|Title||ESTIMATES COMMITTEE E
DEPARTMENT OF HEALTH, HOUSING AND COMMUNITY SERVICES
Program 2--Health Care Access
Subprogram 2.1--Medicare Benefits
|Committee Name||ESTIMATES COMMITTEE E
|Department|| DEPARTMENT OF HEALTH, HOUSING AND COMMUNITY SERVICES
|Program||Program 2--Health Care Access
|Sub program||Subprogram 2.1--Medicare Benefits
CHAIRMAN --We are continuing with subprogram 2.1.
Senator WALTERS --You may remember that I had asked the Department and the Commission whether they used the pollster ANOP to carry out research into Medicare and they had both said yes. In which years, since 1984?
Mr McNeil --I will have to take that question on notice in relation to the Department. My recollection is that we used them only last year and it was in relation to a specific aspect of Medicare. I am not sure about the Health Insurance Commission.
Senator WALTERS --Could you both tell me how much it cost? How much did you pay ANOP?
Mr Hazell --The Commission has undertaken annual research since 1984 and--
Senator WALTERS --Every year?
Mr Hazell --Yes, each year. ANOP has conducted the research each year. The current research is conducted under a contract which we negotiated and which we went to tender for in 1990 for a three-year contract. The costs last year were, I believe, $92,000. I do not have with me the cost this year. We have not yet got the results of this year's survey, but my recollection is that the cost this year was somewhat under $92,000.
Senator WALTERS --If you could get me the exact amounts I would be very grateful, Mr Hazell.
Mr Hazell --For just the last few years, Senator?
Senator WALTERS --No, since 1984.
Mr Hazell --Fine.
Senator WALTERS --ANOP is the pollster for the Australian Labor Party. How long has that pollster been the Labor Party's pollster, Minister?
CHAIRMAN --It is not the pollster for the Labor Party, thank you, Senator Walters. It was for some time, but it is not at present.
Senator WALTERS --I am asking the Minister the question.
Senator Tate --I do not know. I will seek the information. If I think it is relevant to the work of the Estimates Committee to respond, I will do so.
Senator WALTERS --I do because of the connection between the Department and the Labor Party with regard to the pollster.
Senator Tate --You might think so.
Senator WALTERS --Were any caveats imposed on ANOP in relation to research? I will give you as an example the situation of the unpublished results being confined to the Commission and not passed on to the Labor Party or the Minister.
Mr Hazell --We have not sought to put any caveats on the availability of that information. We have presented extracts and executive summaries to committees in the past.
Senator WALTERS --Could the Department and the Commission table the most recent results?
Mr Hazell --Yes. The most recent results are those for last year--1991. As I have said, the 1992 survey has been concluded in terms of the research, but we have not yet had the report from the ANOP.
Senator WALTERS --Could I have a copy of both of them when that one is finished?
Mr Hazell --Certainly.
Senator WALTERS --Can I have the Department's one, Mr Hamilton?
Mr Hamilton --Yes.
Senator WALTERS --Thank you very much. Does the Commission operate a hospitality account for the purpose of providing hospitality to clients and staff?
Mr Murray --We do not operate a hospitality account per se. Officers of the Commission do entertain--if that is the right word--external people from time to time.
Senator WALTERS --Could you give me the total amount spent on hospitality?
Mr Murray --Yes. I would have to take it on notice.
Senator WALTERS --For 1991-92 and what is budgeted for in 1992-93.
Mr Murray --Certainly.
Senator WALTERS --Which clients do you entertain?
Mr Murray --People we deal with. Medibank Private would do it with entertainment. I do not like that word, but that is the best one. We deal with investment people, private hospital people--and people that we deal with from time to time. I suspect that most of the entertainment would be in the form of having lunch with them or having a drink with them; it would not be any more than that.
Senator WALTERS --So you invite representatives of the private hospitals to come and have lunch or something like that?
Mr Murray --Yes.
Senator WALTERS --Could you give me the total amount spent on entertaining your clients?
Mr Murray --Sure.
Senator WALTERS --What cost was allocated within the Commission between the Medicare, pharmaceutical benefits and Medibank Private functions?
Mr Murray --That is for hospitality?
Senator WALTERS --Yes.
