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Wednesday, 10 June 1970

The CHAIRMAN - Order! I point out to the honourable member for Oxley that we are at this moment considering a message from the Senate which includes certain requests. These are the ones in Schedule A that are being discussed by the Minister at this moment. I might say that if the Committee did not consider these requests then there would be nothing further to send back to the Senate because the position would be exactly the same as it was prior to the House having received the message.

Dr FORBES - AsI understand it there are available to honourable members - this is just to clear up the point made by the honourable member for Prospect - copies of this document.


Dr FORBES - The honourable member has that document. Any numbers that I have used in this debate this afternoon or will use subsequently are related to the numbering in that document.

Dr Klugman - The point I made was this: The Minister referred to, I think for example, No. 10 and he said that he would accept that with certain alterations. What does he mean by 'certain alterations'?

Dr FORBES - The reason I made the statement was that, as I have already explained, under the procedures governing these debates we can deal only with the requests at this stage. It would not be appropriate, and no doubt the Chairman of Committees would rule me out of order, if I referred to the amendments without speaking to the requests.

Dr Klugman - I had in mind the. statement that you intend to circulate.

Dr FORBES - I will be very happy to give the . honourable member any elucidation of my statement that he may desire.

The CHAIRMAN - Order! I point out to the honourable member for Prospect that the statement made by the Minister was made in the House in order to assist it in an appreciation of the Bill in general terms. However, in a strict sense in this Committee debate the statement of the Minister in the House has no relevance to what the Committee is considering at the moment. When the requests of the Senate are sent back to the Senate from this Committee and after the Senate has finally decided what to do with the Bill and what amendments it wants inserted and returns the Bill again to this Committee, then at that stage the Committee will be considering the amendments which it will finally make.

Mr Hayden - Well, as soon as the Minister completes what he is proposing to say at this stage I will move that progress be reported at least until we have this statement circulated to members of the Opposition. This is very important because much of what the Minister says refers only to clause numbers and he does not detail the matter being dealt with. I would say that we have been deceived by an artifice. I was told certain things which I repeated a minute ago. Had I known that the Minister was going to operate in the way in which he is-

The CHAIRMAN - Order! If the honourable member for Oxley wants to join in the debate at this moment I remind him that he is interrupting the Minister. He should seek leave to speak, but he cannot seek leave until the Minister has finished speaking. I point out again that the state ment by the Minister to the House has strictly no relevance to the requests that the Committee is discussing at this moment.

Mr Hayden - We would not have given him this opportunity if we had known that he was going to operate in this way. He said nothing about the matters in Schedule B. He made only vague references to proposed amendments.

The CHAIRMAN - Order! I point out to the honourable member for Oxley for the fourth time that we are not at this moment considering Schedule B.

Mr Hayden - I am well aware of that. I am talking about the deceit he practised in this House so that he could get a statement into the House.

The CHAIRMAN - Order! The honourable member for Oxley will resume his seat and he will withdraw the remark he made about deceit by the Minister.

Mr Hayden - I said that the Minister practised deceit, which is true.

The CHAIRMAN - Order! The honourable member for Oxley will withdraw that remark.

Mr Hayden - I withdraw.

The CHAIRMAN - The honourable member will withdraw without any qualification.

Mr Hayden - I withdraw.

Dr FORBES - As I understand it we have before us requests by the Senate for this House to accept certain amendments to the National Health Bill 1970, and they are set out in Schedule A of this proposal which has come from the Senate. I have already moved that the requested amendments as set out in Schedule A, that is, No. 1, No. 2, No. 3, No. 5, No. 6 and No. 7 be not made - that is to say, all the requests except No. 4. I now propose to inform the Committee why the Government believes that the requested amendments be not made, in the normal procedure of dealing with any Bill before the House where the Government is not prepared to accept amendments. I will first say something about the requested amendments numbers 1 and 7, which 1 think honourable members will agree are complementary to each other. Request No. 1 refers to the payment of benefits for a refraction test by an ophthalmologist and the payment of a benefit also for a refraction test by an optometrist. Request No. I is for the deletion of the long-standing provision that Commonwealth benefits are not payable for a consultation at which an eye specialist prescribes spectacle lenses, while request No. 7 proposes the payment of Commonwealth and fund benefits at the rate applicable lo a general practitioner consultation for refraction tests carried out by optometrists.

