Senator MARGETTS (9:09 PM) —I wish to contribute to the debate, but I am very aware of the limitations on time tonight. I seek leave to incorporate my second reading contribution to the Health Insurance Amendment (Professional Services Review) Bill 1999 in Hansard .

The ACTING DEPUTY PRESIDENT (Senator Bartlett) —Is leave granted?

Senator Tambling —Normally the courtesy would be extended with copies being made available in advance. However, on this occasion I will accept the request.

Leave granted.

Senator MARGETTS —I thank the Senate.

The speech read as follows—

The Bill before the Senate today is the Health Insurance Amendment (Professional Services Review) Bill 1999.

The thrust of the Bill is to implement recommendations from the Report of the Review Committee of the Professional Services Review Scheme. It seeks to create a regime for peer review of medical practitioners and to deal with over-servicing and other inappropriate practices.

I have some specific comments to make on the bill, but I would also like to address some broader issues in the health and health insurance areas.

Firstly a comment on the government's general strategy of subsidy of the private health insurance industry.

There is an article in the current issue of Australian Medicine—the newsletter of the Australian Medical Association—which argues as I have done, that the current private health insurance rebate government initiative will probably fail.

The final paragraph of that article explains quite clearly the position of the AMA—and probably that of the government—that the only way to rescue Private Health Insurance is to change public perception that there is always going to be a public system to fall back on. The only way to change this perception is for the government to get taxpayers to lose faith in the public system.

Is this then the reason for current government strategy of transferring large amounts of tax payers' money to the private health funds which will result in further downgrading of the Public System and increasing the size of queues/ waiting lists?

There are several myths propagated in order to undermine Medicare. These myths need to be constantly refuted.

The first is that there is an "explosion in health costs under Medicare" or "Medicare is unsustainable financially in its present form".

The government's own figures indicate that Australia's health services expenditure has been stable at 8.5% of GDP for 3 years and its real rate of growth (2.9%) was significantly lower than for any year since 1991/1992. That is significantly lower than in the private system.

By chance, in last Wednesday's Sydney Morning Herald there is an article by Ross Gittins—"Politicians keep lid on Viagra too"—which very clearly makes the point that Medicare , and the public system in general, keeps the lid on costs.

Why then, is Mr Howard giving $6 billion of taxpayers money over the next 4 years to privatise the health system?

And in whose interest?

The second myth to be debunked is that by transferring taxpayers' funds to the private health insurance system this will "take the pressure off Medicare".

Apart from the fact that this confuses private health insurance with the private health system, the opposite is true. More pressure is being put on the Public system, a) because the government cannot successfully afford to fund both systems, and b) because the majority of private insured patients are using the public system anyway, and without declaring their private status.

This is reported to be sixty three per cent of privately insured patients in Victoria and in NSW 16% of patients were charged for admission to Public Hospitals. This has dropped to 14.9% this year.

Even in the unlikely event that millions of Australians suddenly decided to take up private health insurance the federal/state agreements ensure that allocations to the public system will decrease proportionally to any increase in private health membership.

To turn now to the provisions of the current Bill:

In setting up a system for peer review, the bill overall is quite reasonable and it has broad support from the medical profession. Such support tends usually tends to ring alarm bells for me, but in this instance I think the industry is right.

One of the strengths of Medicare and the Public System is that it is accountable. This Bill reinforces the accountability of the system. It is generally agreed that the system needs to be more enforceable, however there could be some controversy about setting an absolute figure of 80 patients per day on more than 20 days per year as the trigger for investigation of over servicing.

Whilst agreeing that GPs seeing 80 to 100, or even more, patients a day is hardly likely to be compatible with quality health care, there may be some concern about the setting of arbitrary figures i.e is 79 patients a day a reasonable figure but 80 is not.

Will this figure discriminate against some minority groups/ ethnic communities or remote geographical areas and/or some specialities with a shortage of specialists?

I will return to the issue of doctors in remote and rural Australia in a moment.

