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Friday, 22 February 1985
Page: 65


Senator CROWLEY(11.44) —I take the opportunity to make some remarks about the report of the Senate Select Committee into Private Hospitals and Nursing Homes. I preface those remarks by thanking officially the Chairman, Senator Giles. I can say with a particular understanding that Senator Giles on occasions had to deal with some difficulties that arose-very nice difficulties-and she managed them with her particular skill and ability. I joined the Select Committee in 1983 and found myself on, I think, the first all-women Senate committee. At that stage, as Senator Giles has elaborated, the Committee was well under way, so I appreciated that I was not part of the Committee from its beginning. I formally thank the Chairman, both on my behalf and on behalf of the other members of the Committee, for the extraordinary job she has done in chairing this Committee since I have been a member of it.

The points that Senator Giles raised need to be noted. They are that from time to time, when we thought we were ready to write our report and present our recommendations, it suddenly became obvious that we would have to rehear evidence or take into consideration changes in the industry or, as Senator Giles mentioned, reconsider some of the cases brought before courts concerning complaints involving private nursing homes. From time to time we were about to make our report and we found that we just had to start again. Patience was needed by our Chairman in getting us through those difficulties.

I thank my colleagues and I join Senator Giles in thanking the support staff. The Secretariat worked splendidly. Quite often after we had retired wearily at the end of a long day the Secretariat continued to work. Behind the Secretariat was the back-up staff on the word processors and the stenographers who may have kept even longer hours in order to finalise the report. I think it is important to acknowledge them and I thank them in particular.

One of the reasons why I am very appreciative of this report is that if at any time I want to find out about the private nursing home industry I can look up the report. I found it an extraordinary challenge to master the whole range of complexities concerning money, legislation and regulations and the various sub-sections under the heading of the private nursing home industry. I am very grateful to have a report which contains not only recommendations about those difficulties but also much data collected in one place. Anyone looking at it will see that it is a huge report. It is larger than many I have seen tabled in the last couple of years. I do not have too long a history in the Senate, and perhaps there are many reports which are larger, but this report seems to me to be very comprehensive. It has to be as that is the nature of the industry and the nature of what we found out as we went through the inquiry. This is only half of the report, so it is an extraordinary reference to which we have addressed ourselves. The report does address all the complexities that I think have been outlined so adequately and pertinently by Senator Giles. I do not wish to run over those points again.

During the hearing of the evidence I learnt just how confusing and how complex the private nursing home industry is. There are huge numbers of variations contingent on special nursing homes, special requests, special numbers of beds, special nursing requirements and so on, and they have added to the complexity. I think the report is very timely. I understand the Minister for Health (Dr Blewett) is going to examine this report thoroughly because the private nursing home industry is a matter of great concern to the Government, particularly because of the cost to the public purse of expenditure in this industry.

I would like to raise a couple of points before I return to the minority reports. Senator Giles alluded, towards the end of her report, to the care of patients, which we paid particular attention to in the course of our examination. The priority concern for all of us when we examine the private nursing home industry is the quality of care for the patients. I am sure we have no dispute about that. It is not a matter of profit, of nursing regulations or of how the buildings look; it is a matter of what is provided in terms of care for those patients who, mostly for medical reasons and sometimes for medico-social reasons, finish up living part of or the end of their lives in such nursing homes. It is the quality of care, and much of the report attended to that. Like every other section of this report, it turned out to be a sort of Pandora's box. The more we looked at it, the more we found we had to look at and the more complex it became.

There are difficulties in defining what is meant by care. Are we talking about nursing care, something more extensive than nursing care or something more restrictive than nursing care? If we describe nursing care, we have to describe the personnel who will provide it. The Committee attempted to address all of those variations and areas of the definition of the providers of service or care. It is easy enough to say that finding a good quality nursing home with good quality nursing care will fix the problem. But our Committee actually had to define what it meant by a good quality nursing home and good quality nursing care. It turned out to be a very difficult task and a very extensive number of hours were devoted to it. I think we have taken some considerable steps towards the final definition that will probably be necessary in that area.

There are difficulties in terms of defining what is necessary for a patient. There are also difficulties in defining what is necessarily called nursing duties for the staff. In providing good quality care we have to make sure that we have satisfied or happy providers of the care. The problem in the nursing industry has been not only a matter of buildings but also a matter of staffing and definitions of duties for the staff in those nursing homes. Again we became very aware of how difficult it is to define exactly what is a nursing duty, although some of the nursing unions-in particular, the Royal Australian Nursing Federation-have moved some considerable distance in making those definitions. The Committee was able to draw on their already established definitions. Some very extensive research also has been done and that was a help for the Committee too. But I think there will still be room for further definition, further exactness and perhaps further flexibility in how those definitions go.