Mr Murray --That would depend on the nature of the hospitality. Most of it, if not all, would be 100 per cent charged. I cannot imagine many circumstances where it would be apportioned. There would be some where the Board of Commissioners would hold a function and that cost would be apportioned in accordance with the principle determined by the Minister and published in our annual report. But most of the officer level entertainment would be either Medicare, pharmaceutical or Medibank Private and, as such, would be charged directly to that function and would not be subject to any apportionment.
Senator WALTERS --Your functions are of a general nature covering Medibank Private, Medicare and perhaps the pharmaceutical side. Who pays for that? How do you divide that up?
Mr Murray --It is a Commission function. It covers all of the business that the Health Insurance Commission does. It would be apportioned according to the cost apportionment principles.
Senator WALTERS --Could you give me the break-up of the last one.
Mr Murray --Yes. It would be of the order of 75 per cent to Medicare and--
Senator WALTERS --I would be grateful if you could give me the details, Mr Murray. Have members, or a member, of the staff of the Commission been employed on a consultancy basis to assist an eastern European country develop a health insurance system?
Mr Murray --Yes.
Senator WALTERS --What are the details of the consultancy?
Mr Murray --Its project at the moment is in Hungary under the auspices of the World Bank. The Hungarian Government is seeking a World Bank loan. The World Bank approached the Commission, either directly or through the Department of Foreign Affairs, asking whether we could assist, given our expertise in the area, and we agreed to assist and have been doing so since the start of this year or perhaps late last year.
Senator WALTERS --How much has this cost the Commission?
Mr Murray --It has not cost. We believe that we will, at the end of it, come out marginally in front. In other words, the fees that we receive from the World Bank will exceed the costs of the salaries and travel for the people involved.
Senator WALTERS --Good. Could you give me a breakdown of the cost to you and what you got back?
Mr Murray --Yes.
Senator WALTERS --How is this money allocated within the Commission?
Mr Murray --It is apportioned between the two functions--the Government and the Medibank Private function.
Senator WALTERS --Could you give me details of that?
Mr Murray --Certainly.
Senator WALTERS --Has the Commission established a Medibank information hot line?
Mr Hazell --No.
Senator WALTERS --There is no Medicare information hot line?
Mr Hazell --There have been inquiry lines in the States since the beginning of the program. We have not taken any initiatives to expand those in recent years.
Mr McNeil --The Department runs a health care 008 number which was initially set up for the pharmaceutical changes in the 1990 Budget when the pensioner co-payment came in, and it has been used on and off for Medicare inquiries as well as in relation to the GP changes in the last Budget and it has been made available this year in relation to the announcements for hospitals. We have provided statistics on that to Senator Patterson for one of her questions on notice.
Senator WALTERS --Yes. So it is really a propaganda one, is it not?
Mr Hamilton --No, it is not. It is providing factual information about the change and the effects of those changes on the people who call and ask us factual questions.
Senator WALTERS --So Medicare is being improved to ensure that all Australians enjoy better and fairer access to the health care they need. Is that factual information or is that propaganda?
Mr Hamilton --The hot line is there to provide factual information. That is a statement from the Government of what it believes Medicare is doing.
Senator WALTERS --I am just saying it is not factual information that you are trying to get across.
Mr Hamilton --But you asked us about the hot line, Senator.
Senator WALTERS --It is propaganda, as I read it anyway--legislation to strengthen the principles of Medicare and to establish a Medicare hospital-patients charter so people know exact what their entitlements are while they are in hospital. It hardly seems to be factual information.
Mr Hamilton --That is perfectly factual information. It is referring to the proposed patient charter.
Senator WALTERS --Good. How much is this costing us? How much is it costing the taxpayer?
Mr Hamilton --What are you referring to--the hot line or that document you are reading from?
Senator WALTERS --No. The hot line and the advertisements--the lot.
Mr Hamilton --The lot.
Senator WALTERS --The hot line.
Mr Hamilton --The advertisements.
Senator WALTERS --No, not just the hot line.
Mr Hamilton --I am asking you--
Senator WALTERS --The hot line and the advertisements--the whole program.
Mr Hamilton --We provided an answer on notice to that.
Mr McNeil --We provided an answer in relation to the cost of the advertisements which were placed which, if I recall, was $68,000, but the answer has been provided. We provided the statistics in relation to the hot line. We have not provided a cost of the hot line. We will have to take that on notice. The hot line is handling both PPS and Medicare inquiries. I will need to do some apportionment.
