in loads of money for the waiting list reduction program that was introduced by the last Government, because waiting lists seem to be am important issue. All that did was drag a few people off the waiting list. We cannot train on those sorts of patients because we need the throughput to get the numbers down. The CHAIRMAN: Why can you not train with those patients? Mr Clarke: It takes too long. It takes so long that we will not get an efficient system. We will not get somebody standing around. Publ c Accounts Wednesday, 13 March 2002 Page 20

The CHAIRMAN: Did you not tell me before that the registrars are doing the procedures and that you are just there watching? Mr Clarke: That is right. The CHAIRMAN: The registrar can still do the procedures and you can still be watching, so what is the difference? Mr Clarke: How do you remunerate people for that - on a case by case basis? The CHAIRMAN: Are you talking about yourself or the registrars? If more money were thrown at the waiting lists, the registrars would still be doing the procedures and getting the training, and you would still be standing there. Mr Clarke: Those waiting lists had to be dealt with at Joondalup Health Campus, Osborne Park Hospital, Swan District Hospital, Kalamunda District Community Hospital, Bentley Hospital and lots of other places; not at Royal Perth Hospital and Sir Charles Gairdner Hospital. Mr WHITELY: You are saying that there is a catch 22 situation, because there are not enough senior surgeons to do the training, and if we take them out of training to get rid of the patient loads, they cannot do the training. Is that basically your argument? Mr Clarke: I am saying that if you want surgeons in the periphery to train and have the ongoing responsibility for patients, other operations will not be done, so there is less throughput and the waiting list increases. The costs per case will go up because we will be getting through only half as many cases. The CHAIRMAN: What is the solution? [11.00 am] Mr Clarke: We need to amalgamate a number of the hospitals and make them bigger and better places than they are. The CHAIRMAN: Are you talking about centres of excellence? Mr Clarke: Not necessarily. Melbourne has three or four central teaching hospitals, and the hospitals surrounding them are all large. We have a ring of small hospitals. In many ways we would be better off with a number of big campuses rather than multiple small campuses. People would then say they wanted their one hospital appointment - the one they are prepared to work on a pro bono, sessional or salaried basis - at a particular place. They would then base themselves where there were bells and whistles, and where they could do all the things they might wish to do with their patients. It then becomes possible to train people. In Melbourne and Sydney they train them in that ring of hospitals. Mr BRADSHAW: Is that public or private hospitals?. Mr Clarke: Public hospitals. The CHAIRMAN: The secondary hospitals become teaching hospitals. That is how they have rid themselves of fee-for-service arrangements and now use hospitals as a training venue. Mr Clarke: We are trying some training in private hospitals. At Mount Hospital one of the training registrars assists the plastic surgeons with private patients. It is not perfect. Mr DEAN: That is almost a selfish motivation. Mr Clarke: No, we need plastic surgeons. There is no plastic surgeon at Fremantle. We are talking about plastic and reconstructive surgery, not cosmetic surgery. The CHAIRMAN: Victoria has 59 training positions in general surgery. Western Australia has 14. Mr Clarke: Right. Publ c Accounts Wednesday, 13 March 2002 Page 21

The CHAIRMAN: That is a problem. We are well out of the ballpark on a pro rata basis. Mr Clarke: A little bit. What is the population of Victoria? The CHAIRMAN: WA has a population of 1.5 million and Victoria has a population of three million. We are at least five positions short. That is generating the shortage of general surgery positions. That applies across the board; almost every category appears to be the same. Do you wish to make any other statement? Mr Clarke: No, I do not think so. The CHAIRMAN: I thank you for being so frank this morning. Sorry for asking some difficult questions, but that is part of the process. This committee is trying to find a solution and to make recommendations to Parliament. Thank you for your openness and for talking about some difficult and complicated issues. Thank you also for giving us the benefit of your vast knowledge this morning. [The committee took evidence in camera.] Committee adjourned at 11.16 am