Then the consideration extended to the assistant staff, domiciliary staff, caretaker staff and backup support staff and to where their duties finish and where nursing duties start, or vice versa. Again, the Committee spent some time deliberating on these matters and made recommendations in that area. But I imagine that they will be open to continuing consideration. I also comment that one of the things I learnt during my time on this Committee was that if there is any area where history seems to be happening by the day or the week it is the nursing home industry. There have been great changes in this whole area since the late 1950s and early 1960s. There has been a huge increase in the number of beds. Although, as Senator Giles commented, the rate of increase is slowing down now, the expectation of the use of such beds will continue certainly until the turn of the century and possibly even beyond that-perhaps until the year 2010 when it is projected that our aged population will be dramatically increasing as a percentage of those not yet aged.

So we cannot see any likelihood that the number of nursing home beds will lessen. But we can see a change in requirements for who shall go into nursing home beds, how those nursing home beds are allocated and where they are distributed. Considerations such as whether respite care use of nursing home beds should be increased, whether a section of every nursing home should be set aside for respite care and the distribution of respite care beds across a State or an area illustrate just some of the questions we can ask, did ask and did address. I say in summary that my learning on this Committee has come from looking at an industry or an area of our society that is very much in a process of change. I think it will continue to change and that we need to have in place a system that will allow evaluation of that process as it is happening so that we, government, professions and the industry itself can adjust as necessary, depending on the requirements and the consequences of those changes.

I turn now to the minority reports. I think one of the points which again Senator Giles touched on was the coloured photographs that we included in our report. This was raised as a difficulty in one of the dissenting reports. I very strongly endorse the inclusion of those photographs. Again I think it is important for us to make sure that it is understood that we were talking about a very bad, very small part of this comprehensive industry. But I do not believe that our society ought not know of or be protected from some of the really quite horrific things that happen in very few of the nursing homes. It is far better that those things are known and prevented. Such nursing homes should be closed or not allowed to practice in that way, so that elderly people in our society are protected from that kind of gross, dehumanising mismanagement.

So yes, these things do make us draw breath, but they remind us that, in this society of Australia which is so wealthy, so affluent, so beautiful and so caring, such things as poverty and appalling medical care do happen. If we claim to be as good as we sometimes do, I think we must make sure that no small exceptions like that happen. It was claimed in the dissenting report that reporting those stories would get a bad name for the whole industry. I think the situation is no different from any other regulation in any other industry in that when the bad parts are highlighted people can be sure that the part of the industry that remains is more credible because it is quite clear that it is not associated with the very bad service in a few parts of the industry. Besides, I think we should never flinch from making those sorts of facts known, even if it is necessary to change the whole profession or the whole industry. In this case it was a very small change. There were not many hospitals and nursing homes that gave that kind of appalling care.

The other point that I think is important is the conflict of interest. I must say that I would not have been troubled to support the even tougher proposal that doctors not be allowed to own any interest in nursing homes. I think that in the history of this whole industry many medical people with wisdom and care of patients as their principal concern have established nursing homes or helped to contribute to the establishment of nursing homes precisely to provide that sort of assistance and care which they knew, from knowing their patients, was necessary. I have no conflict with that. I think the medical profession can hold its head high in terms of the many wonderful initiatives it has led for the benefit of people in this country.

But we come to a time when we have to look hard at the possibility of a conflict of interest in this area. It is not unlike, I think, the doctors and the pharmacists who, some time ago, for the benefit of their patients, were arranging to provide their services close by. It was quite obvious after a while that there was a possibility of conflict of interest. In fact, I suspect that there was some evidence to that effect. I think it is a case of realising the potential and preventing it. As Senator Giles has said, we have also had some hint of evidence that it is already a possibility in this country. I do not believe that we should discredit the profession or allow anything that might discredit the profession. Nor should we allow anything that might lower the possibility of good quality care for patients. So I do not see that it is impossible to require by legislation that doctors not be allowed to own an interest in nursing home beds. However, the Committee did not make that recommendation to that extent. It simply recommended that doctors not be allowed to refer patients to nursing homes in which they have a financial interest. What is meant by a financial interest of the doctor is very clearly defined in the report.


Senator Peter Baume —Is not this a moral question? You really cannot secure it with legal sanctions. It is a question of moral approach by doctors. You cannot secure it legally.


Senator CROWLEY —Sadly, I think we have evidence that from time to time even the medical profession is less than 100 per cent moral.


Senator Sheil —So is everyone.


Senator CROWLEY —Indeed. I would have thought that, as we now have it clearly from the lips of the honourable senator on the other side of the chamber that everyone is not always 100 per cent moral, we can include the suggestion that the doctors are not 100 per cent moral and have his support in this matter. We know that is so, therefore I think we have a responsibility to address the possibility of conflict of interest. Most doctors do not have that conflict, although some do. We had evidence before the Committee indicating that such a conflict was quite likely to happen-that the potential was there-and that it has happened. Therefore, I believe that it is no hardship and no great matter to change circumstances so that this conflict of interest is not possible.


Senator Peter Baume —It still remains possible.