Senator WALTERS --Good. I would be grateful if I could have how much it is costing the taxpayer to have that--
Senator Tate --Factual information.
Senator WALTERS --It is all in the eye of the beholder, Mr Hamilton.
CHAIRMAN --That is right, and we will argue that out in the chamber once we have got the facts.
Senator WALTERS --I hope we will not.
CHAIRMAN --Are there any further questions?
Senator Tate --I hope not.
CHAIRMAN --We are not going to argue it out here.
Senator WALTERS --I was not intending to. Were you encouraging me to?
CHAIRMAN --No. I am encouraging you not to argue it out here though.
Senator WALTERS --I was not intending to.
Senator WALTERS --It is now almost three years since vocational registration of general practitioners was introduced. I am interested to know the real benefits which have flowed to the community as a whole as a result of this initiative. What percentage of practising general practitioners have been granted vocational registration?
Ms Batman --There are now 11,800 vocationally registered GPs on the register. That is a September figure. I am sorry, Senator, was your question how many or what percentage?
Senator WALTERS --What was the percentage?
Ms Batman --That is not quite so simple to answer because it depends a bit on what denominator you use, but something like 65 per cent of unreferred attendance items are now provided by vocationally registered GPs.
Senator WALTERS --What I am asking is the percentage of general practitioners that have been granted vocational registration. That should be pretty simple.
Mr Hamilton --No, it is not in fact, because the definition of a general practitioner is somewhat difficult.
Ms Batman --The difficulty is that we cannot tell from the registration of doctors under Medicare whether they are eligible or not. If they are eligible under the grandparent arrangements, we can tell perhaps how long they have been in practice, but one of the requirements of vocational registration is that they are predominantly in general practice and that sort of information is not visible through the Medicare data. I can give you some numbers of doctors. Under Medicare data doctors who are classified as GPs derive, in broad terms, more than 50 per cent of their schedule fee income from GP type services. There were 22,962 of those in 1991-92. They are doctors who had at least one service claimed on Medicare for that year. But it would not be true to say that all of those would be eligible. We have no real idea of how many of them are actually in general practice because they are items--
Senator WALTERS --So that makes it pretty difficult for you to know whether the system really is working or not.
Ms Batman --Sixty five per cent of actual services provided are provided by vocationally registered doctors. That gives a pretty clear indication of the sort of percentage--
Senator WALTERS --Would you say that, in 65 per cent of services rendered--
Ms Batman --Unreferred attendance items, which one could say were GP type services, are provided under the vocationally registered items.
Senator WALTERS --But not necessarily all unreferred consultations are by general practitioners.
Ms Batman --That is exactly the point. I am saying it is quite difficult to give you a proportion of GPs who are vocationally registered, because all we have to go on are the unreferred attendance items.
Senator WALTERS --Mr Hamilton, could you tell me what the real benefits have been as a result of the three years?
Mr Hamilton --The intention of the changes, and I think they are beginning to show, was to encourage general practitioners to undergo continuing medical education so that their skills are kept up to date. That would obviously have a benefit for patients in that they are receiving more up-to-date advice and treatment.
Senator WALTERS --No, Mr Hamilton, that is not the question I asked. What benefits have already been shown? What are the real benefits which have already flowed to the community?
Mr Hamilton --I believe that benefit is flowing.
Senator WALTERS --What proof have you?
Ms Batman --The general practice evaluation program which, of course, was set up to inquire into this sort of thing. There have been a few results at this stage but not many. If you are looking at quality of care issues, which are really the sorts of underlying bases of vocational registration, I think you can start to accrue some of the benefits by saying that what we have is a change in the sort of professional characteristic of GPs.
Senator WALTERS --Sorry, I did not hear that sentence.
Ms Batman --I am just saying that what we are building with the vocational register is, if you like, a profession of general practice. We have people becoming vocationally registered GPs who have either a formal qualification in general practice or have a significant amount of experience in general practice. In fact, we have got no new graduates who are actually able to join the register so that in that sense we are able to identify a higher standard of training that is going into general practice. All of the GPs on the register must undertake that to keep their skills up. They have to sign up for a program of continuing medical education--
Senator WALTERS --I know all the detail about vocational registration. I am asking you what benefits have been shown to flow to the community as a result of it. You are just giving me the history of it, which I know.