There does seem to be some hypocrisy in setting patient number limits—which is de facto aiming for better quality care—when the government continues to:

1) squeeze the bulk billing rebate to an all time low—thus attacking the bulk billing doctors and their patients ie those in the less salubrious areas of our capital cities,

2) perpetuate the fee-for-service system which encourages fast throughput of patients by entrepreneurial GPs

Some of us will recall that Dr Wooldridge backed down from his excellent initiative to salary all the young doctors during their 2 General Practice training years because of pressure from the College of GPs just before the last election.

While it is good to see the Government dealing with some of the issues in the health area, there is one serious problem area which needs a good deal more work. I acknowledge that progress is being made here too, but much more remains to be done.

The problem area—and I think the Government would agree with me that this is the biggest problem area in the health portfolio—is in the area of rural health.

The difficulties for rural Australia in getting access to medical services are well known to Senators. While I have some comments to make on the general impact of the shortage of doctors in rural areas, the issue I wish to bring to attention today is the way in which the operation of the Medicare Rebate acts to disadvantage people in country areas.

This is an issue raised with me in the first instance by a constituent in a relatively isolated area of the south of Western Australia—Ravensthorpe, which is some 200 km from Esperance and 300 km from Albany. On investigation I've found that the concerns expressed by this constituent are concerns shared by many country people and by the various medical organisations with an interest in the issue.

The issue is this: In the city, when we go to the doctor, we pay the bill and, usually, l we get a rebate from Medicare of $21.30 for a standard consultation. In the country, where there is much less choice of a doctor, it is much more likely that the rebate for the same consultation would be only $17.85.

How does this situation come about?

It goes back to the provision of Medicare Provider Numbers to various classes of medical practitioners.

Certain items in the Medicare Benefits Schedule are only available to "general practitioners". These are the vocationally registered medical practitioners and fellows of the Royal Australasian College of General Practice.

Other medical practitioners are restricted to a separate group of items when billing their patients. These items have a lower Schedule Fee and consequently a lower Medicare rebate.

The ratio of vocationally registered GPs to other medical practitioners ranges from 3 to 1 in metropolitan areas to about 2 to 3 in some remote areas. Clearly, if this leads to different rebates, it is rural and remote Australians who will be discriminated against.

Among this group of other medical practitioners there are a number of overseas trained doctors on temporary visas working in what are called "declared areas of need".

They may be given a temporary Medicare Provider Number, but they do not have access to vocational registration. This means that the patients they see cannot access the higher level of rebate through Medicare.

Now it may or may not affect the fee that they charge. In the case of the Ravensthorpe example, the up front fee is $36 for a standard consultation. Now the complaint is not with the fee, local residents are thankful that they have a doctor. The complaint is with the rebate—$17.85 instead of $20.30. Why are people in Ravensthorpe—or any number of other similar towns throughout Australia disadvantaged in this way? It is not their fault that it is difficult to attract medical practitioners. They pay the same Medicare levy as the rest of us, why shouldn't they be eligible for the same rebate?

Now, the intention of the split system of rebates is to reward those medical practitioners who do extra training to qualify as general practitioners in addition to meeting a range of other criteria. But it doesn't do that. The fee charged by general and other practitioners may be the same—only the rebate is different. Only if doctors bulk bill, or charge the schedule fee, do they earn less without being vocationally registered. And this again is another disincentive to overseas trained doctors filling positions in areas of need in rural Australia.

Being paid less than vocationally registered doctors when they bulk bill means that they are unlikely to bulk bill non-concession patients. This again disadvantages country people. In the city it is still possible to find the occasional doctor who will bulk bill for any patient. It is much more rare in country areas.

All of this would not be so much of a worry if it wasn't for the sorry state of health of people in country areas. Even excluding the appalling health statistics for Aboriginal people, the health of people in rural areas is below average for the whole of the community. Accident rates are higher and suicide (especially youth suicide) rates are a national scandal.

In this context, anything which adds a further disincentive for people in country areas to attend the doctor, is a matter of concern. Anything which puts another hurdle in the way of doctors moving to country areas is also a matter of concern. What is being done about this?

Well, we have seen some welcome changes in recent months. There is the extension of vocational registration to young solo doctors working in remote areas and also to temporary resident doctors in similar locations with appropriate qualifications.

