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Focus: Sydney: Australian surgeons savaged by cutting report

Against a backdrop of rising health care costs, politically damaging concern about surgical waiting lists, and a media ever ready to frame stories about doctors in terms of medicine-gone-wrong, Porsche driving, and general self interest, the Australian federal health minister for human services and health, Dr Carmen Lawrence, in June this year commissioned a major inquiry into the surgical workforce.

The report, A Cutting Edge: Australia's Surgical Workforce 1994, was delivered last month by its author, Peter Baume, a gastroenterologist who is professor of community medicine at the University of New South Wales. Baume served for 17 years as a Liberal senator in the Australian federal parliament. As a liberal "wet" he championed welfare and health reforms in both government and opposition before quitting politics when the Liberal party turned neo-Thatcherite in the late 1980s. Since then he has served as a bipartisan consultant to several governments, furthering his reputation as a creative egg cracker in medicopolitical cake baking. And the cake of long waiting lists and spiralling costs needs the cracking of an emu sized egg: the mutually beneficial collusion between the private hospital system and many surgical specialists.

Baume's 181 page report highlighted what he saw as:

* The excessively tight controls exercised by the Royal Australasian College of Surgeons on the supply of surgeons - overall, in nearly all specialties, in rural areas, and in the numbers of women being trained

* A future where, by 2001, there would be a shortfall in surgeons in Australia ranging from 26% in plastic surgery to 85% in urology

* Delays in elective surgery in the public hospital system being caused largely by surgeons' reluctance to work in public hospitals and their encouragement of patients to use the private system

* The historical deskilling of general practitioners in routine minor surgery and investigation.

His 98 recommendations started with a frank challenge to each professional surgical body to put up or shut up on the question of the accuracy of the numbers of surgeons central to his main arguments and to provide, by September 1995, preferred solutions to the shortfalls he identified. If the college and the specialist bodies should fail to cooperate Baume's solutions include having them investigated by the Trade Practices Commission for anticompetitive behaviour, the development of other routes of registration for surgeons, and removal from the college and the specialist societies of the exclusive right to recognise surgical specialists.

The lashing Baume has given to the college of surgeons has raised tumult. The President of the Royal Australiasian College of Surgeons, Dr David Theile, has told the department of health, "It's inconceivable that [the college] could perceive any of the proposed changes are sustainable," arguing that quality of care to patients would be compromised. The general practitioners' college has responded with enthusiasm to the surgical reskilling recommendations - providing, of course, they are accompanied by appropriate rewards. The college of surgeons and the Australian Medical Association have long been critical of public medical services. They point to political and bureaucratic neglect of the public system as the true villains. Baume has endorsed this concern, but he points out that "perverse" funding arrangements for specialists, in concert with their restrictive trade practices, have created some fantastic incomes. Otolaryngologists averaged just under $A500 000 (pounds sterling 250 000) each in 1992-3.

Baume's recommendations about reskilling general practitioners are both sensible and politically astute. GPs, who stand to benefit professionally and financially from Baume's recommendations, are by far the largest group of members in the AMA. This will pose a dilemma for the association's twin concerns: to serve all its members while defending any section of the profession whose economic privilege is under attack. 1995 will be a test of health minister Lawrence's political abilities to achieve cooperation from the surgeons or wield the big sticks paraded in Baume's report.

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