Senator PATTERSON --The question is this: has there been any evaluation to say that people who go to vocationally registered doctors have better treatment?
Senator WALTERS --Are better off.
Senator PATTERSON --Or are admitted to hospital fewer times and have fewer drug interactions. Is there some other objective measure of the fact that going to a vocationally registered doctor means they are getting better treatment because that was what they were supposed to get?
Ms Batman --There is some evidence, but it is fairly preliminary. The study actually compared early entrants to vocational registration, so it was taking a cohort of doctors that registered in, I think, the first six months. It is found that the vocationally registered GPs, particularly those who registered early, actually have significant lower volumes of servicing and requesting of investigations per patient than non-vocationally registered GPs. This is consistent with the provision of high quality care in that it tends to suggest that patients are not being subjected to unnecessary tests and procedures. This finding lends support to indicators from other sources external to the general practice evaluation about the value of vocational registration.
Senator WALTERS --Who carried out that survey?
Ms Batman --I would have to check the name of the study.
Senator WALTERS --I would like the whole survey.
Ms Batman --I think the details of that were provided in the answer to the question on notice by Senator Patterson.
Senator WALTERS --Could I have a copy?
Ms Batman --Certainly.
Senator WALTERS --Have you included the detail of the survey--
Mr Hamilton --There is a summary of all the surveys and research done in the answer provided to Senator Patterson the day before yesterday.
Ms Batman --That particular summary, which is GPEP No. 40, has not been completed so there is not a final report, but there is a preliminary report.
Senator WALTERS --Could I have the preliminary report?
Ms Batman --Yes.
Senator WALTERS --Have any general practitioners been removed from the vocational register due to the RACGP being dissatisfied with their retention on the register?
Mr Hazell --We have, as has been explained in previous Estimates hearings, provided information to the College about doctors who, from the Medicare data, appear to be not satisfying the requirement for vocational registration. Our data cannot be definitive on that and in any event it is up to the RACGP to make that determination. The information I have here suggests that during April, May, June and July 1992, seven doctors were withdrawn from the register as a result of inquiries by the RACGP. Others have been removed, but they were mainly deceased members and things like that. That is certainly not what you are asking about so the figure would be seven.
Senator WALTERS --How many appeals against refusal to grant vocational registration have been made?
Mr McNeil --We will have to take that on notice.
Senator WALTERS --I asked through the Secretary that someone with all the details on the vocational registers be present because I had a number of questions in this area. I did not expect any answers to be taken on notice. You will probably have to take on notice how many have had their appeals upheld.
Ms Batman --I am sorry, we do not have that information here.
Senator WALTERS --We are now in the third year. Are you aware of any GPs who have been warned by the College because they have not undertaken sufficient additional continuation education or self-evaluation courses conducted by either the College or any other recognised body?
Ms Batman --The RACGP minimum standard requires that VRGPs undertake one defined activity in the first triennium.
Senator WALTERS --I know all that.
Ms Batman --This will increase to two in the second triennium. The first triennium has not yet been completed so the term in which people have to sign up is not over yet, so nobody could be removed for not having undertaken it. The term ends on 31 December 1992.
Senator WALTERS --But they would have been warned by now by the College if they had not undertaken enough, because, after all, it is now the end of September and they only have a couple of months left. If they had not undertaken sufficient education, then a warning would have gone out from the College.
Ms Batman --I am not sure that you could characterise it as a warning, but the College has fairly vocally told vocationally registered doctors that they only have until the end of this year to sign up for an activity. If they do not, then action will be taken to remove them from the register.
Senator WALTERS --How many people have had a warning?
Ms Batman --It would be a general warning in the press rather than a particular warning to individual doctors.
Senator WALTERS --So the College has not approached any individual doctor--
Ms Batman --Not to my knowledge.
Senator WALTERS --Saying, `You had better get on with it'?
Ms Batman --I have seen articles in the medical press to that effect, but I am not aware whether they have written to individual doctors.
Senator WALTERS --You say you are not aware. Have you not made inquiries?
Ms Batman --I have not made inquiries and it has not come to my attention in any other way.
Senator WALTERS --Has the evaluation steering group recently proposed new terms of reference for themselves?
Ms Batman --Yes, they have.
Senator WALTERS --What were their original ones?
Ms Batman --Would you like me to table a copy?
Senator WALTERS --Yes. Could you paraphrase what they were? What I am after is what they were and why they needed change.