The provision not to pay benefits for eye specialists in these cases, as the honourable member for Oxley (Mr Hayden) pointed out when he made his statement, was first included in the National Health Act in 1953 as a result of strong objections by the optometrical profession to the proposal to pay Commonwealth benefits for sight-testing examinations if they were carried out by medical practitioners. As the Act now stands, therefore, optometrists are placed on the same footing as ophthalmologists so far as Commonwealth benefits are concerned. In other words. Commonwealth benefits are not paid for any attendance at which spectacles are prescribed either by an optometrist or an ophthalmologist. This is regarded as an equitable situation for the 2 professional groups involved. However, ii request No. 1 relating to ophthalmologists, were agreed to in isolation, ophthalmologists would be placed in an advantageous position as compared to optometrists and it would be, of course, a logical extension to extend the payment of benefits to eye refractions carried out by optometrists. - At first glance it would seem that request No 7. would bring about parity between the professions and provide a solution to the problem. But I would point out to honourable members that one has only to look at the proposals in more detail to see that that is not the case. Taking New South Wales as an example, the position would be that patients who visited an ophthalmologist would receive Commonwealth benefit of $4.25 and fund benefit of $4.25, a total of $8.50 from a common fee of $11, while optometrists patients would receive $2.70 - that is, $1.10 Commonwealth and $1.60 fund benefit - towards the the usual charge of $8.50. Thus a per son visiting a ophthalmologist would pay only $2.50 while a person visiting an optometrist would pay $5.80.

Sizable expenditure is involved in the proposed amendments. On a point of principle the Government is concerned at the effect on budgeting which is involved in proposals of this nature. The estimated cost to the Commonwealth of paying the benefits for these services by both doctors and optometrists is expected to be $2m, but, as 1 have explained already the 2 professions would still not be in equal position. To provide Commonwealth benefits to optometrists equal to those proposed for ophthalmologist would cost the Commonwealth some $4m. Insofar as fund benefits are concerned, the payment of fund benefits for optometrists services - they are paid already for opthalmologists - would necessitate an increase in the rates of contribution's to most funds if not immediately then after a short time.

As 1 indicated in the statement I made to the House, the Government is not prepared, nor is it reasonable to expect it to do so, to change a long standing policy of this kind without having an opportunity for investigation of the proposed change in detail, along with questions of a similar nature, such as the provision generally of ancillary medical services under the health benefits plan. As I advised honourable members in this House, a full scale review of ancillary services is proposed by the Government. Such an overhaul review is essential before ad hoc decisions can be taken in specific areas of ancillary services. We must determine priorities in this area. Who can decide objectively at this point of time whether benefits for patients who have had spectacles prescribed should be provided before benefits for patients receiving other costly health services such as physiotherapy and home nursing? For these reasons the Government is not prepared to accept those 2 amendments.

I now move on to discuss the reasons for amendment No. 2 dealing with oral surgeons. The request for amendment is directed to the definition of 'professional service' in the Bill. This is available to honourable members. This definition varies from that in the principal Act in that it recognises for the purposes of paying medical benefits prescribed services rendered by dentists in an operating theatre of a hospital. The amendment requested by the Senate is for the deletion of the words in an operating theatre of' an approved hospital' from the definition. The effect of this amendment would be that medical benefits would become payable for the prescribed services irrespective of where they are carried out. For instance, benefits would be payable for services carried out in private dental surgeries. The Government, in recognising some services provided by dentists for benefit purposes in the manner proposed, sponsored an important addition to the medical benefits plan. It arose from the recommendation of the Nimmo Committee that medical benefits be paid when a specialist oral surgeon carries out a procedure for which an operating theatre at a public hospital is required and used.

During its consideration of this recommendation the Government extended the proposal so that services performed in an operating theatre in an approved hospital, whether public or private, would attract medical benefits. The essence of the Government's intention in this matter is that in a situation where Commonwealth benefits are not payable in respect of dental services generally, the concession ought to apply only to those procedures which can be and are undertaken by both medical practitioners and oral surgeons. It is anomalous that patients receiving identical services could be recognised for benefits in one situation and not the other, depending on the professional status of the person rendering the service.

