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Monday, 14 October 1991
Page: 1816


Mr HOWE (-Minister for Health, Housing and Community Services)(3.20 p.m.) —-What honourable members have just heard is fairly typical Opposition fare. It was totally negative and its analysis was riddled with contradictions. On the one hand, I am supposed to want to introduce price signals, to introduce approaches which in some ways might be seen as market elements, and, on the other hand, I am supposed to be pursuing a socialist model like the national health system in Britain.

The fact of the matter is that the Government is seeking to bring about a reform of general practice and the Opposition is seeking to avoid making any sensible comments about general practice. What we have heard from the Opposition spokesperson, the honourable member for Lowe (Dr Bob Woods), is another bit of a rave about how he is in favour of private health insurance, or perhaps in favour of co-payments, how he is against bulkbilling, how he thinks something is wrong with the public hospitals system and how the loony Left is taking over the world. After he said all that, there was not a sentence of any substance. There was also a reference to the spending of $250,000, an issue that I thought was settled at the Senate Estimates hearings, where it was made clear that the Government had spent so far something of the order of $30,000, certainly nothing of the order of a quarter of a million dollars.

As I have said, the Government is about improving the quality of general practice. We believe there are some economic considerations that have something to do with what I think is a depreciating quality of general practice. I do not believe that is particularly the responsibility of Medicare, just as I do not think a system of private insurance would either gain or destroy the quality of general practice, but the way that we pay is not unrelated. It has got some influence.

At the moment we have a health system which essentially is underwritten and therefore we are in a position where we are able to restrain costs. Health is not like any other commodity. Through the 1980s we have been able to sustain health at less than 8 per cent of GDP. The United States, a classic example of a country which has gone predominantly the private health insurance route, is spending about 12 per cent of GDP. Australia has, on the whole, done very well.

Nevertheless, there is a concern that through the 1980s there has been a growth in the number of health services. That preceded Medicare. It was not caused by Medicare but, nevertheless, it is there and it was a matter of some concern to the Government. We picked up that concern, particularly in relation to general practice, because we were interested in how to improve general practice. Our analysis was a simple one. Firstly, it said that there was a very rapid increase in the supply of doctors through the 1980s--so much so that people were saying that there might be as many as 5,000 too many doctors in the system. Secondly, people were saying that in that situation of oversupply there was an incentive for doctors to lift the number of services under a fee for service system to the point where they were able to achieve a certain level of income, a level of income that they thought might be adequate.

So the Government said that if the incentive is there to overservice, or the incentive is to see as many patients as can be squashed in rather than provide quality health care, perhaps we ought to look at providing some other incentives. That is all practice grants are. They are being tried out not by a socialist government but by a conservative government in Britain which has used a number of ideas which are in fact included in the package that we are talking about. It is not a package that is the first step of nationalisation or something, or the first step of a national health service; it is a simple change to provide some alternative incentives, particularly incentives that will improve the quality of general practice.

For us to go in that direction, of course, we will need the profession to agree, or at least the doctors within the profession; we will also need some agreement about what is good quality general practice, because that is what we are seeking to support. Of course, as honourable members will know, we have gone some way in that direction already with vocational registration, and this is about quality and accredited general practice. General practice can also include taking account of other factors within the primary health system. We are interested, for example, in the way that drugs are administered or are ordered up by doctors. They often order up ancillary service, without any awareness at all of the cost to the community of the drugs or the tests that they order up, whether they are radiology or pathology tests or whatever.

So the notion of asking doctors to at least pilot or experiment with a scheme or consider ways in which they could play a larger role seems to me to be directly in line with the principles of the College and something which, frankly, I do not think the College is likely to be antithetical to. In fact, I suspect the College has had rather stronger reservations about the concept of a co-payment than it is likely to have about the thrust of better quality general practice. But the honourable member suggests, disapprovingly, that that would not be the case. I am not sure whether his background is general practice, but my feeling is that out there in the community general practice is looking for a much better deal, and I think there is an opportunity to gain rather more status for the professional, to gain rather better working conditions, to have access to rather better technology, to be seen as having a crucial role rather than a peripheral role in terms of health care, and to be seen as having a recognised speciality alongside the so-called specialists who very often gain most of the income and a great deal of the status.