Senator CROWLEY —I do not believe it is an amazing statement. As we have evidence that doctors are open to that kind of conflict of interest we should ensure that it is not possible. Of course our principal reason for doing that is that we are looking at continuing respect for the profession and continuing the quality of care of patients. As I said in the beginning, I think that is our priority concern. We must provide people with the sort of medical and humane care that will make their time in a nursing home-if such time is necessary-compatible with humanity and compassion. We should not allow the moving of people in and out of nursing homes merely because it increases the nursing home's profit. That does not help patients. Moving patients is against their good care, particularly the elderly who may be approaching senility or who cannot care for themselves because they are no longer clear in their minds. I am interested that there is an objection to this recommendation. As Senator Giles said, we were certainly far less harsh and far less direct and comprehensive than we could have been. We settled for a moderate half-way approach which simply states that doctors may not refer patients to a nursing home in which they have a financial interest.

The dissenting report recommended instead that medical practitioners with such a financial interest be required to notify the patients in writing of that interest. I suggest that to write to many of these elderly confused patients informing them of a financial interest in a nursing home may cause only further confusion or possibly even fear or fright. I think that is an unsatisfactory way of dealing with a possible conflict of interest. Also, I think it makes patients the deciders as to whether the doctor is in a potential conflict of interest situation. I do not believe that any elderly or ill patient requiring nursing home care ought to be the person to make that decision. I think in some way that is a classic example of an abdication of responsibility. As we have evidence that the medical profession is not 100 per cent honourable, I think this requires that the Government unashamedly ensure that the possibly does not arise. Of course, in that way the proposed recommendation in the dissenting report would not come into effect and indeed would not be necessary because patients would be protected from having to decide whether they might be putting their doctors in a potential conflict of interest situation.

The second dissenting report sees the need for the Government to make some recommendation about the numbers of nursing home beds and suggests an attempt at fairness in the distribution of nursing home beds. However, the dissenting report comments that changes to the 35-day hospital occupancy rule could make such a change in the requirement for nursing home beds that proper or responsible planning will not actually be effected. As I understand the dissenting report, it is being suggested that as from time to time things may be very difficult, we should not do it in the first place. I think that is an insufficient argument to mount against our majority recommendations. I think it is more important to say that we unashamedly support the idea of responsible government planning in terms of the distribution and number of nursing home beds, particularly in regard to the number of dollars involved in the nursing home industry. I think it is important that from time to time, with changes that may affect nursing home bed occupancy, those matters be considered and taken into account-not in terms of not having planning in the first place but in consideration of the proposed changes being introduced. I do not find myself persuaded by the argument put forward in that dissenting report. I support the majority report.

I differ with the dissenting report as to how we address what is an honourable return on investment in a nursing home. There are numbers of points raised in the dissenting report as to whether goodwill should be included in the valuation of the nursing home-particularly at a time of sale. The Committee appreciates that this has been a matter of considerable difficulty and that it remains a difficulty for the industry. In fact I think it could be said that it is an area that still needs to be addressed comprehensively and, presumably, by both the Government and the industry.

However, it is true to say also that when a nursing home is built and a person occupies a bed that automatically guarantees a considerable number of government dollars, as part payment of the cost of that bed, to the nursing home. That is not a situation which is matched in almost any other industry in this country. Goodwill, which is really very much a government contribution as well as a good name notion, needs to be taken into account when looking at the sale of such a nursing home and when looking at the whole pricing and fee structure in that area. That is a very important point. It is something that the Committee spent much time and took much evidence on. I am not persuaded by the arguments in the dissenting report.

I also disagree with the dissenting report in respect of requirements by the Committee on the display of nursing home ownership. Much of the evidence taken by the Committee addressed the question of who owned nursing homes. We discovered it was very difficult to know who owned a nursing home. Very often company names were involved. The names of some members of the medical profession or relatives of medical professionals, or the names of sub-companies of other companies, were involved. To find out who actually were the owners of a nursing home was a considerable hunt and chase task. The Committee felt that it was very important the ownership of nursing homes be displayed in some easy way so that people coming into that nursing home, particularly people visiting or people looking to be admitted to such a nursing home, would have the option of reading a list of owners and knowing who they were.

In some way it is a disappointment that a committee should have to make a recommendation such as that. It highlights two things: One is the difficulty of knowing who has owned nursing homes in the past; the other is the possibility of conflict of interest which I referred to before. I think it would be part of a general increase in information giving people a better opportunity to make decisions. Sometimes people are not sure who owns a nursing home. Sometimes it is said: 'I thought it was a charitable nursing home or a home owned by so and so'. We feel it is a matter of importance that the ownership of nursing homes be clearly displayed so that kind of confusion is less possible. However, I presume there is always a possibility for some confusion.

I finish my comments by alluding to the comprehensive nature of this report in its analysis of the nursing home industry. As I said earlier, I am delighted to have the report because I do not now have to hold all the information in my memory; I can look it up in the report. I think it is important that we have discovered just how extensive and complex the whole industry is. Again, I think it is important to say that with the focus of the quality of care as our priority in all our considerations, so we have set our recommendations. I again thank my colleagues and in particular Senator Giles for the very great effort and satisfactory result in producing this report. I am looking forward to what we will discover in tackling the private hospitals to produce the second half of the report.