Dr Klugman - But why does it have to be done in an operating theatre?

Dr FORBES - I will come to that point later. The Nimmo Committee, in paragraph 15.3 of its report, considered it was not practicable to bring all services rendered by oral surgeons into the medical benefits scheme and the Government accepted this view. In sponsoring this amendment to the Bill in the Senate, it was claimed that the services in question are equally as well performed in a dental surgeon's surgery as in a hospital. However, on the basis of the experience in Canada, which influenced the Nimmo Committee in relation to this matter, the view was taken by the Government that it is desirable in this new area of benefits, initially at least, to limit the benefits to services which can be clearly identified as being quasi-medical in nature. These services can be identified in this way if they are actually carried out in a hospital. It is for these reasons that the Government is not prepared to accept the request for amendment made of this House by the Senate.

I move now to request No. 3 which again deals with oral surgeons. The proposed amendment also is directed to the definition of 'professional service' in the Bill. As I explained in speaking to the previous request for an amendment, the definition of professional service' varies from that in the principal Act in that it recognises for the purposes of paying medical benefits certain services rendered in operating theatres of hospitals by dentists or dental practitioners approved by the Director-General of Health. The amendment requested by the Senate is for deletion of the words 'approved by the Director-General for the purpose of this definition'. The effect of this amendment would be that the benefits would be payable for any of the prescribed services rendered by any registered dentist or dental practitioner.

The Government's policy in relation to the proposed amendment is that benefits should be restricted to the patients of oral surgeons who are competent by experience, qualification and status to carry out any of the procedures prescribed. The difficulty the Government faces in this area is that not all States have registers of oral surgeons with higher degrees. In any case it is known that a number of dental practitioners without higher degrees would properly be recognisable for the purposes of this proposal - for example, by virtue of holding hospital appointments. In these circumstances it is impracticable at this stage to include in the Bill1 specific criteria for the recognition of dental practitioners for this purpose. This and other matters affecting the provision of these services are being negotiated with the Australian Dental Association with a view to developing an agreed procedure for identifying oral surgeons and the Government therefore is not disposed to accept an amendment of the nature proposed at this time.

Turning now to proposed amendment No. 5, relating to the payment of a medical benefit of $2 per day in circumstances which have been mentioned already, this is directed to section 46 (1.) of the principal Act which states:

Where a contributor -

That is a person who is insured with a registered hospital benefit fund - receives hospital treatment in an approved hospital, there is payable, subject to this Part, Commonwealth benefit of two dollars for each day on which that contributor is a qualified hospital patient.

The Senate s request for amendment is for the substitution of the word person' for the word 'contributor' with the intention of making every patient in hospital automatically eligible for the Commonwealth hospital benefit of $2 per day. Membership of a hospital benefits fund would no longer be a requirement. Speakers to this amendment in the Senate directed their comments mainly to the situation in Queensland where no charge is made on public ward patients. lt was alleged that Queensland is disadvantaged as compared with other States due to its adherence over the years to a policy of free public hospitalisation At this point, the Government is sympathetic to this argument and has been ever since the Nimmo Committee submitted its view that Queensland's policy gives full effect to the Commonwealth objective of affording the community adequate financial protection aganst the cost of hospital treatment. This view was strongly endorsed by the Wedgwood Committee. I can appreciate that to a person who has not followed the debate on this Bill, the immediate reaction will be: Then why has the Government not acted? Indeed, this was the point made by the honourable member for Oxley (Mr when he made his statement a little while ago. The reason was given in my statement, and that is that the Government wished to complete its negotiations with the State governments before formulating its proposals on the hospital benefits arrangments and introducing amending legislation.