My view is that we will see what the situation is when we get on to those discussions. The Opposition spokesperson indicated that we had given up some of these things. Not at all. We have not been in a position where we could hold the discussions, which we expect to commence later this week, now that the Government has completed its reconsideration.

The honourable member opposite seems to advocate two things. He seems to advocate private health insurance--he wants to see a lot more private health insurance--and a lot less bulkbilling. He does not like bulkbilling and he likes a lot of private health insurance. The reason that the Government is not going to be particularly pursuing the area of gap insurance or seeking to increase private health insurance in terms of general practice is that we believe it sends all the wrong signals. What it essentially suggests to people is that they need to pay more out of their own pockets; that is, that the aged people who are currently taking out private insurance need more private insurance and more of the workers who have private insurance need to be taking out more private insurance, presumably for greater cost. A greater share of health costs, if you like, would be borne by the private sector.

Essentially the Opposition is saying that an average person ought to be spending a lot more out of his or her pocket on health, and that ought to be taken out not only through a consumption tax but also through private health insurance. I am certainly aware of private health insurance and I know that quite a high proportion of the population has such insurance, not specifically for visits to the doctor but in relation to potential visits to hospitals. So the issue of private health insurance and the issue of hospitals and how we fund them will need to be looked at as part of the national health strategy.

The Opposition spokesperson's contribution cast great doubts on bulkbilling. Of course, bulkbilling is really the Opposition's bete noir; it is the thing it wants to get rid of. The notion that somehow people might be able to go to the doctor and not have heavy out of pocket expenses is for the Opposition a great deal of worry. The fact that one might, through bulkbilling, get a greater handle in terms of what actually occurs in the health system, where costs are being incurred and perhaps get a greater hold on costs does not seem to be of great concern to the Opposition. The fact is that bulkbilling has enabled the Health Insurance Commission to build up a picture of what actually is occurring, and that has been part of the approach that the Health Insurance Commission has used to ensure that the health system is a very disciplined one. Whereas the spokesperson for the Opposition would like to diminish bulkbilling, in fact bulkbilling has operated effectively and well as a system, and has operated as a system that has not contributed to any blow-out in costs. In fact in terms of costs Medicare, the health system, works well and does not need that kind of attention.

The Government nevertheless recognises that some members of the Government party had some concern about bulkbilling and some concern that the introduction of the co-payment might be a disincentive for bulkbilling, or that the structure of the cut in the rebate might be adjusted so it was clear, at least as far as the Government was concerned, that there was a degree of neutrality about bulkbilling as well as a recognition that that has positive consequences. So in the design of the changes that were announced last week the Government has built in a modest incentive--not for patients, but for doctors--to continue to bulkbill. I think something like 70 per cent of all services are currently bulkbilled. We are not anxious to make a change in relation to those services. We are anxious, however, to ensure that patients are aware that a visit to the doctor involves costs, and we are anxious to use the concept of price signals.

The Government is putting into place over the next few months a comprehensive package of reform of general practice which will mean that we will improve the quality of general practice and we will be able to sustain Medicare as a system--and a very popular system of health care it is--in the longer term.

The honourable member for Lowe referred to words such as crisis. I have never used such words about Medicare. I have simply indicated that changes are necessary--not simply in the area of general practice but overall--to ensure that over time we are able to deal with the growth in demand for services, guarantee equitable access to hospitals, and develop a comprehensive system of health care which is properly coordinated, particularly with regard to aged care and other services. In our negotiations with the States, that will also be an important part of what we seek to achieve.

So, as the Government begins on this significant process of reform, we expect that we will get some cooperation from the medical profession. We understand that there will be disagreements, but we would like progressively over the next year or so to put those reforms into place, dealing with problems as they arise, but making sure that our health care system continues to maintain the popularity it has had in the past. (Time expired)