In WA moves to recruit suitably trained and qualified overseas trained GPs to work in the bush for a minimum of five years, is a useful stop-gap measure to alleviate the worst of the problem.

The introduction in the recent budget of retention payments for general practitioners in rural and remote areas is also welcome. One of the most significant and welcome new items in the Health budget is the fly-in fly-out female general practitioner scheme which has significant potential to meet the needs of rural women.

The goals of the Australian Health Ministers in the 1999 publication Healthy Horizons: A Framework for Improving the Health of Rural, Regional and Remote Australia are a welcome contribution to the debate and it will be interesting to see if resources are allocated to meeting those goals.

But there is something else that needs to be done. The limit imposed on the number of doctors who can be vocationally registered must be lifted. The argument that there are too many doctors is no excuse. In WA the shortage of doctors is not restricted to country areas. In Perth we have the ridiculous situation in which the State Health Minister has declared areas of need in the Intensive Care Units of the major teaching hospitals.

Contrary to the view of the federal government, the only way to address the problem in the long term is to increase the numbers of doctors being trained and being qualified as general practitioners.

In this context I would like to raise the issue of a second graduate medical school in WA. Were there to be such a graduate school, with a focus in rural medicine, we could start to address the disadvantages faced by country people in WA.

Research on what attracts doctors to rural practice includes exposure to rural medicine as a medical student and exposure during vocational and early hospital training to rural practice, especially rural general practice. The lack of training in the special skills required of rural doctors is a big disincentive.

We also need to increase the number of training positions allocated to this state by the Royal Australasian College of General Practitioners (the number has been reduced from 65 to 43 in the last two years, which is totally inadequate—we need 30-35 new doctors in rural WA alone each year!)

We must be able to continue to access doctors for rural areas and for the much needed locum support which the WA Centre for Rural and Remote Medicine has organised in WA. The locum program relieves hard working rural doctors so that they can have a holiday and not burn out, and stay in rural areas longer. It is very successful and appreciated.

To return to the Provider Numbers issue. I have been told—though it makes very little sense—that there is a constitutional reason the problem of non-vocationally registered doctors in country areas can not be resolved by the apparently simple method of allocating the Provider Numbers to doctors by region (the so-called Geographic Provider Numbers). It somehow becomes "civil conscription" of doctors and therefore unconstitutional.

Leaving aside the constitutional argument, though, perhaps there is another solution. Maybe what we need to do is recognise the special skills required of rural doctors and accord them an enhanced status in much the same way as general practitioners have recently been recognised.

Only this time we will make the training and qualification available to the rural doctors where they are and provide generous "grandfather" clauses to allow existing rural doctors (including those in areas of need who do not have full access to the Medicare Benefits Schedule) to qualify as rural practitioners.

That way we might be able to address the training needs of rural doctors, and the institutionalised discrimination against country people regarding Medicare rebates, at the same time.

Speaking of discrimination, I'd like to conclude by quoting Dr Col Owen in the 7 May 1999 edition of Australian Doctor. Dr Owen is a past President of the Royal College of General Practice and a prominent rural GP. He was inaugural President of the Rural Doctors Association of Australia.

He says of the vocational registration, "As well as being professionally divisive, politically disastrous and legally embrangled, we can add that vocational registration has been and is discriminatory. It discriminates against those doctors doing the toughest jobs in the toughest areas at the toughest times—and their patients."

I hope that I have given some food for thought on these issues and raised a few points which National Party Senators can pursue in the Coalition Party Room. You are, after all, the ones who claim to be looking after the interests of rural Australia.

While you are there in the Party Room you might like to enlighten your liberal colleague, Senator Eggleston who, in a letter to a rural constituent on this matter, indicated that the problem was that "young doctors tend to marry city girls who are reluctant to go into country areas and move away from their friends and families."

You might like to tell him that the majority of students entering medical school are now women, and of those graduating in recent years the figures are close to 50%. Any policy to attract doctors to rural areas must take account of what this gender shift means. It has nothing to do with young doctors marrying city girls!