Ms Batman --They had seven terms of reference. They were to strengthen evaluation capacity around Australia. In fact, I am not sure whether these are the old ones or the new ones. I might have to check. They were to strengthen evaluation capacity around Australia where participative involvement of the interested parties is an essential element of all parts of the program. The second one is that they are developing proposals for an integrated network of local structures. These are the new ones.
Senator WALTERS --Could you tell me how they vary from the old ones? Why was there a need for the new ones?
Ms Batman --I am not sure that I have the old ones here at the moment. I can get those for you today some time. The committee has been meeting for something like three years now. They originally started with a brief that came out of the Senate Select Committee inquiry. At that time it was felt that there was very little research that was available to support some of the things that a large number of people had been saying to that inquiry.
The terms of reference were set up basically responding to the sorts of issues that had come out in the inquiry and in the report of the Senate Select Committee. Over the last three years, in attempting to put that into place, they have learnt a lot from that experience. One of the things that they have discovered about what is missing is a research base in general practice and also, as they have tried to encourage researchers to take up the quite difficult and complex evaluations, that there is a very limited pool of researchers with an interest and knowledge in general practice.
So one of the things that they have been trying to do is to increase that capacity. The other is that they believe that the snapshot approach to research has its limitations; that going in and collecting new data each time is probably an expensive way to go. They would like to set up a methodology which collects data over a long period so that they can use that to inquire into things as they change rather than having to set up a whole new methodology each time that there are changes. So they are trying to get in place something that will act as an ongoing monitoring arrangement. To do that, they need to set up more of an infrastructure. I believe they are the sorts of reasons that have brought about the change in their terms of reference.
Senator WALTERS --In the new lot is there any reference at all to vocational registration?
Ms Batman --Not specifically.
Senator WALTERS --Why is that? That was the original intention, was it not?
Ms Batman --The terms of reference, I think, have been broadened so that they would encompass vocational registration.
Senator WALTERS --Yes, but you have not included vocational registration on those terms of reference.
Ms Batman --It is included but it is not specifically mentioned.
Senator WALTERS --How do you say it is included but it is not mentioned?
Ms Batman --It is included by looking at changes to general practice to improve quality and the financial value of care. It is part of the improvement of quality.
Senator WALTERS --Yes, but it was originally appointed to oversee the program to monitor the measurable effects of vocational registration.
Ms Batman --That was one of its tasks.
Senator WALTERS --And content based descriptions and to strengthen the research. It seems to have left out now--
Ms Batman --I do not believe that it is left out.
Senator WALTERS --Could I see a copy, please?
Ms Batman --That is my only copy, though.
Senator WALTERS --Do you want it back?
Ms Batman --Yes.
Senator WALTERS --We could perhaps photocopy it. Is that all right?
Ms Batman --Yes.
Senator WALTERS --Which one of the terms of reference would you say covers it?
Ms Batman --I think the preamble at the top covers it where it says that it is looking at changes and improving the quality of general practice.
Senator WALTERS --So you think that preamble substitutes now for its original main intent?
Ms Batman --The other thing I might show you is some of the questions. I am not sure whether they specifically mention vocational registration either. The thing about vocational registration is that it actually involves vocational training for general practice so, in terms of looking at questions of whether training is a factor in improving quality, that is implicit in those terms of reference.
Senator WALTERS --How much is this new set-up going to cost?
Ms Batman --An additional $3m is being provided.
Senator WALTERS --An additional $3m?
Ms Batman --Yes.
Senator WALTERS --Who ordered the change in the terms of reference?
Ms Batman --The evaluation steering group proposed the changes. They were agreed to by the general practice working group. The evaluation steering group is the subcommittee of the general practice working group. The general practice working group approved the changes and, in the Budget considerations, the Cabinet approved the proposals as well, and provided the funds.
Senator WALTERS --I see. And there is no need for any alterations at all in the legislation?
Ms Batman --No, Senator.
Senator WALTERS --So it moved away from the Senate Committee's recommendations and--
Mr Hamilton --It broadened them; that is the point.
Ms Batman --The additional money has been provided to broaden the evaluation program to take account of the new initiatives and to enable it to evaluate those.
Senator WALTERS --Is there in that a doubling up or overlap with the NHMRC?
Ms Batman --I am not aware that there is an overlap.