I now return to the specific terms of the amendment requested by the Senate. Although clearly directed to the Queensland situation, it went further and proposed the payment of the Commonwealth s2 benefit irrespective of whether the patient was insured and irrespective of whether a hospital charge was made or not. The amendment therefore goes further than the Government is prepared to accept. However, the Government is prepared to include an amendment in the Bill. As I indicated earlier in my statement when I outlined the terms of this amendment, owing to the procedures of the House th:s particular amendment, (hat the Commonwealth benefit of s2 a day be paid to hospitals in all cases in which no charge is made to patients, will be requested by the Government in the Senate.

Finally, I move to the request for amendment No. 6, assessing eligibility of low income families. The honourable member for Oxley has specifically asked me why the Government felt that it could not accept this request. I might add that I gave my reasons when the matter was debated in this House. Perhaps I could point mit the Government's attitude by saying that the Act at present provides for low income families to be assisted with the cost of contributing for medical and hospital benefits and, as honourable members ure aware, the Natonal Health Bill proposes extensions to this assistance. The relevant provisions are set out in the new section 82 r in clause 42 of the Bill.

The bases of assessing eligibility are weekly income for families below pensionable age and 'means as assessed' for families of pensionable age. in explanation of section 82Q (2) (e), 1 advise that the Social Services Act provides for certain forms of income to be 'exempt income', that is, not included, when calculating the means as assessed' of a person for pension purposes. The forms of income specified in the Social Services Act to which section 82q (2) (e) relates are: (a) sheltered employment assistance; (b) rehabilitation allowances; (c) tuberculosis allowances; (d) certain service pensions paid under the Repatriation Acf; and (e) age or invalid pensions. The National Health Act, however, provides for these forms of income to be included when calculating the 'means as assessed' for low income families. The amendment would have the effect of providing that, for families over pensionable age, eligibility would be based on means as assessed identical with that applied under the Social Services Act. Means as assessed for the purposes of the National Health Act would then not include any income falling within the categories I have mentioned.

Families with means as assessed under the Social Services Act equivalent to $47 or less a week are eligible for age pensions, plus enrolment in the pensioner medical service. Families with means assessed under the Social Services Act equivalent to between $47 and $70 per week are eligible for what we have come to term tapered pensions, but are not eligible for enrolment in the pensioner medical service. The figures I have just given are by way of illustration and are based on a family of husband and wife and would vary if the family included one or more dependent children, or consisted of one parent and a child A further relevant provision is in section 82u (1.) (b) of the National Health Act which excludes pensioners enrolled in the pensioner medical service from low income family assistance.

It follows, if honourable members have been able to trace these provisions through, that the amendment would affect only a very small number of applicants whose means as assessed are equivalent to between $47 a week, which is the eligibility ceiling for the pensioner medical service, and $48.50 a week which is the eligibility ceiling for low income family assistance under the Bill. The real point at issue is that the amendment would create anomalies by providing assistance with the cost of health insurance for some applicants whilst other applicants in similar financial situations would be denied assistance. To assist honourable members appreciate this point, I have circulated a table setting out comparisons between 3 typical families. If the income falling within the categories I have listed above were excluded when assessing eligibility, then it would place the recipient of the income in an advantageous position as compared with other families.

A further anomaly affecting the position of applicants above pensionable age compared with applicants under pensionable age would arise from the amendment. Eligibility for assistance is to be determined for applicants under pensionable age on the basis of total weekly income which includes any pension and other allowances. It would be anomalous to have pensions, etc., taken into account in making determinations for applicants under pensionable age, but not to have these sources of income taken into account when determining eligibility of applicants over pensionable age. Although the amendment would involve only a small increase in the cost of providing assistance to low income families, the Government rejects the amendment on the grounds that it would introduce a number of anomalies as between families in similar financial circumstances. With the concurrence of honourable members, I incorporate in Hansard the table to which I have referred.

REQUEST FOR AMENDMENT No. 6 (Table as referred to by Minister for Health)

The table below illustrates the effect of the amendment on three families, A, B and C.

Family A is of pension age and receives a pension.

Family B is of pension age but is not entitled to any pension (e.g., because residential qualifications under the Social Services Act are not satisfied).

Family C is under pensionable age.

That completes the reasons why the Government feels that it cannot accept the requested amendments Nos 1, 2, 3, 5, 6 and 7. We ask the Committee that these amendments be not made.

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