Mr Hamilton --In the sense of the NHMRC funding research in this area?
Senator WALTERS --And doing all the monitoring.
Mr Hamilton --The NHMRC tends not to fund research in relation to health care practice. It funds biomedical research and public health research. There are certainly processes within the Department to ensure that there is no double dipping, as it were, in relation to individual research grant programs. The sorts of things that the general practice evaluation program is doing would not be the sorts of things that the NHMRC would fund.
Senator WALTERS --So we now have two groups doing research: one doing one section of research, and another doing another lot?
Mr Hamilton --The NHMRC funds biomedical and public health research.
Senator WALTERS --I realise that.
Mr Hamilton --So there is no overlap.
Senator WALTERS --The GP consultative council has evidently removed the requirements for after-hours care and home visits. Will you explain the reason for that?
Ms Batman --No, that is not the case.
Senator WALTERS --I have here the criteria for the vocational registration of general practitioners, and it is no longer in that.
Ms Batman --That is not my understanding. Maybe you could refer me to the part where you believe it is taken away.
Senator WALTERS --The Royal College of General Practitioners' criteria for vocational registration, dated 1 September 1992.
Ms Batman --On page 5, general practice is defined as:
. . . the provision of primary, continuing, comprehensive whole-patient care to individuals, families and their community.
Indicators of compliance with the RACGP definition include the acceptance of unreferred patients presenting to the practice, acceptance of a direct responsibility to ensure that practice patients have access to care by an appropriately qualified medical practitioner at all times and at locations away from the practice, and the undertaking of continuing as well as episodic care.
I am not sure that the words are exactly the same, but that was certainly the principle before.
Senator WALTERS --Why was there a need for an alteration? It has been excluded. I was just wondering why.
Ms Batman --These are the criteria of the Royal Australasian College of General Practitioners. They are passed by it. I imagine that it might have tried to clarify the wording.
Senator WALTERS --I thought that muddied it rather than clarified it. They previously had after-hours home visits, but it has been cut out and now just says, `continuous care'.
Ms Batman --That has always been the case. It has never been an absolute requirement. The requirement has been that a vocationally registered GP has to have been predominantly in general practice. General practice has then been defined as `continuing, comprehensive whole-patient care', and indicators of that in the past have been that the GP provides out-of-hours services and home visits where required. I believe that that is precisely what this says. The words may have changed. I do not have the old criteria with me.
Senator WALTERS --Sure, the words have changed. Last night when I mentioned the smart card, Mr Hamilton said, `We have no smart card'.
Mr Hamilton --That is correct. I believe I said, `We are doing no work on the smart card'. I said it comes up nowhere since we are doing no work on it.
Senator WALTERS --Therefore, he said you can bring it up whenever you like.
Mr Hamilton --Exactly.
Senator PATTERSON --I thought 2.3 was the appropriate place for it to come up.
Senator WALTERS --So I would like to ask some questions about it. When you say no work is being done on it, what is the intention?
Mr Hamilton --There is no intention. The Minister has announced that there is no intention by the Government to introduce smart cards. I have added to that in saying we are in fact doing no work on it either.
Senator WALTERS --What work had been undertaken?
Mr Hamilton --None.
Senator WALTERS --So there was never any thought about it or any intention?
Mr Hamilton --There has never been any intention to introduce smart cards; no work had been done on it.
Senator WALTERS --And it has never been thought of?
Mr Hamilton --I am thinking about it now, so I can hardly say there has been no thought on it.
Senator WALTERS --I would be most surprised if you did not know about it.
Mr Hamilton --The issue is in the papers. We have to think about it.
Senator WALTERS --No work has ever been done on it?
Mr Hamilton --No work has been done.
Senator WALTERS --There has been some public comment about it. There have been meetings--for example, the national health Ministers conference.
Mr Hamilton --If you are referring to the meetings of health Ministers, they have been discussing a health communications network. Smart cards are not part of the health communications network.
Senator WALTERS --What is the difference?
Mr Hamilton --The health communications network does come up under 2.3.
Senator WALTERS --We will wait until then. Could you tell me the difference between the smart card and the health communications network?
Mr Hamilton --The smart card is like a credit card of any sort with information coded onto the back of it which in some of the proposals, whether they be in health or elsewhere, carry personal information on it. There is no such proposal that we are considering. The health communications network is not about a card. We can talk a little later on what it is about.